Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hopkins Center during CMS and state inspections, most recent first.
Food was not stored, prepared, distributed, and served in accordance with professional standards. Surveyors observed trash around the dumpsters, boxes blocking a side entrance, food and supplies stored too close to ceilings and ductwork, an uncovered light fixture with exposed wires, an unlabeled pan of purple jelly-like substance in the walk-in refrigerator, dust buildup on a kitchen heater, flies in the kitchen, a nonoperational reach-in refrigerator without a warning sign, and a dish machine that was not sanitizing because no chlorine was present.
The facility failed to keep the DOH survey binder in the main lobby updated with the most recent survey results and any active POC. During observation, the binder was available but only contained a 2024 document, despite more recent surveys having been completed. The NHA stated they were responsible for updating the binder and were unaware it had not been updated since 2024.
A facility failed to protect resident privacy when an unattended laptop on a med cart was left open facing the hallway with a resident's medication information visible. In another instance, a sign on a resident's wall disclosed dietary instructions, stating thickened liquids only, and an LPN confirmed the sign was present and did not know who placed it there.
Unsafe and Unclean Resident Environment: The facility failed to maintain a safe, clean, comfortable, and homelike environment on the 2nd and 3rd floors. Observations found multiple rooms with brown-stained ceiling tiles and soiled curtains, and one bathroom door handle was broken, taped with masking tape, and inoperable. The Maintenance Director stated replacement doorknobs had been ordered about 1.5 weeks earlier.
Incorrect MDS Coding for Oxygen Therapy: A resident with a history of atherosclerotic heart disease had an order for continuous O2 via nasal cannula, and staff observed the resident on O2 during the assessment period. However, the quarterly MDS coded oxygen therapy as "No," and the RNAC confirmed the resident had received O2 during the time the MDS was completed.
A resident with COPD was identified as a smoker, but the care plan did not include any smoking-related plan. Facility policy required a person-centered care plan with measurable objectives and timetables, and an LPN confirmed the resident was a smoker and that no smoking care plan had been developed.
Medications were left at bedside for two residents even though neither had documented evidence of being assessed or ordered to self-administer. On one unit, a resident with DM, HTN, CKD, osteomyelitis, and malnutrition had pills and a liquid medication left in the room while the nurse did not return to verify ingestion. On another unit, a disoriented resident with dementia and other psychiatric diagnoses had a cup of pills on a tray table, and the LPN confirmed the medications were the resident’s despite no documentation supporting self-administration.
A resident with a history of atherosclerotic heart disease and hypoxemia had an order for O2 at 3 L/min via NC, but was observed receiving O2 via concentrator at 2 L/min instead. The resident confirmed continuous O2 use, and staff also confirmed the lower flow rate during follow-up observation.
Failure to maintain ongoing communication with the dialysis provider was identified for a resident with ESRD receiving HD three times weekly. Facility records showed missing pre- and post-dialysis log documentation on multiple dialysis days, and the Unit Manager acknowledged the log sheets should be completed each time the resident returned from dialysis.
Annual performance reviews were not completed within 12 months for two nurse aides. The facility could not provide 2026 appraisal forms for either aide, and the Regional Nurse confirmed the evaluations could not be found.
Controlled meds were not stored in separately locked, permanently affixed compartments in the med refrigerators on two units. Two unopened vials of Lorazepam labeled for one resident were found in an open bin with non-controlled meds on the 3rd floor, and one opened vial of Lorazepam labeled for another resident was found the same way on the 2nd floor. An LPN confirmed the storage conditions, and staff reported that licensed nurses and central supply had access to the med room.
A resident with COPD and a pressure ulcer, including a stage 3 wound and MASD, did not have EBP signage posted outside the room. The facility policy called for EBP use for residents with wounds, and an LPN confirmed the resident had a wound and that no EBP signage was present.
A resident’s call bell at the bedside was not working, and the resident reported using the roommate’s call bell instead. Observation showed the device was cracked, the button could not be pressed to activate it, and the ceiling light outside the room did not illuminate when tested. The unit manager confirmed the call bell was not working.
Failure to Post Current Nurse Staffing Information: The facility did not keep the daily nurse staffing posting current. Surveyors observed the staffing sheet at the front desk in the lobby, but it was dated several days earlier. The front desk receptionist said the staffing coordinator had been out of work, and the NHA confirmed the staffing was only posted in the front lobby and was not up to date.
Facility assessment was completed without active input from direct care staff, residents, or resident representatives. Review showed the only contributors were the Medical Director, DON, NHA, and one Governing Body representative, and the NHA stated the assessment was only reviewed quarterly during admin QAPI meetings with no opportunity for broader involvement.
A nurse aide identified a bruise on a resident with severe cognitive impairment and promptly informed the assigned LPN, who failed to report the injury of unknown origin to facility administration as required by policy. This resulted in a delay in notifying the facility of a potential abuse allegation.
A deficiency occurred when residents were not offered nourishing snacks at bedtime, resulting in a 15-hour gap between the evening meal and breakfast. Although dietary staff prepared and delivered snacks, nursing staff did not consistently offer them to residents, leaving individuals hungry during the night.
A resident did not have a full privacy curtain in their room, resulting in inadequate privacy during morning care. For several months after admission, no curtain was provided, and later only a partial curtain was installed, which did not fully cover the resident's bed. This lack of privacy required the resident to ask a roommate's guests to leave during care, as confirmed by staff and direct observation.
A resident's bathroom sink repeatedly became clogged and leaked over a two-month period, causing standing water and water damage to both the bathroom floor and the ceiling of the conference room below. Despite notifications to maintenance staff, the issue persisted, resulting in an environment that was not clean, safe, or comfortable for residents and staff.
Two residents did not have complete care plans addressing their specific needs: one with bilateral below-knee amputations developed a pressure injury linked to improper prosthesis fit, and the care plan lacked interventions for skin checks and prosthesis evaluation; another resident with legal blindness had no care plan interventions for communication related to their condition, as confirmed by nursing staff.
LPNs failed to follow professional standards during medication administration by not verifying resident identity using full name, date of birth, or armband, and by not ensuring proper administration of medications. There was also a lack of documentation and assessment for self-administration of medication.
A resident with multiple medical conditions and at risk for pressure ulcers did not have their protein intake adjusted according to facility policy and professional standards. The nutrition assessment and dietary plan provided less protein than required, and there was no documented re-assessment after the resident was identified as at risk. The dietitian confirmed the resident should have received a higher protein amount.
A nurse administered a prescription Omega-3 capsule to a resident by cutting it open and mixing the contents with applesauce, contrary to professional standards and the medication's instructions, which require the capsule to be swallowed whole. The DON confirmed this was not appropriate and that a different form should have been used if swallowing was an issue.
Surveyors observed multiple medication administration errors, including improper administration of eye drops, incorrect handling of a fish oil capsule, and failure to apply lidocaine patches as ordered. LPNs did not follow physician orders or facility protocols, resulting in a medication error rate of 14.81%.
Staff failed to follow infection prevention protocols, including not wearing required PPE when providing care to a resident with a wound under Enhanced Barrier Precautions, and not performing hand hygiene between medication administration and resident care. An LPN also did not ensure proper medication administration or complete one resident's care before moving to another.
Two residents were exposed to unsafe and uncomfortable room temperatures due to malfunctioning air conditioning units, inconsistent temperature monitoring, and lack of clear maintenance responsibilities. Staff interviews and documentation revealed that temperature checks were not performed on all shifts, and there was no evidence that residents were offered room changes when high temperatures were identified.
A resident with bipolar disorder, alcohol dependence, and chronic pain was issued a discharge notice due to non-payment, but the care plan was not updated to reflect this change. Despite social services working on housing placement, the care plan still indicated long-term care placement, highlighting a failure in timely care plan revision.
The facility did not maintain the required staffing ratios for nursing assistants (NAs) on several occasions. Specifically, the facility failed to meet the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the overnight shift on four out of seven days reviewed. This occurred with a census of 98 to 99 residents, affecting various shifts on different days.
The facility did not meet the required LPN staffing ratios on five out of seven days reviewed. With resident censuses of 98 and 99, the facility failed to provide the mandated number of LPNs per residents during day, evening, and overnight shifts, as identified through staff schedules and interviews.
A facility failed to develop a comprehensive care plan for a resident with alcohol dependency, resulting in multiple incidents of intoxication and hospitalization. Despite the resident's diagnosis and observed behaviors, staff were unaware of the condition, and a care plan was not implemented until after hospitalization.
A resident with alcohol dependency was found intoxicated multiple times, leading to hospitalization with a high blood alcohol level. The facility failed to provide appropriate supervision and did not develop a care plan addressing the resident's alcohol dependency, resulting in actual harm.
The facility did not complete annual performance reviews for five nurse aides, as required by personnel policies. Employees hired between 2004 and 2023 did not receive reviews in 2024 or 2025. The DON confirmed the oversight, violating 28 Pa. Code 201.19(2).
The facility failed to implement proper infection control measures for residents under special contact and droplet precautions. A resident with COVID-19 was not provided with adequate PPE by staff, and enhanced barrier precautions were not enforced for another resident receiving wound care. Additionally, staff did not follow PPE protocols for two residents, one of whom tested positive for COVID-19, indicating significant deficiencies in the facility's infection prevention program.
The facility did not provide necessary Medicare and Medicaid coverage notifications to three residents, failing to issue both a Notification of Medicare Non-Coverage (NOMNC) and an Advanced Beneficiary Notice of Non-Coverage (ABN). This was confirmed through documentation review and staff interviews, highlighting a compliance lapse.
The facility failed to provide operable call bells for two residents. One resident's call bell was found with a severed cord, rendering it non-functional, while another resident's adaptive call bell had been broken and remained unrepaired. Staff confirmed the issues, and parts for the specialty call bell were ordered.
The facility failed to maintain a sanitary and comfortable environment in four rooms on the third floor, with issues such as food crumbs, strong urine odor, and scattered debris observed. These findings were confirmed with a housekeeping employee, indicating a lapse in maintaining required sanitary conditions.
A resident with multiple complex medical conditions who required two-person assistance for care was left unattended by a nurse aide during bed mobility, contrary to the care plan and facility policy. The resident fell from bed during care, sustaining a left humerus fracture, T11 wedge compression fracture, and right shin contusion, resulting in hospitalization and further medical intervention.
The facility failed to ensure residents and their emergency contacts were properly informed and involved in care plan meetings. A resident with dementia did not have their emergency contact invited to a care plan meeting, despite requests for updates. Another resident did not have required meetings conducted, and a third resident had not had a meeting since May. The social worker admitted to late or missing meetings, and the Regional Nurse confirmed the lack of evidence for timely meetings.
The facility failed to maintain an effective pest control program, resulting in persistent pest issues. Despite a contract for bi-monthly pest control services, observations and reports indicated ongoing problems with roaches and other bugs in various rooms. Contributing factors included clutter and poor sanitation in resident rooms. Management acknowledged that recommendations from the pest control company were not implemented.
A facility failed to notify a resident and their emergency contact of a room change, as required by policy. The resident, with multiple health conditions including dementia, was moved from the second to the third floor without prior written notification. Staff interviews revealed inconsistent reasons for the move, and no documentation was provided to the resident or their emergency contact.
A resident with dementia was discharged from an LTC facility without necessary medication prescriptions due to a failure in the discharge planning process. The resident's emergency contact reported the issue, and the Medical Director was unaware of the discharge, leading to a delay in providing the prescriptions.
A resident with diabetes, hypertension, and bipolar disorder was involved in a verbal altercation with a nurse after requesting medication post-smoke break. The facility failed to conduct a thorough investigation or report the incident timely, despite identifying the nurse as the perpetrator. The deficiency lies in the lack of comprehensive investigation and timely reporting.
A facility failed to notify the Department of Health of a verbal altercation between a registered nurse and a resident in a timely manner. The incident occurred but was not reported to the Event Reporting System until later, and the report lacked specific details about the event. The Nursing Home Administrator confirmed this oversight during an interview.
A facility failed to provide a functional heating unit in a resident's room, where the unit was used for storage instead. A resident reported that a temporary portable heating unit emitted only cold air. The Director of Maintenance confirmed that an air conditioner was mistakenly installed and not connected. An order for new units was placed months prior, but no delivery date was available, and two portable heating units were unused.
The facility's pest control program was ineffective, with multiple reports of pests like mice, roaches, and gnats not being addressed by the contracted pest control company. Despite bi-monthly services, pest issues persisted from May to September 2024, with specific incidents on the 2nd floor not being serviced. Interviews revealed a lack of recommendations from the pest control company to improve the situation.
A resident with diabetes went on a leave of absence without proper education on insulin administration and blood sugar monitoring, leading to an immediate jeopardy situation. The facility failed to locate the resident when they did not return as scheduled, and staff did not follow protocol for medication education and LOA procedures.
The facility failed to update the PASARR for three residents with mental health diagnoses, including schizophrenia, bipolar disorder, and depression. The PASARRs did not reflect the residents' current conditions, as required by federal and state regulations. An interview with the social worker confirmed the oversight.
The facility failed to conduct Level 2 PASARR evaluations for two residents with mental disorders. One resident had a history of multiple mental health conditions, yet no Level 2 evaluation was documented. Another resident, with serious mental illness, was incorrectly screened as having no mental health conditions, resulting in no further evaluation. The director of social services confirmed these deficiencies.
The facility failed to maintain an effective antibiotic stewardship program, lacking a system to monitor antibiotic usage over seven months. Monthly reports were insufficient, missing critical information such as antibiotic duration, lab results, and infection details. Interviews confirmed no documentation evidence of an effective program, and the facility could not provide requested policies or evidence of surveillance and tracking.
The facility did not adhere to its abuse prohibition policy by failing to conduct an FBI fingerprint check for a newly hired LPN, Employee E8, who was hired from out of state. This oversight was identified during a review of personnel records and confirmed by the Administrator.
Food Service Storage and Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, the surveyor observed trash on the side and back of the dumpsters outside the receiving area and a large stack of boxes on wooden pallets blocking a side entrance in the receiving area. In the dry storage area, boxes of beard nets and hair nets were stored under ductwork less than 18 inches from the fixtures, and a case of crackers was stored less than 18 inches from the ceiling in the storage area adjacent to the walk-in freezer. A fluorescent light fixture in the storage area outside the walk-in freezer had no covering and exposed wires were hanging down. In the walk-in refrigerator, a one-third size stainless steel pan containing a purple jelly-like substance had no label or date. The heater hanging from the ceiling in the kitchen had a heavy build-up of dust and dirt on the back of the unit. Several flies were observed buzzing around the kitchen. A reach-in refrigerator was not operational, but there was no sign on the unit to alert staff not to use it for food storage. The dish machine was a low-temperature sanitizing machine, and when the rinse water was tested, the test strip did not change color, showing no chlorine present to sanitize dishes. The Assistant Food Service Director confirmed these findings during interview.
Survey Binder Not Updated With Most Recent Survey Results
Penalty
Summary
The facility failed to ensure that the results of the most recent surveys were posted in a place readily accessible to residents, family members, and legal representatives in the main lobby. A tour of the facility on July 14, 2026, found the Department of Health Survey binder on the wall in the lobby, but the binder contained a last printed document from 2024. Review of the facility survey history showed a full health survey was conducted on August 7, 2025, and additional abbreviated complaint surveys were conducted in 2025 and 2026. During interview, the Nursing Home Administrator stated they were responsible for updating the survey binder and were unaware it had not been updated since 2024, and confirmed the binder should contain the results of the most recent federal or state survey and any plan of correction in effect.
Resident Clinical Information Left Exposed
Penalty
Summary
The facility failed to protect resident privacy related to clinical information for two residents. Facility policy on Patient's Privacy Rights stated that access to physical and electronic health records is restricted to personnel directly involved in patient care or authorized organization operations, and that personal and medical information is only to be shared with a patient or individuals explicitly authorized. During observation on the second-floor medication cart, the laptop was open, facing the hallway, and unattended, with Resident R78's medication information exposed. An employee later confirmed that the laptop on the medication cart had been open and unattended. The facility also failed to protect Resident R10's privacy when a sign was observed on the resident's wall stating, "Please stop giving 304D ice water. thickened liquids only." The sign remained in place during a follow-up tour of the third-floor nursing unit, and a licensed nurse confirmed that Resident R10 had the sign on the wall and stated uncertainty about who placed it there.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on the second- and third-floor nursing units. On the second floor, observations on July 14, 2026, identified several areas that were not clean or homelike, including room [ROOM NUMBER] with seven ceiling tiles stained brown, room [ROOM NUMBER] with curtains soiled with brown stains, and room [ROOM NUMBER] with three ceiling tiles stained brown. The facility policy titled, Safe and Homelike Environment, stated the center must provide a safe, clean, comfortable, and homelike environment and allow residents to open and close bedroom and bathroom doors, access areas of the room and bath, and operate room lighting. On the third floor, room [ROOM NUMBER] was observed with a bathroom door handle that was broken and inoperable, with tan masking tape on the handle. During interview on July 14, 2026, the Maintenance Director stated the doorknobs had been ordered one and a half weeks earlier and should be coming any day. On July 15, 2026, the same bathroom door handle was again observed broken, taped with tan masking tape, and inoperable. The third floor also included room [ROOM NUMBER] with curtains soiled with brown stains.
Incorrect MDS Coding for Oxygen Therapy
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident. Resident R78 was admitted with a diagnosis of atherosclerotic heart disease and had a physician order for oxygen at 3 L/min via nasal cannula continuously, with weaning as tolerated to maintain an SpO2 of 92% or greater every shift. Review of the resident’s quarterly MDS showed a BIMS score of 15, indicating cognitive intactness, and Section O0110, Special Treatments, Procedures, and Programs, coded oxygen therapy as "No." During observation on July 14, 2026, Resident R78 was seen on an oxygen concentrator via nasal cannula at 2 L/min. The resident stated she had been receiving oxygen continuously via nasal cannula since last year. The RNAC confirmed on July 17, 2026, that the resident received oxygen in June during the period the quarterly MDS was completed and also confirmed that the MDS had been incorrectly coded as "No" for oxygen therapy. The record review and staff interview showed the quarterly MDS was coded incorrectly.
Missing Smoking Care Plan
Penalty
Summary
A comprehensive person-centered care plan related to smoking was not completed for Resident R66. Facility policy required a person-centered care plan for each resident with measurable objectives and timetables, developed by the interdisciplinary team and reviewed and revised after each assessment. Review of the clinical record showed that Resident R66 was admitted with a diagnosis of chronic obstructive pulmonary disease, and the facility smoking list identified the resident as a smoker. However, the resident's care plan did not include a smoking care plan. During interview, the resident stated that he or she was a smoker. A licensed nurse also confirmed that Resident R66 was a smoker and acknowledged that the facility did not develop a person-centered care plan related to smoking for the resident. The deficiency was cited because the facility did not ensure the smoking-related care plan was completed for this resident.
Medications Left at Bedside for Residents Not Assessed for Self-Administration
Penalty
Summary
The facility did not ensure an environment free of accident hazards related to medications left at bedside for two residents on the second and third floors. During a tour of the second-floor nursing unit, a surveyor observed a plastic medication cup with pills and a plastic medication cup with a brown liquid in Resident R5’s room. The resident stated that he/she takes a while to take medications one at a time and that the nurse usually leaves them for him/her to take. The licensed nurse confirmed that he/she usually checks back to ensure the resident takes all medications, but did not do so that day. Resident R5’s record showed diagnoses including Type Two Diabetes, Hypertension, Chronic Kidney Disease, Osteomyelitis, and Protein Calorie Malnutrition, and there was no documented evidence that the resident had been assessed or had a physician order to safely self-administer medications. On the third floor, a surveyor observed Resident R17 in bed and appearing disoriented, with a tray table a few feet away holding a plastic medication cup filled with pills. The resident was unable to say whether the pills were his/her medications. The licensed nurse confirmed the pills were Resident R17’s medications and stated that the resident was able to self-administer medications. However, the clinical record showed no documented evidence that Resident R17 was able to self-administer medications. Resident R17’s diagnoses included Dementia, Major Depressive Disorder, Schizoaffective Disorder, Psychophysiologic Insomnia, and Anxiety Disorder. The DON later confirmed that both Resident R5 and Resident R17 were not able to self-administer medications.
Oxygen Not Provided per Physician Order
Penalty
Summary
Failure to provide oxygen to a resident according to physician orders was identified for a resident with diagnoses including atherosclerotic heart disease and hypoxemia. The resident had an order for oxygen at 3 L/min via nasal cannula continuously for signs and symptoms of shortness of breath or pulse oximetry below 92% every shift, with post-treatment monitoring of heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds related to hypoxemia. During observation, the resident was seen on an oxygen concentrator via nasal cannula at 2 L/min, and the resident confirmed receiving oxygen continuously via nasal cannula since last year. A follow-up observation again showed the resident on an oxygen concentrator via nasal cannula at 2 L/min, and staff confirmed the resident was receiving oxygen at that rate.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to maintain ongoing communication between the facility and a dialysis provider for one resident who required hemodialysis three times per week. The resident was admitted with diagnoses including end stage renal disease and received dialysis at a local dialysis center on Monday, Wednesday, and Friday with a 9:30 a.m. pickup time. Facility documentation and clinical records showed that the required dialysis communication log was not completed for the resident on multiple occasions, including no documented predialysis or postdialysis entry on one date and no documented postdialysis entries on numerous other dialysis days in June and July 2026. Review of progress notes showed no refusals or missed dialysis appointments during June and July 2026. During an interview, the Unit Manager stated that he or she was not sure why the log papers were not completed after dialysis and acknowledged that both the pre- and postdialysis parts of the log sheets should be completed each time the resident went to dialysis. The deficiency was cited under resident care policies, clinical records, and nursing services requirements.
Annual Performance Reviews Not Completed for Two Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews at least every 12 months for two of six nurse aides reviewed, Employee E16 and Employee E18. Employee E16 was hired on November 19, 2017, and the most recent performance review provided was dated March 22, 2025; the facility was unable to provide a performance appraisal form for 2026. Employee E18 was hired on November 4, 2020, and the most recent performance review provided was dated March 27, 2025; the facility was also unable to provide a performance appraisal form for 2026. During an interview on July 17, 2026, at 1:33 p.m., the Regional Nurse confirmed the evaluations for 2026 could not be found for Employees E16 and E18.
Controlled Medications Not Secured in Medication Refrigerators
Penalty
Summary
Controlled substances were not securely stored on the second and third floor medication rooms. Facility policy required controlled medications to be stored separately from non-controlled medications, with Schedule II medications and controlled substances in a separately locked permanently affixed compartment, including when stored in a refrigerator. However, during observation of the third floor medication room, two unopened vials of Lorazepam Oral Concentrate 2 mg/ml labeled for Resident R81 were found in the medication refrigerator in an open bin with non-controlled medications and not in a separately locked permanently affixed compartment. Employee E12 confirmed the vials were stored that way. A similar condition was observed in the second floor medication room, where one opened vial of Lorazepam Oral Concentrate 2 mg/ml labeled for Resident R30 was found in the medication refrigerator in an open bin with non-controlled medications and not in a separately locked permanently affixed compartment. Employee E10 confirmed the vial was stored with non-narcotic medications and stated that licensed nurses had the keys to the medication room and that the central supply person also had access to the medication room. Resident R81 had diagnoses including adjustment disorder with depressed mood and had orders for Lorazepam oral concentrate as needed for anxiety; Resident R30 had generalized anxiety disorder and also had an order for Lorazepam oral concentrate as needed for anxiety.
Missing EBP Signage for Resident With Wound
Penalty
Summary
The facility did not maintain an effective infection control program related to enhanced barrier precautions (EBP) for one resident with wounds. A facility policy on EBP stated that, in addition to standard precautions, enhanced barrier precautions are to be used for novel or targeted multidrug-resistant organisms, and that gowns and gloves are used during high-contact patient care activities. Review of the resident’s clinical record showed diagnoses including COPD and a pressure ulcer of the left hip, and progress notes documented a stage 3 pressure ulcer and moisture associated skin damage. During the initial tour of the facility, observation on July 14, 2026, at 11:59 AM revealed that there was no EBP signage posted outside the resident’s room. A Licensed Nurse confirmed that the resident had a wound and also confirmed that there was no EBP signage outside the room. The nurse further confirmed that EBP was necessary for residents with wounds.
Nonworking Call Bell at Resident Bedside
Penalty
Summary
The facility failed to ensure that a working call bell was available for Resident R57 in room [ROOM NUMBER], bed D. Review of the facility policy stated that patients are to have a call light or alternative communication device at each bedside, toilet, and bathing room so they can call for assistance when unattended, and that staff will respond promptly. During interview, Resident R57 stated that he/she was using the roommate’s call bell because his/hers was not working. Observation showed that the call bell for bed D was cracked at the top, the red button was cracked and could not be pressed in to operate the bell, and pressing it did not activate the call light. The ceiling light outside the resident’s door also did not illuminate after multiple attempts. The unit manager confirmed that the call bell for bed 326-D was not working.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility did not accurately post daily nurse staffing information as required. On July 14, 2026, surveyors observed the nurse staffing posting at the front desk in the lobby and found that it was dated July 7, 2026. The front desk receptionist stated that the staffing coordinator had been out of work and that this may be why the staffing information was not up to date. The Nursing Home Administrator confirmed that nurse staffing was only posted in the front lobby, that it was posted for July 7, 2026, and that there was no other place in the facility where the nurse staffing was posted.
Facility Assessment Lacked Direct Care Staff and Resident Input
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment with active involvement from direct care staff and input from residents or resident representatives. Review of the facility assessment showed that the only contributors were the Medical Director, DON, NHA, and one representative from a Governing Body. The assessment did not include input from direct care staff, residents, or resident representatives. During an interview, the NHA stated that the facility assessment is reviewed quarterly during administration's QAPI meetings, but there were no opportunities for staff, residents, or resident representative involvement in the assessment process.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when a nurse aide discovered a bruise with red and purple discoloration on a resident's left hand while providing care. The resident, who had diagnoses of chronic obstructive pulmonary disease and vascular dementia and was documented as severely cognitively impaired, exhibited pain and would not allow the aide to touch the affected area. The nurse aide immediately reported the injury to the assigned LPN, who observed the bruise and attributed it to possible poor circulation. However, there was no documented evidence that the LPN reported this injury of unknown origin to facility administration as required by facility policy. Facility policy mandates that any incident or injury of unknown origin be reported immediately to a supervisor, who must then notify the administrator. The failure of the LPN to escalate the report of the resident's injury resulted in a delay in the facility being made aware of a potential abuse allegation. This lapse was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the required reporting procedures were not followed when the bruise was initially found.
Failure to Provide Bedtime Snacks Between Evening Meal and Breakfast
Penalty
Summary
The facility failed to ensure that nourishing snacks were provided to residents when there was a 15-hour gap between the evening meal and breakfast on all three nursing units. According to the facility's policy, bedtime snacks are to be provided to all residents, with the dining services department responsible for assembling and delivering snacks to each unit, and nursing services responsible for offering these snacks to residents. However, interviews with residents during a council meeting revealed that snacks were not being offered at bedtime, and residents reported feeling hungry later in the evening after eating dinner at 4:45 p.m. Further interviews with dietary and nursing staff confirmed that while night snacks were prepared and delivered by dietary staff, it was unclear whether nursing staff were actually offering them to residents. The established meal schedule showed that dinner was served as early as 4:45 p.m. and breakfast was not offered until 7:45 a.m. the next day, resulting in a 15-hour interval without a substantial meal or snack. This failure to provide snacks as required by policy and resident needs was observed on all three nursing units.
Failure to Provide Adequate Privacy Curtain During Resident Care
Penalty
Summary
The facility failed to maintain personal privacy for one resident during the provision of morning care. On August 4, 2025, while maintenance staff were addressing a plumbing issue in a nearby conference room, it was observed that the privacy curtain in the resident's room only covered a quarter of the bed, leaving the resident exposed during care. The resident reported that for the first nine months of admission, no privacy curtain was provided, and five months prior to the observation, only half of a curtain was installed, which still did not provide adequate privacy. The resident stated that when a roommate had guests and care was being provided, the lack of a full curtain required the resident to ask guests to leave to maintain privacy. An observation with the Administrator confirmed the lack of a full privacy curtain in the room, resulting in insufficient privacy during care. These findings were based on a review of facility policies, staff interviews, and direct observations, and were determined to be noncompliant with 28 Pa. Code 201.29(a) regarding resident rights.
Repeated Plumbing Failures Lead to Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment on the second-floor nursing unit, as evidenced by repeated plumbing issues in a resident's bathroom. On multiple occasions, the sink in a specific room became clogged and overflowed, causing standing water on the bathroom floor and leaks into the first-floor conference room below. These incidents were directly observed by surveyors and reported by a resident, who stated that the problem had recurred three to four times over the past two months and that maintenance staff had been notified. Staff interviews confirmed that the sink leak was an ongoing issue, resulting in repeated water damage to both the bathroom and the conference room ceiling. The administrator acknowledged the recurring bathroom leak.
Failure to Develop Comprehensive Care Plans for Residents with Prosthetic and Communication Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with bilateral below-knee amputations and a history of peripheral vascular disease, the clinical record showed the development of a stage 2 pressure injury on the left knee, which the resident attributed to a prosthesis being too tight. Despite the facility's policy requiring routine inspection of prosthetic devices and skin checks at contact points, the care plan did not include interventions for skin checks before or after wearing the prosthesis, nor did it address evaluating the fit and function of the prosthetic devices. This omission was confirmed by the lead wound care nurse, who acknowledged that these interventions were not included in the resident's care plan. Another resident, admitted with a diagnosis of legal blindness, did not have a care plan that addressed communication needs related to their visual impairment. Interviews with the Director of Nursing and the Regional Nurse confirmed that there were no care plan focuses, interventions, or goals documented for the resident's legal blindness. These findings demonstrate that the facility did not complete comprehensive care plans to meet the specific needs of these residents as required.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice during three observed medication administrations. In each instance, the LPNs did not verify the resident's first and last name, date of birth, or check the resident's armband prior to administering medications, as required by the five rights of medication administration. Specifically, one LPN prepared and administered medication to a resident without confirming their identity, and then interrupted the process to take another resident's vital signs before completing the initial medication administration. The LPN also did not ensure that the resident was administering eye drops as ordered by the physician. Additionally, there was no documented evidence that the resident had a physician's order for self-administration of medication, nor was there an assessment or care plan developed for medication self-administration. Another LPN also failed to verify a resident's identity before administering medication, only calling the resident's first name. Staff interviews confirmed that the required verification steps were not followed during these medication administrations.
Failure to Adjust Protein Intake for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to modify and implement appropriate protein interventions for a resident who was at risk for developing pressure ulcers. According to the facility's policy, residents at risk for pressure ulcers should receive 1.2g/kg of protein. However, the nutrition assessment for the resident prescribed only 1.0g/kg, and the dietitian documented a daily protein prescription of 86 grams based on this lower factor. The resident's Braden Scale assessment indicated a risk for pressure ulcers, but there was no documented evidence that the resident's protein needs were re-assessed after this risk was identified. The resident involved had multiple medical conditions, including aphasia, obesity, dysphasia, multiple sclerosis, and hemiplegia. Despite these complex needs and the identified risk for pressure ulcers, the facility did not update the resident's nutritional plan to align with current professional standards and the facility's own policy. The registered dietitian confirmed that the resident should have received at least 1.2g/kg of protein, but this adjustment was not made or documented.
Improper Administration of Prescription Omega-3 Capsule
Penalty
Summary
A deficiency was identified when a nurse administered a prescription Omega-3 fatty acid capsule to a resident by cutting open the capsule and mixing its contents with applesauce, rather than administering it whole as required by professional standards and the medication's prescribing information. Observation revealed that some of the medication remained in the capsule shell after this process. The physician's order specified that the capsule should be given by mouth once daily, and drug information indicated that the capsule should not be broken, crushed, dissolved, or chewed. The Director of Nursing confirmed that the medication should not have been opened and that an alternative form should have been provided if the resident was unable to swallow the capsule whole.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by observations and record reviews involving three residents during medication administration. One LPN administered eye drops to a resident but did not complete the medication administration before attending to another resident's vital signs. The nurse also failed to ensure the resident was administering the eye drops correctly as ordered by the physician, and there was no documentation of an order or assessment for self-administration of the medication. Additionally, another LPN administered a fish oil capsule to a resident by cutting it open and mixing the contents with applesauce, contrary to the physician's order and drug instructions, which specified the capsule should be swallowed whole. Observation revealed that some medication remained in the capsule shell after administration. For another resident, the LPN removed and applied lidocaine patches to the resident's knees instead of the lower back as ordered, and did not follow the prescribed wearing schedule. The nurse, who was from an agency and unfamiliar with facility protocols, could not provide further details regarding the administration. These actions resulted in a medication error rate of 14.81%, significantly exceeding the acceptable threshold.
Failure to Follow Infection Control and Medication Administration Protocols
Penalty
Summary
The facility failed to implement proper infection prevention and control techniques on the second-floor nursing unit and during two observed medication administration passes. On one occasion, a nursing assistant provided care to a resident with a wound, who had Enhanced Barrier Precaution (EBP) signage posted on the door, without wearing any personal protective equipment (PPE) as required by facility policy. Additionally, there was no appropriate disposal container for PPE inside the resident's room. Interviews with staff revealed a lack of awareness regarding the reason for the EBP signage, and the infection preventionist confirmed that staff were not consistently using EBP gowns when providing care to the resident. The resident also reported that this was the first time a nursing aide had worn a PPE gown during care, indicating a pattern of non-compliance with EBP protocols. During medication administration, an LPN failed to complete one resident's medication pass before moving to another resident to take vital signs, and did not ensure the correct administration of eye drops as ordered by the physician. The LPN also did not perform hand hygiene after administering medication to one resident and before providing care to another, nor after taking vital signs and before handling medication again. These actions were in direct violation of the facility's infection control policies and standard precautions, as well as state regulations regarding nursing services.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment for residents, as evidenced by excessively high temperatures in two of eleven resident rooms reviewed. Facility policy requires maintaining room temperatures between 71 and 81 degrees Fahrenheit, but observations and temperature logs revealed that several rooms, including those occupied by two residents, consistently exceeded this range, with recorded temperatures as high as 98.4 degrees Fahrenheit. The issue was exacerbated by malfunctioning air conditioning units, inadequate monitoring, and delayed or incomplete maintenance responses. Interviews with staff, including the Director of Maintenance and the Nursing Home Administrator, revealed confusion and lack of clarity regarding responsibilities for monitoring room temperatures, especially during second and overnight shifts. The Director of Maintenance was unable to provide comprehensive temperature logs prior to his employment and noted a backlog of incomplete maintenance requests. Additionally, there was no evidence of an external air conditioning servicing company being used, and all maintenance was handled internally, with the Regional Director of Maintenance unavailable due to personal reasons. Documentation showed that temperature checks were not consistently performed, particularly on weekends, and that the facility was unable to provide proof that residents or their representatives were offered room changes when unsafe temperatures were identified. The Nursing Home Administrator admitted to not overseeing the temperature monitoring process or reviewing temperature logs, and there was no documentation to confirm that residents were given options for relocation. These failures resulted in residents being exposed to unsafe and uncomfortable environmental conditions.
Failure to Revise Care Plan for Discharge Planning
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely manner concerning discharge planning for a resident. The resident, who was admitted to the facility with diagnoses including bipolar disorder, alcohol dependence, and chronic pain, received a discharge notice due to non-payment. Despite the issuance of this notice, the resident's care plan, developed earlier in the year, still indicated plans for long-term care placement at the facility. Interviews with the Nursing Home Administrator and the social worker revealed that social services had been working with the resident to find suitable housing since February. However, the care plan was not updated to reflect the change in discharge planning status, indicating a lapse in the facility's adherence to regulatory requirements for timely care plan revisions.
Plan Of Correction
Resident R2 careplan has been updated to reflect the change in discharge planning status. An initial audit of current residents has been conducted to ensure the discharge careplan is reflective of the residents discharge planning status. New admissions will be reviewed during clinical meeting to ensure the discharge planning status is current and/or updated as indicated with changes. The DON or designee will re-inservice the Social Workers on the Discharge Policy with the focus on careplans. The Social Worker or designee will conduct weekly audits of 10 residents to verify discharge careplans are reflective of the residents current discharge planning status. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Failure to Maintain Required NA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nursing assistants (NAs) on multiple occasions, as evidenced by a review of nursing staff schedules and interviews with staff. Specifically, the facility did not meet the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the overnight shift on four out of seven days reviewed. On April 1 and April 2, 2025, with a census of 99 residents, the facility did not meet the staffing ratios for the day and evening shifts, and the day and overnight shifts, respectively. On April 4, 2025, with a census of 98 residents, the facility failed to meet the staffing ratios for the evening shift. On April 5, 2025, with a census of 99 residents, the facility did not meet the staffing ratios for the day shift.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Maintain LPN Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on five out of seven days reviewed, specifically on April 1, 2, 3, 4, and 5, 2025. The regulation mandates a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. On April 1 and 2, with a census of 99 residents, the facility did not meet the staffing ratios for all shifts. On April 3 and 4, with a census of 98 residents, the facility failed to meet the staffing ratios for the evening and overnight shifts. On April 5, with a census of 99 residents, the facility again did not meet the staffing ratios for all shifts. These deficiencies were identified through a review of nursing staff schedules and interviews with staff.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Develop Care Plan for Alcohol Dependency
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident R75, who was diagnosed with alcohol dependency, among other conditions. Despite the facility's policy requiring a person-centered care plan within 48 hours of admission, there was no evidence of such a plan addressing the resident's alcohol dependency. This oversight persisted even after multiple incidents of intoxication were observed, including one where the resident was found with a water bottle containing alcohol and exhibited signs of intoxication. Resident R75, who was cognitively intact with a BIMS score of 15, was admitted with diagnoses including alcohol dependence, bipolar disorder, and alcohol cirrhosis of the liver. The resident was found intoxicated on several occasions, with incidents involving slurred speech, aggressive behavior, and possession of alcohol. Despite these occurrences, the facility did not implement a care plan to address the resident's alcohol dependency until after the resident was hospitalized for alcohol intoxication. Interviews with staff revealed a lack of awareness regarding the resident's alcohol dependency diagnosis and the incidents of intoxication. The Director of Nursing confirmed that the care plan was only updated after the last known occurrence of intoxication. This failure to develop and implement a timely and appropriate care plan resulted in actual harm to the resident, who required hospitalization and intravenous therapy for alcohol intoxication.
Failure to Supervise Resident with Alcohol Dependency
Penalty
Summary
The facility failed to provide appropriate staff supervision and a thorough assessment of the resident environment for a resident with a diagnosis of alcohol dependency. This deficiency resulted in actual harm to the resident, who was found with symptoms of intoxication and required hospitalization. The resident was admitted to the facility with multiple diagnoses, including alcohol dependence, bipolar disorder, and alcohol cirrhosis of the liver. Despite being cognitively intact and independent with ambulation, the resident was found with alcohol on multiple occasions. On September 17, 2024, the resident was discovered with a water bottle containing alcohol and exhibited signs of intoxication, such as slurred speech. The resident refused to disclose how the alcohol was obtained and declined a room search. Despite these incidents, there was no evidence of a care plan addressing the resident's alcohol dependency or the incident itself. The facility documentation did not show any interventions to monitor and supervise the resident's environment for alcohol presence and consumption. Further incidents occurred, including a drinking episode over the weekend of September 29-30, 2024, leading to a 30-day discharge notice due to endangerment of resident safety. On October 3, 2024, the resident was again found intoxicated, with multiple empty alcohol containers discovered in their room. The facility conducted an investigation, but it was inconclusive regarding how the resident obtained the alcohol. The lack of documented interventions and supervision led to the resident's hospitalization with a blood alcohol level of 0.27%, requiring intravenous therapy.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for nurse aide staff as required, affecting five nurse aides. Personnel records for Employees E5, E6, E21, E22, and E23 were reviewed, revealing that none had received an annual performance review. Employee E5 was hired on June 13, 2023, Employee E6 on July 16, 2004, Employee E21 on October 2, 2006, Employee E22 on April 1, 2020, and Employee E23 on June 23, 2021. An interview with the Director of Nursing confirmed that no performance reviews were conducted for these employees during 2024 or 2025, violating the facility's personnel policies and procedures as outlined in 28 Pa. Code 201.19(2).
Failure to Implement Proper Infection Control Measures
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for residents under special contact and droplet precautions. Specifically, Resident R15, who tested positive for COVID-19, was observed to have inadequate protective measures in place. A licensed nurse, Employee E4, entered Resident R15's room without wearing the required personal protective equipment (PPE), such as a gown and gloves, despite the room being marked with a sign indicating the need for such precautions. Employee E4 incorrectly believed that only handwashing was necessary, demonstrating a lack of adherence to the facility's infection control policies. Additionally, the facility did not enforce enhanced barrier precautions for Resident R7, who was receiving wound care. Both the hospice licensed nurse, Employee E16, and the nursing aide, Employee E17, were observed wearing only gloves without gowns during the procedure. This was contrary to the facility's policy and the CDC guidelines, which require gowns and gloves for high-contact care activities to prevent the transmission of multidrug-resistant organisms (MDROs). Furthermore, the facility's staff failed to follow proper PPE protocols for Residents R69 and R75. Despite Resident R69 testing positive for COVID-19 and both residents' rooms being marked with signs for special contact and droplet precautions, Employee E24, a nurse aide, entered their room wearing only a surgical mask and did not perform hand hygiene. This lack of compliance with infection control measures highlights significant deficiencies in the facility's implementation of its infection prevention and control program.
Failure to Provide Medicare/Medicaid Coverage Notifications
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare and Medicaid coverage to three residents. Specifically, the facility did not issue a Notification of Medicare Non-Coverage (NOMNC) or an Advanced Beneficiary Notice of Non-Coverage (ABN) to Resident 91, Resident 151, and Resident 152. This deficiency was identified through a review of facility documentation and confirmed during interviews with the Administrator in Training and the Nursing Home Administrator. Both staff members acknowledged the absence of these critical notifications for the residents in question, indicating a lapse in the facility's compliance with regulatory requirements.
Inoperable Call Bells for Two Residents
Penalty
Summary
The facility failed to ensure that call bells were available and operable for resident use, affecting two residents. Resident R63 was observed with a call bell that was wound around the bedrails, with the cord cut off and lying on the floor. The severed cord was still attached to the plug in the wall jack, and pressing the button did not activate the call system. An interview with a licensed nurse confirmed that the call bell was not functioning. Resident R39 had an adaptive call bell that she could blow into to call for help, which had been broken since the night before and remained non-functional the following day. The Unit Manager confirmed that the call bell was not working and mentioned that parts for this specialty call bell had been ordered, as none of the sister facilities had this type of call bell available.
Sanitation and Comfort Deficiency in Resident Rooms
Penalty
Summary
The facility failed to ensure a sanitary and comfortable environment for residents in four out of eleven rooms observed on the third floor unit. Observations revealed various cleanliness issues, including food crumbs on the floor, a strong urine odor, a dry yellow substance under a chair, and a urinal on the floor. Additional observations noted mustard packets, an empty soda can, sweetener packets, a lotion cap, papers, and a brief bag scattered on the floor. Further inspection showed food crumbs under a bed, snack wraps on the floor, and a dirty and dusty bedside table. These findings were confirmed with a housekeeping employee, indicating a lapse in maintaining the required sanitary conditions as per the facility's policy 'Accommodation of Needs,' revised on February 1, 2023.
Failure to Follow Safe Resident Handling Guidelines Resulting in Resident Harm
Penalty
Summary
The facility failed to prevent neglect of a resident by not following established safe resident care guidelines, resulting in significant harm. According to the facility's Safe Resident Handling Program and the resident's care plan, the resident required two-person assistance for all care and extensive or total assistance for turning and repositioning in bed. Despite these documented requirements, a nurse aide provided care to the resident alone, without the required assistance, and allowed the resident to roll over independently during care. This action was contrary to the resident's care plan and the facility's policies, which were designed to prevent such incidents. The resident involved had multiple complex medical conditions, including heart failure, respiratory failure, renal failure, diabetes, morbid obesity, and lymphedema, and was assessed as being at risk for falls due to impaired mobility. The resident was cognitively intact and required substantial or maximal assistance for bed mobility. During the incident, the resident rolled out of bed while the nurse aide was providing care alone, resulting in a fall. The aide admitted to performing care without assistance, believing the resident could roll over independently, and this was confirmed by both the resident and facility documentation. As a result of the fall, the resident sustained a left humerus fracture, a T11 wedge compression fracture, and a right shin contusion, requiring hospitalization and further medical intervention. The facility substantiated the incident as neglect, as the care provided did not adhere to the resident's care plan or the facility's policies, directly leading to the resident's injuries.
Failure to Involve Residents and Contacts in Care Planning
Penalty
Summary
The facility failed to ensure that residents and their emergency contacts were properly informed and involved in care plan meetings, as required by 42 CFR Part 483.10(c)(2)(3). Specifically, the facility did not provide advanced notice of care plan meetings to residents and their emergency contacts, nor did they hold these meetings in a timely manner. This deficiency was identified for three residents, all of whom were not given the opportunity to participate in the planning of their care. Resident R1, who had impaired thought processes due to dementia, was not provided with the opportunity for his emergency contact to participate in care plan meetings. Despite the emergency contact's requests for updates and meetings with the medical director, there was no evidence that she was invited to the care plan meeting held on November 24, 2024. The social worker admitted to only contacting responsible parties if the resident was not alert or oriented, and often did so with insufficient notice. For Resident R2, the facility failed to conduct the required care plan meetings prior to the one held on January 7, 2025. Similarly, Resident R3 had not had a care plan meeting since May 2, 2024, and reported not remembering the last time a meeting was held. The social worker acknowledged that some care plan meetings were late or not held at all, and the Regional Nurse confirmed the lack of evidence for timely meetings. This lack of compliance with care planning requirements was corroborated by interviews with facility staff, including the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
Res R1, R2 and R3 careplan meetings have been conducted. Current residents scheduled for careplan meetings and their emergency contact are being notified by the Social Worker or designee in advance of upcoming careplan meetings and documented. The Social Worker and Nursing management team have been re-inserviced on the careplanning process with the focus on advance notifications to the resident, emergency contact, and timely completion of care plan meetings. The Social Worker or designee will schedule and notify the resident and emergency contacts and review upcoming care plan meetings during the morning meetings. Scheduled careplan meetings are being reviewed during morning meeting with the management team. The Social Worker or designee will conduct weekly x4 weeks, then monthly x2 audits of upcoming care plan meetings to verify advance notification of the resident and emergency contact have been completed and documented, and the careplan meeting has been conducted. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and reports of pest activity. The pest control contract, which began in May 2024, covered mice, ants, roaches, and stinging insects but excluded bed bugs, termites, and wildlife. Despite the contract stipulating bi-monthly services, pest control logs and observations indicated persistent pest issues, including roaches and other bugs in various rooms and common areas. Interviews and observations revealed that residents and their emergency contacts frequently reported sightings of bugs, particularly in bathrooms and living areas. Specific rooms were noted for having clutter and poor sanitation, which were identified as contributing factors to increased pest activity. For instance, one resident's room was cluttered with food items and had a soiled floor, while another room had flying bugs and debris under the radiator. Additionally, a room was found with numerous deceased roaches in a mouse trap, and residents reported frequent sightings of roaches. The facility's pest control logs documented several instances of pest sightings, yet there was no evidence that recommendations from the pest control company were implemented to address these issues. Interviews with facility management, including the Regional Nurse, NHA, and DON, confirmed that the recommendations from the pest control company were not acted upon, leading to ongoing pest problems in the facility.
Plan Of Correction
Room 221, 225, and 316 clutter has been removed, trash and debris was cleaned from under the heating unit, and rooms deep cleaned. Recommendations from December pest control visits have been completed. An initial audit was conducted of resident rooms to ensure trash and debris was removed if found under the heating unit. All resident rooms are maintained on a deep cleaning schedule. NHA will re-educate the Maintenance department to ensure recommendations/comments made during pest control visits have been addressed. Housekeeping Director and/or designee will re-educate the housekeeping department to ensure that trash and debris under a heating unit is removed. A biweekly audit will be conducted of the pest control logbook for 3 months to verify recommendations/comments made during pest control visits have been addressed as an effort to achieve a pest-free environment. Results of the monthly audit will be reviewed in subsequent QAPI for recommendations.
Failure to Notify Resident and Emergency Contact of Room Change
Penalty
Summary
The facility failed to provide documented room change notifications to a resident and their emergency contact, as required by regulations. This deficiency was identified for one resident, who was admitted with multiple diagnoses including dementia, heart failure, and diabetes. The facility's policy on room changes, revised in January 2024, mandates that notifications be provided within a reasonable time and that social services coordinate room change requests. However, the resident's emergency contact reported not being informed of the room change from the second to the third floor, which was discovered during a visit when the resident was not found in their original room. Interviews with facility staff, including the Regional Nurse and the Nursing Home Administrator, revealed that the facility could not provide a consistent reason for the room change, citing various explanations such as the resident's long-term care status and the need for a more compatible roommate. Additionally, there was no evidence that the resident or their emergency contact received written prior notification of the room change, as required. The lack of proper documentation and communication regarding the room change led to the deficiency being cited.
Plan Of Correction
The facility can not retroactively correct the cited deficient practice for Resident R1. Current residents with room changes for the past 7 days were reviewed to verify notification to the resident, emergency contact, and roommate were provided. The Social Worker and nursing management team have been re-inserviced on the Room Changes policy. Residents with upcoming room changes are being reviewed during morning meetings to verify notification to the resident, emergency contact, and roommate are completed and documented. The Social Worker or designee will conduct audits of residents with room changes weekly x4 weeks, then monthly x2 months to verify notification to the resident, emergency contact, and roommate have been completed and documented. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was reviewed for this care area. The resident, who had impaired thought processes due to dementia, was admitted for rehabilitation services and later discharged back to his home. However, the discharge process was not properly executed, as the resident was discharged without the necessary prescriptions for his medications, which included Bumetanide, Metoprolol Succinate ER, Haloperidol, and Ferrous Sulfate. The emergency contact for the resident reported that upon discharge, the resident needed prescriptions for his medications, but a physician was not available to write them, and the facility did not provide any medication samples. This lack of preparation left the resident without the necessary medications until the prescriptions could be fulfilled. The unit manager confirmed that the emergency contact called two days after the discharge, still without the medications or prescriptions. The Medical Director was unaware of the resident's scheduled discharge and received a call from the facility on the day of discharge, requesting him to write the prescriptions. However, he was unable to do so at that time. It was not until two days later that the Medical Director wrote the prescriptions, which were then faxed to the pharmacy. This series of events highlights the facility's failure to ensure a smooth and effective discharge process, as required by their policy.
Plan Of Correction
The facility can not retroactively correct the cited deficient practice for Resident R1. Current residents scheduled for discharges are being reviewed during morning meeting to verify an effective discharge plan is in place. The Social Worker and nursing management team has been re-inserviced on the Discharge Planning Process policy. Current residents scheduled for discharges are being reviewed during morning meeting to verify an effective discharge plan is in place. The Social Worker or designee will conduct audits of discharged residents to verify an effective discharge planning process was in place, and prescriptions/or medications were given as indicated. Audits will be completed weekly x4 weeks, then monthly x2 months. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Investigate Alleged Mental Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation related to an allegation of mental abuse involving a resident diagnosed with diabetes mellitus, hypertension, and bipolar disorder. The incident occurred when the resident requested his scheduled medication after returning from a smoke break, leading to a verbal altercation with a registered nurse. The resident reported feeling intimidated by the nurse, who allegedly yelled at him. The facility's documentation included a grievance form and statements from involved parties, but the investigation was not comprehensive, and the incident was not reported to the department of health in a timely manner. The facility's documentation identified the registered nurse as the perpetrator of the verbal altercation, yet the follow-up investigation submitted to the State Survey Agency did not acknowledge this, nor did it determine whether the allegation was substantiated or unsubstantiated. Interviews with staff confirmed the occurrence of the verbal altercation, but the facility failed to submit a thorough investigation or a PB22 report form for the alleged abuse. This lack of a comprehensive investigation and timely reporting constitutes a deficiency in the facility's handling of the incident.
Plan Of Correction
1. The facility has completed a thorough investigation related to the allegation of mental abuse for Resident R1. 2. Current residents with allegations of alleged mental abuse will be reviewed for the past 14 days to verify a thorough investigation has been conducted. 3. The NHA or designee will re-inservice the management team on how to conduct a thorough investigation. Residents with allegations of mental abuse will be reviewed during morning meetings to verify a thorough investigation has been conducted. 4. The NHA or designee will conduct audits of allegations of alleged weekly x4 weeks, then monthly x2 months. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Timely Report Verbal Altercation
Penalty
Summary
The facility failed to comply with the Pennsylvania Department of Health's regulation requiring immediate notification of noncompliance that seriously compromises quality assurance or patient safety. This deficiency was identified based on a review of facility documentation and interviews. Specifically, a verbal altercation occurred between a registered nurse and a resident on November 7, 2024. However, the facility did not report this incident to the Department of Health's Event Reporting System (ERS) until November 18, 2024, and even then, the report lacked details about the specific incident. During an interview, the Nursing Home Administrator confirmed the failure to submit the event to the ERS in a timely manner.
Plan Of Correction
1. The facility reported the allegation of mental abuse for Resident R1 on 11.7.24. 2. Current residents with allegations of alleged mental abuse will be reviewed for the past 14 days to verify they have been reported via the ERS to the Pennsylvania Department of Health. 3. The NHA or designee will re-inservice the management team on requirements of reporting abuse. Residents with allegations of mental abuse will be reviewed during morning meetings to verify that the allegation has been reported via the ERS to the Pennsylvania Department of Health. 4. The NHA or designee will conduct audits of allegations of alleged mental abuse weekly x4 weeks, then monthly x2 months to verify reporting to the Pennsylvania Department of Health has been completed. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Non-Functional Heating Unit in Resident Room
Penalty
Summary
The facility failed to provide a functional heating unit for one of the rooms observed, specifically room [ROOM NUMBER]. During an observation on November 6, 2024, it was noted that the heating unit in this room was non-functional and was being used to store the resident's hygiene supplies, linens, and personal belongings. A resident residing in the affected room reported that a portable heating unit was installed temporarily in late October 2024, but it only emitted cold air. Further investigation with the facility's Director of Maintenance revealed that an air conditioner, not a heating unit, was temporarily installed and was not connected to an outlet. The facility's administrator mentioned that an order for six units was placed on July 15, 2024, but there was no known delivery date. Additionally, the Director of Maintenance confirmed that the facility had two portable heating units available, which were not in use.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple reports of pest sightings, including mice, roaches, gnats, and flies, across various areas of the facility. Despite having a contract with a pest control company since May 2024, which included bi-monthly services, the facility's pest control logs from May to September 2024 indicated numerous instances where pest issues were documented by staff but not addressed by the pest control company. Specific incidents included reports of bed bugs, mice, and roaches on the 2nd floor on August 1, 2024, and widespread pest issues on the same floor from September 13 to September 19, 2024, which were not adequately serviced by the pest control company. Interviews with the facility's maintenance director and Nursing Home Administrator revealed that the pest control company provided written reports after each visit, but there was no evidence of recommendations being made to improve the pest control program. The pest control logs also showed that the company did not address specific areas of concern, such as room [ROOM NUMBER] on August 30, 2024, where gnats and a crawling bug were reported. The lack of action and recommendations from the pest control company contributed to the facility's inability to maintain a pest-free environment, as required by regulations.
Failure to Ensure Resident Safety and Education During Leave of Absence
Penalty
Summary
The facility failed to ensure the safety and proper education of a resident, identified as Resident R81, who went on a leave of absence (LOA) without adequate preparation and monitoring. The resident, who had a history of diabetes and required insulin, was not educated on how to monitor blood sugar levels or administer insulin before leaving the facility. This lack of education posed an immediate jeopardy to the resident's health, as they were insulin-dependent and at risk for complications related to improper medication management. The resident was approved for a LOA with family, but did not return at the scheduled time. The facility did not attempt to locate the resident until two shifts after the expected return time, leaving the resident's whereabouts unknown for an extended period. During this time, the resident did not take their medications as prescribed and failed to record blood sugar levels, which could have led to serious health consequences. The facility's policy required staff to review patient care and medication needs with the resident or responsible party before leaving, which was not adequately done in this case. Interviews with staff revealed a lack of communication and adherence to protocol regarding the resident's LOA. The resident was given a bag of medications without proper instruction, and there was no documented evidence of efforts to locate the resident or obtain a new physician order for an extended LOA. This oversight and failure to follow established procedures resulted in a deficiency that compromised the resident's safety and well-being.
Removal Plan
- Resident educated on how to assess, monitor, and administer blood sugar levels per sliding scale.
- Look back completed on resident with active LOA orders that receive insulin to ensure insulin education has been provided.
- DON or designee to re-educate Licensed nursing staff on insulin education prior to the resident leaving for an ordered LOA. Licensed nursing staff will also be re-educated on LOA policy and when to initiate effort/notification to locate a resident who does not return to the facility.
- Audits to be completed for all residents who went on a LOA that receive insulin to ensure education was provided prior to LOA occurring. Results of audits to be reviewed at QAPI meeting.
Failure to Update PASARR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to revise the Pre-Admission Screening and Resident Review (PASARR) for three residents with mental health diagnoses, as required by federal and state regulations. The facility's policy mandates that the social worker or designated staff ensure appropriate pre-admission screening and coordinate updates for residents with mental disorders. However, the review of clinical records revealed that the PASARR for Resident R15, who was admitted with diagnoses of paranoid schizophrenia, Parkinson's disease, bipolar disorder, and depression, was not updated to reflect these conditions. The PASARR Level I screen completed in 2019 failed to include the resident's mental health diagnoses, indicating a lack of compliance with the facility's policy. Similarly, Resident R37's PASARR Level I screen, completed in 2023, did not reflect the resident's diagnoses of schizoaffective disorder and depressive type, which were added in March 2023. The facility did not update the PASARR or conduct a significant change in status assessment. Additionally, Resident R63's PASARR Level I screen from 2021 did not include the resident's diagnoses of major depressive disorder and anxiety disorder, despite these being added in October 2021. An interview with the social worker confirmed that the PASARRs were not updated with the new diagnoses, highlighting a systemic issue in maintaining accurate and current assessments for residents with mental health conditions.
Failure to Conduct Required Level 2 PASARR Evaluations
Penalty
Summary
The facility failed to ensure that a Level 2 PASARR evaluation was conducted for residents with mental disorders as required. Specifically, two residents, R86 and R13, were identified as needing further evaluation based on their mental health diagnoses. Resident R86's clinical record indicated a history of psychosis, anxiety disorder, major depressive disorder, schizoaffective disorder, mood disorder, and unspecified disorder of adult personality and behavior. Despite meeting the criteria for a Level 2 PASARR evaluation, there was no documentation in the clinical record to show that this evaluation was completed, and the facility was unable to provide the necessary form upon request. Similarly, Resident R13, who had diagnoses including anxiety, depression, schizophrenia, paranoia, dementia, and Alzheimer's disease, was also not provided with a Level 2 PASARR evaluation. The resident's care plan indicated the need for such an evaluation due to a serious mental illness. However, the PASARR Level 1 form failed to indicate the resident's mental health diagnoses, incorrectly stating that the resident had no mental health conditions other than dementia. This oversight led to a negative screening outcome, and no further evaluation was conducted. The director of social services confirmed the incompleteness of the PASARR Level 1 and the absence of a Level 2 evaluation for Resident R13.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a period of seven months, as determined by a review of facility documentation, clinical records, and staff interviews. The facility did not have a system in place to effectively monitor antibiotic usage, which is a critical component of antibiotic stewardship. The CDC guidelines emphasize the importance of antibiotic stewardship in nursing homes to optimize infection treatment and reduce adverse events associated with antibiotic use. However, the facility's monthly antibiotic/infection analysis reports were found to be insufficient and missing critical information such as length of antibiotic use, lab results, site of infection, symptoms, and diagnosis. Some reports even lacked basic details like resident names, antibiotics used, and precautions taken. Interviews with the Infection Preventionist confirmed the absence of documentation evidence for an effective antibiotic stewardship program. The facility was unable to provide any policy or evidence of an antibiotic stewardship program, including surveillance, tracking, and analysis, despite requests made to the infection preventionist, the director of nursing, and nursing home administrators throughout the survey. This lack of documentation and monitoring indicates a significant deficiency in the facility's ability to manage and oversee antibiotic use effectively, as required by the CDC guidelines and state regulations.
Failure to Conduct FBI Fingerprint Check for New Hire
Penalty
Summary
The facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history. Specifically, the personnel file of a newly hired Licensed Practical Nurse (LPN), identified as Employee E8, lacked documented evidence of an FBI fingerprint check, which is a part of the screening process for potential hires. This deficiency was identified during a review of facility policies and procedures, employee personnel records, and staff interviews. The facility's policy, titled OPS300 Abuse Prohibition, mandates the screening of potential hires to prevent abuse, mistreatment, neglect, misappropriation of resident property, and exploitation. However, the absence of an FBI fingerprint check for Employee E8, who was hired from out of state, indicates a failure to adhere to this policy. The deficiency was confirmed during an interview with the Administrator, Employee E1.
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What surveyors actually found near you
We read the 1,860 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wyncote
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wyncote Care Center | 0.3 mi | ★★★★★ | 11 | 0 |
| Hillcrest Center | 0.3 mi | ★★★★★ | 22 | 0 |
| York Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 18 | 1 |
| Edgehill Nursing And Rehab Cen | 2 mi | ★★★★★ | 5 | 0 |
| Rydal Park Of Philadelphia Presbytery Homes, Inc | 2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.