Immaculatemarycenter For Rehabilitation&healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 2990 Holme Avenue, Philadelphia, Pennsylvania 19136
- CMS Provider Number
- 395338
- Inspections on file
- 32
- Latest survey
- October 3, 2025
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Immaculatemarycenter For Rehabilitation&healthcare during CMS and state inspections, most recent first.
A resident with dementia and impaired mobility exited a secure unit after staff failed to identify them as at risk for elopement due to an inaccurately coded assessment. The resident followed dietary staff into an elevator and was mistaken for a visitor by front desk staff, allowing them to leave the facility unnoticed. The absence of a visitor sign-out process contributed to the oversight, and the resident was found two hours later at a family member's home after traversing busy streets.
A resident with dementia and physical impairments exited a locked unit and left the facility unsupervised after staff failed to recognize them as a resident. The individual was able to leave with the assistance of dietary staff and was mistaken for a visitor by the receptionist, leading to their exit. The resident was found two hours later, over a mile away, after traversing busy areas. The lack of effective supervision and inadequate processes for monitoring contributed to this Immediate Jeopardy event.
A resident with dementia, muscle weakness, and major depressive disorder was incorrectly assessed as not at risk for elopement, despite documentation of cognitive impairment. An LPN confirmed that the assessment did not accurately reflect the resident's condition or decision-making ability.
A resident with diabetes and multiple wounds did not receive recommended wound care or blood glucose management as advised by podiatry. Despite repeated high blood glucose readings, staff did not notify the physician or adjust care, leading to worsening wounds and hospitalization for infection.
A resident with moderate hearing difficulty was not provided with necessary hearing services after her hearing aid went missing shortly after admission. Despite care plan interventions for hearing loss, there was no evidence of audiology evaluation or replacement of the hearing aid, and an audiology consult was cancelled due to a language barrier. The DON confirmed the resident had not been seen by an audiologist and did not have hearing aids.
A resident with diabetes and multiple wounds had persistently elevated blood glucose levels despite repeated podiatry recommendations to maintain glucose below 180 mg/dL for wound healing. The facility did not notify the physician of these elevated levels or implement changes in nutritional or pharmacological interventions, and the podiatry recommendations were not addressed. The resident's condition worsened, resulting in hospitalization for wound infection and osteomyelitis.
Staff did not adhere to infection control protocols during wound care for two residents. In one case, staff performed wound care under Enhanced Barrier Precautions without wearing required PPE such as gowns and gloves. In another case, a nurse placed wound care supplies on a resident's bed, allowed saline to drip onto the bed, and failed to perform hand hygiene between glove changes.
A resident with severe cognitive impairment and multiple health conditions was found with a fractured lower leg of unknown origin. The facility conducted an internal investigation but did not report the injury to the State Survey Agency as required by policy and regulation. The DON confirmed the failure to submit the necessary report within the required timeframe.
Surveyors found that several resident rooms were not kept clean or sanitary, with used linens, overflowing trash, spills, stained privacy curtains, and unclean surfaces observed. Staff interviews revealed lapses in cleaning responsibilities between shifts.
The facility did not update PASRR Level II referrals for three residents who were newly diagnosed with serious mental illnesses such as Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, and Anxiety Disorder after their initial screenings indicated no need for further evaluation. Staff confirmed that required updates and referrals were not completed following these new diagnoses.
Surveyors identified that the facility did not develop care plans for two residents: one receiving oxygen therapy for pneumonia and another prescribed an antipsychotic for behavioral management. In both cases, the care plans lacked documentation addressing these treatments and monitoring for potential adverse effects, as confirmed by staff interviews and record reviews.
During a kitchen inspection, staff observed multiple opened food items—including spices, pasta, stuffing mix, and Parmesan cheese—stored without required labels or dates, and two sandwiches in the refrigerator also lacked labeling. These findings were confirmed by the Dietary Supervisor and were not in compliance with the facility's food storage policy.
Garbage and refuse were not properly disposed of as leaking commercial trash cans in the food service area caused liquid and food residue to spill onto floors and the loading dock, creating unsanitary and slippery conditions. Staff and the Administrator were aware of the issue for several weeks, but replacement trash cans had not yet been received.
Surveyors observed that staff failed to disinfect medical equipment between residents, did not use required PPE during care of residents on Enhanced Barrier Precautions, and improperly disposed of soiled gowns. In several instances, staff provided wound and catheter care without gloves or gowns, and a Foley catheter bag was found touching the floor.
A resident with multiple medical conditions was left exposed on a raised bed when both a nurse aide and an LPN exited the room simultaneously during wound care, at which time maintenance staff entered. This action failed to maintain the resident's dignity and privacy as required by facility policy.
A resident with a physician order and care plan specifying an 18 Fr Foley catheter was found to have a 14 Fr catheter in place. This discrepancy was confirmed by a nurse, indicating a failure to follow the prescribed incontinence management and catheter care.
Two residents did not receive supplemental oxygen at the flow rates ordered by their physicians. One resident with COPD and polyneuropathy received oxygen at a higher rate than ordered, while another with heart failure and atrial fibrillation received oxygen at a lower rate than ordered. These discrepancies were confirmed by a unit manager during observations.
A resident with a diagnosis of dementia was admitted without an individualized care plan addressing their dementia care needs. Review of the clinical record and care plan revealed no measurable goals or interventions for dementia care, and the DON confirmed that such residents should be care planned.
The facility failed to maintain dignity and privacy for five residents, as observed through untied gowns and exposed briefs. Residents expressed discomfort and inability to manage their clothing due to physical limitations. Staff left gowns untied for easier access, and one resident waited over an hour for assistance, with staff citing a lack of available personnel. All residents had their privacy compromised with open doors and curtains.
The facility did not offer or document influenza and pneumococcal vaccinations for ten residents, as required by their policy and regulations. Despite the infection control nurse's assurance to update records, no updates were made by the survey exit. This deficiency highlights a failure in adhering to vaccination protocols and documentation requirements.
A facility failed to assess a resident's ability to self-administer eye drops for glaucoma, as required by policy. The resident was found with multiple medications unsecured in her room, including one not listed in her physician orders. The unit manager confirmed no assessment was conducted to ensure the resident's capability to self-administer safely.
A resident with multiple medical conditions was moved to another room without prior written notice to her or her responsible party, following a complaint and threat from her roommate. The facility's policy requires written notification before room changes, which was not adhered to in this instance.
A resident with diabetes mellitus repeatedly refused prescribed insulin doses, but the facility failed to notify the physician as required by their medication administration policy. The resident refused a significant number of doses of Humalog and Levemir over two months, yet assessments by medical staff did not address these refusals, indicating a communication lapse.
The facility failed to update care plans for two residents, one with communication barriers and another with aggressive behavior. A resident with dementia and hearing loss had no updated interventions for communication in their care plan, despite language barriers. Another resident with dementia and aggressive behavior had multiple incidents of aggression documented, but their care plan lacked specific interventions to manage these behaviors.
A resident experienced significant weight fluctuations that were not timely addressed by the facility's staff. The dietician failed to verify the initial weight and did not document or respond to significant weight changes promptly. This led to a failure in maintaining the resident's nutritional status.
A resident with low back pain did not receive her prescribed Gabapentin on time, leading to unmanaged pain. The medication was scheduled to be administered three times daily, but a nurse confirmed it was delayed due to staffing shortages.
A facility failed to maintain accurate dialysis communication records for a resident with End-Stage Renal Disease. The resident's Hemodialysis Communication Record lacked pre-weight information before dialysis sessions, despite physician orders for regular treatment. The DON confirmed it was the nursing staff's responsibility to complete this paperwork.
A resident with a history of serious medical conditions expressed a desire to die after refusing hospital transport for chest pain. Despite this, the facility failed to assess her mental state or refer her for behavioral health services. The nurse practitioner was not informed of the resident's statement, and no documentation of an assessment or referral was made, indicating a deficiency in providing necessary behavioral health care.
A resident with diabetes was mistakenly given her roommate's medications, including glipizide, due to an LPN being distracted during administration. This resulted in the resident experiencing low blood sugar and requiring hospitalization for monitoring.
A resident with diabetes and hypertension was inaccurately documented by a nurse as having hypotension and mental status changes post-dialysis on three occasions. However, interviews with the Unit Manager and dialysis nurse confirmed no such changes occurred, highlighting a failure in maintaining accurate clinical records.
The facility failed to maintain an effective pest control program, with significant roach activity in the kitchen and laundry areas, and delayed bedbug treatment in a resident's room. Additionally, contaminated laundry was not properly bagged, potentially contributing to pest spread.
The facility did not maintain a clean and homelike environment on the Third Floor Nursing Unit, as evidenced by a persistent strong urine odor near a room. This was confirmed during observations by surveyors and acknowledged by the Nursing Home Administrator.
A resident and their representative reported grievances about not receiving the appropriate diet, including food that was easy to chew and double portions as ordered. Despite multiple reports, the facility failed to document or resolve these grievances. The facility's grievance policy was also found to be incomplete, lacking procedures for tracking and documenting grievances.
The facility did not report alleged neglect involving two residents to the State Survey Agency. One resident was left unattended in the bathroom, and her call bell was ignored, while another resident's family expressed dissatisfaction with care and decided to take the resident home. The facility's failure to report these incidents was confirmed by the Nursing Home Administrator.
A facility failed to thoroughly investigate a resident's care concerns, as required by its policies. The resident's family reported dissatisfaction with care, including call bell response time and male staff presence. The investigation lacked written statements from the resident or representative and included only partial staff interviews, despite multiple staff being on duty. The Director of Nursing confirmed the incomplete investigation.
Resident Elopement Due to Inadequate Supervision and Elopement Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with dementia, muscle weakness, and major depressive disorder was able to exit a secure, third-floor lockdown unit without staff knowledge. The resident's care plan identified them as at risk for falls and noted impaired cognitive function, but an elopement evaluation was inaccurately coded, failing to identify the resident as cognitively impaired or at risk for elopement. As a result, the resident was not care planned for elopement risk, and no additional supervision or interventions were implemented to prevent unauthorized exit. On the day of the incident, the resident was last seen in bed by staff and subsequently left the secure unit by following dietary staff into the elevator. The dietary staff did not recognize the resident as a resident, and the front desk receptionist, also failing to identify the individual as a resident due to their attire and lack of identification, allowed them to exit the facility. The absence of a process for signing out visitors further contributed to the failure to recognize the resident's departure. The facility only became aware of the resident's absence when a family member called to report that the resident had arrived at their home, which was 1.2 miles away and required crossing busy streets and high-traffic areas. The resident was missing for approximately two hours before being returned to the facility. This sequence of events demonstrated a lack of adequate supervision and failure to maintain a secure environment for residents at risk, resulting in an Immediate Jeopardy situation.
Removal Plan
- Resident was assessed by the nursing supervisor and no concerns were noted.
- Resident was provided with an anti-elopement device and was placed on a one-to-one observation by staff until seen by Geri-Psych Nurse Practitioner.
- Nurses reviewed or completed an elopement evaluation for all current residents.
- All residents who were deemed high risk for elopement were also provided with an anti-elopement device and care planned.
- Facility Elopement Policy was updated by Administration to include how the facility will identify residents who are at risk for elopement.
- New process was put in place for the front desk staff to oversee the completion of entrance logs for visitors and staff.
- Kitchen staff started a new process to not allow residents and visitors in facility elevators when in use for dietary functions.
- Elopement drills were completed.
- Facility staff were educated on the updated elopement process.
- Facility staff were educated prior to the start of their shifts with any per diem, part time, or agency staff education to occur before their next shift.
- Director of Nursing or designee will complete an audit of resident's charts to ensure residents who are at risk for elopement have an elopement evaluation completed. The audit will be conducted twice a week for 30 days.
- Results of the audit will be presented to the monthly QAPI committee for review.
Failure to Supervise Results in Resident Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure adequate supervision for a resident with dementia, muscle weakness, and major depressive disorder. The resident was admitted to a locked unit and was identified as being at risk for falls and impaired cognitive function. Despite these known risks, staff were unaware of any elopement history for the resident, and there was no process in place to sign out visitors, which contributed to the lack of oversight. On the day of the incident, the resident was last seen in bed and was able to leave the locked unit with the assistance of dietary staff, who did not recognize the individual as a resident. The resident then used the elevator to reach the first floor. At the front entrance, the receptionist mistook the resident for a visitor due to their attire and lack of identifying medical bands, and allowed them to exit the facility. Staff only became aware of the resident's absence after receiving a call from the resident's family member. The resident was located approximately two hours later, 1.2 miles away from the facility, after having accessed high traffic areas and busy intersections. The investigation revealed that the facility's failure to provide adequate supervision and to implement effective processes for monitoring residents and visitors directly contributed to the resident's unsupervised exit. This incident was identified as an Immediate Jeopardy situation due to the high risk for injury.
Inaccurate Elopement Risk Assessment for Resident with Dementia
Penalty
Summary
The facility failed to ensure the accuracy of an elopement risk assessment for one resident. Clinical record review showed that the resident was admitted with diagnoses including dementia, muscle weakness, and major depressive disorder. Despite documentation in the care plan indicating impaired cognitive function due to dementia, the elopement evaluation inaccurately coded the resident as not cognitively impaired and not at risk for elopement. Staff interview confirmed that elopement assessments should consider the resident's decision-making ability and any relevant diagnoses or behaviors, which was not reflected in the assessment reviewed.
Failure to Implement Podiatry Recommendations and Manage Blood Glucose for Wound Healing
Penalty
Summary
The facility failed to implement podiatry recommendations for wound care and diabetic management for a resident with multiple risk factors, including diabetes, peripheral vascular disease, decreased mobility, and existing wounds to the foot and heel. Despite repeated podiatry consults recommending specific wound care protocols and maintaining blood glucose levels below 180 mg/dl to promote healing, the facility did not follow through with these recommendations. Clinical records showed that the resident's blood glucose levels were consistently above the recommended range, with 39 out of 43 entries exceeding 180 mg/dl after the recommendations were made. There was no documented evidence that the physician was notified of the resident's persistently elevated blood glucose levels, nor were there any documented attempts to modify nutritional or pharmacological interventions to address the issue. The resident's condition worsened, resulting in a wound infection and subsequent hospital admission for osteomyelitis. The Director of Nursing confirmed that the podiatry recommendations for diabetic management were not addressed and that staff did not notify the physician of the elevated blood sugar levels.
Failure to Provide Hearing Services and Replace Lost Hearing Aid
Penalty
Summary
The facility failed to provide appropriate services to promote and maintain hearing abilities for a resident with documented moderate hearing difficulty. The resident's Minimum Data Set (MDS) indicated the use of a hearing aid, but interviews and record reviews revealed that the hearing aid was missing shortly after admission and was not replaced. The resident's representative reported ongoing difficulty with hearing and confirmed that the resident had not been seen by an audiologist, nor was there evidence in the clinical record of a scheduled audiology visit to address the hearing impairment or replace the lost hearing aid. Further review of the care plan showed interventions for communication problems related to hearing loss, including the use of hearing aids and communication devices. However, there was no documentation of follow-through on these interventions. An audiology consult was scheduled but later cancelled, with a note indicating a language barrier as the resident primarily spoke Italian. The Director of Nursing confirmed that the resident had not been evaluated by an audiologist and did not have hearing aids at the time of the survey.
Failure to Address Diabetic Management and Physician Notification for Wound Healing
Penalty
Summary
The facility failed to ensure that a physician assessment was completed and that changes in medical status were addressed in accordance with professional standards of practice for diabetic management to promote wound healing for a resident with diabetes and multiple wounds. The resident's care plan identified risks related to decreased mobility, incontinence, aged skin, peripheral vascular disease, and a history of diabetes. Despite repeated podiatry consults recommending blood glucose control below 180 mg/dL to promote wound healing, the resident's blood glucose levels were consistently elevated, with 39 out of 43 readings above the recommended threshold. Physician orders required notification for blood glucose levels below 70 or above 250, but the majority of readings were above 180, and several exceeded 250. There was no documented evidence that the physician was notified of the persistently elevated blood glucose levels, nor that any nutritional or pharmacological interventions were attempted or modified to address the hyperglycemia. The podiatry recommendations for optimal diabetic management were not addressed by the physician, and the resident's wounds worsened, ultimately resulting in hospitalization for wound infection and osteomyelitis. The Director of Nursing confirmed that the podiatry recommendations for diabetic management to promote wound healing were not addressed.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
Staff failed to follow infection prevention and control protocols during wound care for two residents. In one instance, a Licensed Practical Nurse and a Nurse Aide provided wound care to a resident who was under Enhanced Barrier Precautions (EBP), as indicated by a sign on the resident's door, but neither staff member wore a gown or gloves during the procedure. This was confirmed by a licensed nurse during an interview. In another instance, a licensed nurse placed wound care supplies, including gloves, gauze, saline, border dressing, and medication, directly on the resident's bed at the foot of the bed. During the procedure, saline was observed dripping from the gauze onto the bed. The nurse removed used gloves and applied new gloves that had been placed on the bed, without performing hand hygiene between glove changes. These actions were not in accordance with facility policy or CDC guidelines for infection prevention and control.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Survey Agency as required by policy and regulation. A resident with severe cognitive impairment and multiple medical conditions, including atrial fibrillation, muscle wasting, and chronic kidney disease, was found with pain, redness, and swelling in the right lower extremity. Subsequent assessment and a stat x-ray revealed a fracture, and the resident was transferred to the emergency department per physician order. The facility initiated an internal investigation, which included review of witness statements, but no staff reported witnessing the injury or any change in the resident's condition prior to the complaint of pain. Despite the facility's policy requiring the reporting of all alleged violations involving mistreatment, neglect, or abuse—including injuries of unknown origin—to the Department of Health and other relevant agencies, there was no evidence that the injury was reported to the State Survey Agency. The Director of Nursing confirmed that the required report was not submitted within the mandated timeframe, resulting in noncompliance with state regulations regarding the timely reporting of suspected abuse, neglect, or injury of unknown origin.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, sanitary, and homelike environment in five resident rooms. Specific findings included used wash cloths on the floor, unemptied trash bins, overflowing trash, excess trash on the floor, liquid spills, trash under beds, food crumbs, unclean bedside tables, and used portable urinals left on the floor. Additionally, a privacy curtain was found with large yellow and white stains, walls had multiple brown stains, and an air conditioner vent cover had visible brown spills. Two empty medication cups were also observed in a resident's room. Staff interviews indicated that cleaning responsibilities were not consistently fulfilled between shifts.
Failure to Update PASRR Level II Referrals for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer residents with newly diagnosed mental disorders for a Level II Pre-Admission Screening and Resident Review (PASRR) as required. Clinical record reviews and staff interviews revealed that three residents with diagnoses such as Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, and Anxiety Disorder did not have updated PASRR Level II evaluations completed after these diagnoses were made. The original PASRR forms for these residents indicated negative screens for serious mental illness, and no further evaluation was deemed necessary at the time, despite subsequent diagnoses that should have triggered a Level II referral. Specifically, one resident was diagnosed with Schizoaffective Disorder, Bipolar Type, and Major Depressive Disorder after the initial PASRR screening, but the PASRR was not updated. Another resident had diagnoses of Schizoaffective Disorder, Anxiety Disorder, and Major Depressive Disorder entered after the initial negative PASRR screening, with no update or referral for Level II evaluation. A third resident was admitted with physical health conditions, but later received diagnoses of psychosis, major depressive disorder, and anxiety disorder, again without an updated PASRR. Staff interviews confirmed that the required updates and referrals were not completed as mandated.
Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Antipsychotic Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents regarding their specific clinical needs. For one resident with chronic obstructive pulmonary disease and polyneuropathy, a physician order was in place for oxygen therapy due to pneumonia, but the comprehensive care plan did not address the use of oxygen therapy. This omission was confirmed by the unit manager during an interview. For another resident with diagnoses of dementia, depression, and breast cancer, a physician order was present for the administration of Rexulti, an antipsychotic medication, to manage behaviors. However, the care plan did not include any information regarding the use of the antipsychotic medication or monitoring for potential adverse reactions. The Director of Nursing confirmed that no care plan had been developed for the antipsychotic use. These findings were based on observations, staff interviews, and review of clinical records and policies.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple observations during a kitchen tour with the Dietary Supervisor. Various opened spices, including ground cinnamon, chicken herb, Italian seasoning, and poultry seasoning, were found on the preparation table without dates. An opened container of Parmesan cheese, which per manufacturer instructions requires refrigeration after opening, was stored with the spices and lacked both a label and date. In the dry storage room, three bags of opened pasta and a traditional stuffing mix seasoning were also found without labels or dates. Additionally, two sandwiches in the walk-in refrigerator were observed on a tray without labels or dates. All these observations were confirmed by the Dietary Supervisor, and the facility's policy requires all refrigerated or frozen foods to be covered, labeled, and dated.
Improper Disposal of Garbage Due to Leaking Trash Cans
Penalty
Summary
Garbage and refuse were not disposed of properly in the facility's Food Service Department, as evidenced by observations of leaking 96-gallon commercial trash cans. During a tour, a trash can was seen leaking significant amounts of yellow and brown liquid while being moved from the dishwasher area to the loading dock, and staff were observed cleaning residue from the cement near the dumpster. On a subsequent day, two trash cans were actively leaking, with one in use near the dishwasher and another at the loading dock, resulting in trails of spilled food and a puddle of white and yellow residue that created a slippery surface. The Dietary Supervisor confirmed these observations, and the Administrator acknowledged being aware of the broken trash cans for several weeks, stating that replacement orders had not been fulfilled by the supplier.
Failure to Follow Infection Control Protocols and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in the facility's infection prevention and control program, specifically regarding the cleaning of medical equipment and adherence to Enhanced Barrier Precautions (EBP). During medication administration, a licensed nurse used a sphygmomanometer on multiple residents without disinfecting it between uses. Additionally, a nurse applied a nicotine patch, checked oxygen saturation, and changed oxygen tubing for a resident with a known MRSA infection without wearing the required PPE, despite the resident being on EBP. These actions were confirmed by staff present at the time. Further deficiencies were observed during wound care and hygiene activities. A licensed nurse failed to properly dispose of a used gown after wound treatment for a resident on EBP, leaving it on a PPE cart intended for clean items. Another resident with a Foley catheter had the catheter bag touching the floor, and both a nurse aide and a licensed nurse provided hygiene and wound care to this resident without wearing PPE. The facility's policies required the use of PPE and proper cleaning of reusable equipment, but these protocols were not followed as observed.
Resident Left Exposed During Wound Care
Penalty
Summary
Facility staff failed to ensure resident dignity during wound care treatment for one resident. During hygiene and wound care, both a nurse aide and a licensed nurse left the resident's room at the same time, leaving the resident exposed on a raised bed. While the resident was left unattended and exposed, a maintenance staff member entered the room. The resident's care plan indicated the bed should be in the lowest position when care is not being provided, and facility policy required staff to maintain and protect resident privacy, including bodily privacy during treatment procedures. The resident involved had a medical history including unspecified intellectual disabilities, a non-pressure chronic ulcer of the back, muscle wasting and atrophy, orthostatic hypotension, and heart failure.
Failure to Follow Physician Order for Foley Catheter Size
Penalty
Summary
A review of facility policies, clinical records, and staff interviews revealed that the facility failed to implement appropriate treatment and services for incontinence management for one resident. Specifically, the physician's order for the resident indicated the use of a Foley catheter sized 18 French (Fr) with a 60 cc sterile saline irrigation as needed for blockage. The resident's care plan also documented the use of an 18 Fr Foley catheter. However, during an observation, it was found that the resident had a Foley catheter of size 14 Fr with a 30 cc balloon in place, which did not match the physician's order or the care plan. This discrepancy was confirmed at the time of observation with a licensed nurse. The failure to provide the correct catheter size as ordered by the physician constituted a deficiency in the facility's incontinence management and nursing services.
Failure to Administer Supplemental Oxygen as Ordered
Penalty
Summary
The facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two residents. For one resident with chronic obstructive pulmonary disease and polyneuropathy, the physician ordered oxygen at 2 liters per minute via nasal cannula. However, during observation, the oxygen was set at 3 liters per minute. The unit manager confirmed the discrepancy and noted that the setting should have been 2 liters, while the resident denied changing the oxygen setting. For another resident with acute on chronic diastolic heart failure and chronic atrial fibrillation, the physician ordered oxygen at 3 liters per minute via nasal cannula. Observation revealed that the oxygen was set at 2 liters per minute. The unit manager confirmed this observation. These findings indicate that the facility did not follow its own policy and physician orders regarding oxygen administration for these residents.
Failure to Develop and Implement Dementia Care Plan
Penalty
Summary
A resident admitted with a diagnosis of dementia did not have an individualized, person-centered care plan developed or implemented to address their dementia care needs. Review of the resident's clinical record and care plan dated March 13, 2025, showed no measurable goals or interventions related to dementia care. During an interview, the Director of Nursing confirmed that residents diagnosed with dementia should have a care plan in place. This deficiency was identified for one of 35 residents reviewed.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain personal dignity for five residents, as evidenced by observations and interviews. Resident R1, with moderately impaired cognition, was found with her gown untied and partially exposing her chest, causing her discomfort and distress. She expressed her inability to tie the gown due to limited range of motion, and staff left it untied for easier access to her sling. Similarly, Resident R2 was observed with her gown untied, exposing her back and brief, and she expressed a desire for her gown to be tied, which she could not do herself. Resident R3 was found with her gown untied and brief exposed, while Resident R4 had his gown above his waist, exposing his brief, with personal care items left on a table beside his bed. Resident R5, with intact cognition, was observed with his undergarment pulled down and brief exposed, waiting for over an hour for assistance to pull up his undergarments and be transferred to his wheelchair. An employee acknowledged the delay, citing a lack of available staff for the required two-person assist. All residents had their doors and privacy curtains open, compromising their privacy and dignity. These observations and interviews indicate a failure to uphold the facility's policy on resident dignity, which mandates respect for residents' private space and bodily privacy during care.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to maintain personal dignity for all residents. 1. R1, R2, R3, R4, and R5 were immediately provided privacy. 2. Resident care areas were checked to ensure privacy and were in compliance. 3. Education was completed with nursing staff to maintain and protect resident privacy, including bodily privacy. Unit managers will routinely check resident care areas to ensure nursing staff are maintaining and protecting their privacy. 4. The Director of Nursing or designee will complete an audit once a week for one month to ensure residents are receiving privacy, including bodily privacy. Results of audits will be reviewed at the facility QAPI meeting.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to offer or provide influenza and pneumococcal vaccinations to ten residents, as determined by a review of clinical records and staff interviews. The facility's policy, dated November 2018, mandates that all residents without medical contraindications be offered the influenza vaccine annually, with proper documentation of the vaccination or refusal in the resident's medical record. However, the records for residents R15, R36, R39, R73, R110, R111, R190, R204, R228, and R231 showed no evidence of receiving or being offered these vaccines. The infection control nurse, Employee E16, confirmed the absence of documentation for the vaccines and believed the information was located elsewhere, promising to update the records. Despite this, by the time of the survey exit on June 17, 2024, the records had not been updated. The facility's failure to document or offer the vaccines is a violation of the regulations requiring pneumococcal immunization offers and proper documentation, as well as the facility's own policy.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the clinical appropriateness of self-administering medication. The facility's policy requires an assessment of the resident's mental and physical abilities, comprehension of medication instructions, and safe storage of medications. However, there was no evidence of such an assessment for the resident, who was self-administering eye drops for glaucoma treatment. The resident's physician orders included instructions for self-administration of one medication, but not for another, and the resident was found to be keeping multiple medications, including an over-the-counter product, unsecured in her room. During an observation, the resident was seen with a sandwich bag containing three bottles of eye medication, including Combigan and Latanoprost, as well as Systane, which was not listed in her physician orders. The resident confirmed that she self-administers these medications and stores them in her room. An interview with the unit manager confirmed that no assessment had been conducted to determine the resident's capability to self-administer the medications safely, as required by the facility's policy.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide written notice to a resident and her responsible party before a room change was made. This deficiency was identified for one resident, who was moved to another room without prior written notification. The facility's policy requires that residents and their roommates be notified of the reason for a room change before it occurs. However, in this case, the resident was moved during the night shift after her roommate complained about her behavior, without any written notice being given to the resident or her responsible party. The resident involved had multiple medical conditions, including dysphagia, respiratory failure, dementia, anxiety, hypertension, and COPD, and was cognitively impaired. The room change occurred after the roommate expressed distress and threatened violence if the resident was not moved. The nursing staff moved the resident to another room during the night shift, but there was no documentation of written notice being provided to the resident or her responsible party, as required by the facility's policy.
Failure to Notify Physician of Insulin Refusal
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusal to take prescribed insulin medications, which is a violation of their policy on administering medications. The policy requires that medications be administered safely, timely, and as prescribed, and that any concerns, such as medication refusals, be reported to the doctor. Resident R108, who is cognitively intact and diagnosed with diabetes mellitus, was prescribed Humalog and Levemir insulin injections. However, the resident refused a significant number of these doses over the months of May and June 2024. Specifically, Resident R108 refused 21 out of 31 doses of Levemir and 58 out of 93 doses of Humalog in May 2024, and 10 out of 13 doses of Levemir and 24 out of 39 doses of Humalog in June 2024. Despite these frequent refusals, there was no documented evidence that the physician was informed. Assessments by a physician and a nurse practitioner during this period did not address the refusals, indicating a lack of communication regarding the resident's non-compliance with the prescribed insulin regimen.
Deficiencies in Care Plan Updates for Communication and Behavior Management
Penalty
Summary
The facility failed to ensure that resident care plans were reviewed and revised to reflect the residents' status and care needs related to communication and aggressive behavior for two residents. Resident R507, who was admitted with dementia, renal deficiency, and hypertension, has a communication barrier due to a hearing deficit and a preference for speaking Spanish. Despite these challenges, the resident's care plan did not include updated interventions or goals related to speech and language, nor did it address the communication barrier adequately. Interviews with staff and the resident's family representative revealed discrepancies in the resident's language abilities, indicating a lack of accurate assessment and documentation in the care plan. Resident R205, admitted with dementia, anxiety, depression, hypertension, renal insufficiency, and diabetes, exhibited aggressive and agitated behaviors. The resident's care plan identified a risk for behavior symptoms related to dementia and language barriers but did not include an updated assessment or plan to address the resident's abusive behavior. The resident's clinical records documented multiple incidents of physical aggression towards other residents and visitors, yet the care plan lacked specific interventions to manage these behaviors effectively.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident R112, due to improper weight monitoring and documentation. The resident was admitted with a recorded weight of 152 lbs, which was later questioned by the dietician and changed to 171.2 lbs based on a re-weight and the resident's input. However, the dietician did not verify the accuracy of the initial weight or ensure that the correct admission weight was used for monitoring the resident's nutritional status. Significant weight fluctuations were recorded for the resident, including a 28.1% weight gain from January to February and a 41.7% weight loss from February to March. These changes were not addressed in a timely manner by the nursing staff or the dietician. The dietician did not document any actions taken to address the significant weight gain until 14 days after it was recorded, and a re-weight was not obtained until 21 days later. Similarly, the significant weight loss was not acknowledged or addressed promptly, with a re-weight only obtained 8 days after the initial recording. Further weight loss was recorded in April and June, with no evidence of timely intervention or re-weight requests by the dietician. The dietician confirmed during interviews that the significant weight changes were not addressed or documented appropriately, and re-weights were not requested or obtained in a timely manner. This lack of timely response and documentation led to the failure in maintaining the resident's nutritional status.
Failure in Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R71, consistent with professional standards of practice. The resident, who was admitted with diagnoses including low back pain and complications from cardiac and vascular devices, reported not receiving her pain medication, Gabapentin, on the morning of June 17, 2024, and experiencing significant back pain. The physician's order required Gabapentin to be administered three times daily at specific times. However, the Medication Administration Records indicated that the medication was not given as prescribed and was administered more than one hour after the scheduled time. A licensed nurse, identified as Employee E7, confirmed the delay, citing being short-staffed as the reason for not administering the medication on time.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident diagnosed with End-Stage Renal Disease, who was admitted to the facility and required regular dialysis treatment. The physician's order specified that the resident should receive dialysis treatment in the facility from Monday through Friday. However, a review of the resident's Hemodialysis Communication Record from May 24, 2024, through June 14, 2024, revealed missing information on the resident's pre-weight before going to dialysis. The top part of each communication record indicated that it was for nursing home use only prior to dialysis. An interview with the Director of Nursing confirmed that it was the nursing staff's responsibility to complete the paperwork for residents before they went to dialysis.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident who expressed a desire to die. The resident, identified as R606, had a medical history that included an aortic aneurism, hypertension, epilepsy, and glaucoma. On May 28, 2024, the resident experienced chest pain and was administered Nitrostat, which did not alleviate the pain. When Emergency Medical Services arrived, the resident refused to go to the hospital and expressed a wish to die. Despite this significant statement, there was no evidence in the clinical records that the nursing staff assessed the resident's mental state or explored the reasons behind her statement. Additionally, there was no documentation indicating that the resident was referred for psychiatric or counseling services to address potential behavioral health needs. The resident was seen by a nurse practitioner the following day, but there was no documentation that the nurse practitioner was informed of the resident's statement about wanting to die. The progress notes from the nurse practitioner only mentioned the resident's chest pain and her refusal for further testing, without addressing the behavioral health concern. During an interview with the Unit Manager, it was confirmed that there was no documentation of an assessment or referral for behavioral health services following the resident's concerning statement. This lack of action and documentation represents a deficiency in the facility's provision of necessary behavioral health care and services.
Significant Medication Error Due to Distraction
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving Resident R174. The resident, who was diagnosed with Diabetes Mellitus, high blood pressure, and unspecified intellectual disabilities, was mistakenly given her roommate's medications. This error occurred despite the facility's policy requiring the verification of the five rights of medication administration: right resident, right time and frequency, right dose, right route, and right drug. On the day of the incident, Resident R174 received her prescribed dose of metformin and, two hours later, was erroneously administered her roommate's medications, including glipizide, which is also used to treat high blood sugar levels. The error was identified when the resident began feeling light-headed and dizzy, prompting a nurse practitioner to order her transfer to the emergency room. Upon arrival, her blood glucose level was found to be 67 mg/dL, which is below the normal fasting range. The resident was admitted to the ICU for close monitoring of her blood glucose levels, which remained stable, allowing her to be downgraded to a medical/surgical floor before being discharged back to the facility. The LPN responsible for the error admitted to being distracted during medication administration, which led to the mistake.
Inaccurate Documentation of Resident's Post-Dialysis Condition
Penalty
Summary
The facility failed to ensure complete and accurate clinical records for a resident, identified as R98, who had a medical history of diabetes, hypertension, and dependence on renal dialysis. The deficiency was identified through interviews and clinical record reviews, which revealed discrepancies in the documentation of the resident's condition post-dialysis. Specifically, on three consecutive days, a licensed nurse, Employee E12, documented that the resident returned from in-house dialysis with hypotension and a change in mental status. However, there was no additional information, monitoring, or physician notification related to these documented changes in the resident's health status. Further investigation, including interviews with the 4th floor Unit Manager and the dialysis nurse, revealed that the resident completed dialysis treatments on those days without any reported changes in blood pressure or mental status. The Unit Manager and dialysis nurse both confirmed that there were no concerns with the resident's condition, contradicting the documentation by Employee E12. The facility was unable to provide an explanation for the inaccurate documentation, leading to the identification of this deficiency.
Pest Control and Laundry Deficiencies
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple reports of roach activity in the main kitchen and laundry areas. Initial pest control reports indicated significant roach activity behind the wall covering by the steamers in the kitchen, with recommendations for a clean-out. However, the administration opted for conventional treatments first, delaying the recommended clean-out until several months later. Observations revealed that the kitchen's door sweep was not completely sealed, allowing pests easy access, and a live cockroach was seen behind the steam tables. In addition to the issues in the kitchen and laundry, the facility also failed to address bedbug activity in a resident's room promptly. The pest control management service identified bedbugs during a routine inspection, but the initial treatment was delayed until the sighting was confirmed. This delay resulted in multiple treatments over several weeks, with live bedbug activity still observed during subsequent inspections. The administrator was unaware of the original sighting, contributing to the delay in treatment. Furthermore, the facility's laundry services were found to be inadequate, as contaminated textiles and fabrics were not properly bagged. During a tour of the laundry room, it was observed that laundry from the chute was loose and unwrapped, which was confirmed by the maintenance director. This failure to properly contain contaminated laundry could contribute to the spread of pests and other microorganisms within the facility.
Failure to Maintain Clean Environment on Third Floor
Penalty
Summary
The facility failed to provide a clean and homelike environment on the Third Floor Nursing Unit, specifically in the area designated as 3-North. During an observation on May 16, 2024, at approximately 11:00 a.m., a strong odor of urine was detected near a specific room. A follow-up observation conducted later that day at 2:10 p.m., with the Nursing Home Administrator present, confirmed that the strong urine odor was still noticeable in the same area. The Nursing Home Administrator acknowledged the presence of the odor, indicating a deficiency in maintaining a clean and comfortable environment for residents.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to properly document and resolve a grievance reported by a resident and their representative. The grievance involved the resident not receiving the appropriate diet, specifically not being provided with food that was easy to chew and not receiving the ordered double portions. Despite the resident and their representative reporting these concerns multiple times to the facility staff, the issues were not resolved, nor was there any documented response from the facility. Interviews with the facility administrator and a nursing unit coordinator confirmed that the grievance was not documented, and the facility only initiated written grievances when issues could not be addressed quickly. Additionally, the facility's grievance policy was found to be lacking in required components. The policy did not include procedures for tracking all grievances, documenting grievance decisions, or providing summary statements of all grievances. The administrator confirmed that the existing policy was the only one available related to the grievance process, indicating a systemic issue in handling grievances. This deficiency was identified during a review of clinical records, facility documentation, and interviews with residents and staff.
Failure to Report Alleged Resident Neglect
Penalty
Summary
The facility failed to report alleged violations of resident neglect to the State Survey Agency as required. The facility's policy mandates that all alleged violations involving mistreatment, neglect, or abuse must be reported to the Department of Health and other relevant agencies. However, in the cases of two residents, this protocol was not followed. Resident R1 reported that a nurse aide did not assist her while she was in the bathroom, and her call bell was not answered in a timely manner. The resident's representative confirmed that staff did not provide care and that she had to come to the facility in the middle of the night to assist the resident. Similarly, Resident R2's daughter expressed concerns about the care provided, including dissatisfaction with weekend care, call bell response time, and the presence of male staff. The social worker and dietician documented the family's dissatisfaction with the overnight care, and the family decided to take the resident home. Despite these grievances, the facility did not report the allegations to the State Survey Agency, as confirmed by the Nursing Home Administrator.
Incomplete Investigation of Resident Care Concerns
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of improper resident care for one resident. The deficiency was identified through a review of clinical records, facility policies, and staff interviews. The facility's policy on abuse prevention and reporting requires immediate investigation of all claims, including obtaining written statements from residents or their representatives, and conducting interviews with all relevant staff. However, in this case, there was no documented evidence that the facility obtained written statements from the resident or their representative regarding the specifics of the allegations. Additionally, the investigation included only four staff interviews and one supervisor statement, despite there being eight nurses' aides and multiple LPNs working on the unit during the relevant time period. The deficiency was further highlighted by the grievance filed by the resident's daughter, who reported concerns about the care provided, including dissatisfaction with weekend care, call bell response time, and the presence of male staff in the resident's room. The social worker's statement confirmed that the family was unhappy with the care provided during specific shifts, and the dietician's statement indicated that the family intended to take the resident home due to dissatisfaction with overnight care. The Director of Nursing confirmed that the facility did not obtain witness statements from all staff who worked on the unit, which is a requirement under the facility's policy and state regulations.
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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