Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ivy Hill Post Acute Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia with behavioral disturbance, and an anxiety disorder had an active order and care plan interventions for lorazepam (Ativan) gel to be given TID for generalized anxiety. During observation, an RN/LPN confirmed the order but reported the medication was on hold and could not locate it in the med cart. Review of treatment records over two months showed numerous missed doses documented as not available or on hold, despite standing instructions to call the pharmacy every 30 days for delivery. The DON reported the family paid out of pocket for the medication, acknowledged discrepancies in timely refills and intermittent signing by nursing staff, and could not identify when the medication was last obtained and administered.
Survey results were not readily accessible to residents and visitors on three of three nursing floors. Residents reported that only a sign at the front desk indicated survey results were available upon request, while the binder had to be requested. During tour, staff stated the binder was kept on the first floor and observation showed the posted sign was not at a wheelchair-accessible level; the binder was located in the Administrator's office.
Unsafe and Unclean Environment with Inadequate Linen Supply: A broken front door repeatedly stuck to the floor and had to be propped open, while residents and the DON confirmed multiple environmental issues including dirty privacy curtains, missing drawer and closet handles, incomplete wall repairs, and other damaged room fixtures. Residents also reported shortages of clean linens and towels, and observations found limited linen supplies in the laundry area and on the 2nd and 3rd floor unit carts for the resident census.
A resident with Cerebral Palsy and Acute Respiratory Failure had conflicting code status documentation in the chart: physician orders listed Full Code, while the POLST was marked DNR and signed by the resident. The resident stated a wish to be DNR if the heart stops beating, and an LPN said the resident was Full Code based on the EMR until shown the POLST, which she then confirmed indicated DNR. The DON confirmed the resident should have been DNR.
The facility failed to complete quarterly MDS assessments within the required 7-day timeframe for two residents. An RN in Extended Care confirmed the assessments were late and attributed the delay to high staff turnover.
Failure to Coordinate PASARR Level II Services: A resident with schizophrenia, legal blindness, and atrophy was identified for PASARR Level II review and qualified for additional services, but the facility did not document coordination with the Office of Long-Term Living or show that the recommended services were obtained, coordinated, or provided. A mental health counselor reported sessions were limited to redirection and minimal communication, and the DON confirmed there was no evidence of PASARR-related service coordination or care plan implementation.
A resident who did not speak English had a care plan calling for a communication board at the bedside at all times, but surveyors found no board in the room and no evidence of an interpreter line. Staff could not identify the resident’s language, and a nurse said the language was unknown. Later, when a UM used the communication board, the resident was able to review the pictures and agree to reschedule a cardiology appointment.
Missing Treatment Order for Left Foot Pressure Wound: A resident with cerebral infarction and a brain bleed had a stage 3 pressure wound on the left dorsal foot with a documented dressing plan, but no physician order or TAR entry was found for that wound. During wound care observation, the resident received treatment for other wounds, but the left foot wound was not treated, and the RN and unit manager confirmed there was no order for it.
Enteral feedings were not administered and monitored according to professional standards for one resident with a PEG tube. The resident had a hx of stroke, dysphagia, muscle wasting, and HTN, and was observed receiving tube feeding with a feeding bag that was not labeled with the start time, feed rate, or the nurse’s initials.
An open vial of Tubersol was found in the Unit 2 med room refrigerator without an open date, so staff could not determine its discard date. An LPN confirmed the vial should have been dated when opened to allow proper disposal after 30 days.
Unqualified Food Service Director: The FSD was responsible for oversight of food ordering, receiving, storage, preparation, and service, but was not a CDM, CFM, nationally certified in food service management and safety, or educated in food service management or hospitality. She also did not receive frequently scheduled consultations from a qualified dietitian, and the NHA acknowledged she did not meet the required qualifications for operational oversight of the dietary department.
The facility assessment did not show involvement from direct care staff, resident representatives, or family members when determining resources needed for resident care. Review of the assessment found no indication that these individuals were included, and the DON confirmed their input was not part of the process.
The facility failed to provide a safe and homelike environment, with residents lacking access to locked drawers for personal belongings and experiencing maintenance issues like broken beds and heating units. Observations revealed unmaintained windowsills, thick dust, and soiled ceiling tiles, confirmed by the Maintenance Director and resident council.
A resident with a history of bipolar disorder and moderate cognitive impairment engaged in inappropriate sexual behaviors towards other residents, despite being on one-to-one supervision. The facility failed to adequately supervise the resident and document incidents, resulting in a deficiency in resident safety and care.
The facility failed to conduct criminal background checks for two volunteers and did not implement its abuse policy, resulting in unreported incidents involving a resident with a history of inappropriate sexual behavior. Despite staff reports, the administration was unaware of these incidents, highlighting a lapse in policy enforcement and resident protection.
The facility did not update the PASRR applications to include new mental health diagnoses for three residents. A resident's PASRR did not reflect a mental disorder and anxiety disorder obtained after the initial assessment. Another resident's PASRR failed to include a mood disorder diagnosed later, and a third resident's PASRR did not update a schizophrenia diagnosis. The social worker confirmed that updates were not made unless residents were targets for level 2, violating resident care policies.
The facility did not provide required training on abuse, neglect, and exploitation to two volunteers, despite policy mandates for all staff, including volunteers, to receive such training. Interviews confirmed that the volunteer Pastor and his wife, who have been conducting religious activities at the facility for years, were not trained, and the Human Services Director was not responsible for volunteer training.
A resident, who is a retired pharmacist, was not assessed by the interdisciplinary care team for the ability to self-administer medications, despite expressing interest and being cognitively intact. The facility's policy requires such an assessment to ensure safety and resident rights, but no care plan was developed, leading to a deficiency.
The facility failed to document and resolve grievances related to missing personal belongings for residents. A resident reported missing money, and another resident's family reported missing clothing, both of which were not properly documented or resolved. The facility did not provide a locked drawer for personal items as promised and failed to communicate the grievance process effectively. Staff confirmed the lack of a clear process for tracking clothing when families handled laundry, contributing to unresolved grievances.
The facility failed to assess and document the use of restraints for two residents. One resident was found with a locked seatbelt in a wheelchair without a physician's order, and another had their bed against the wall, restricting movement, without proper assessment or care planning. These actions indicate a lack of proper evaluation and documentation regarding restraint use.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing their specific needs. A resident with a history of substance-seeking behavior experienced an overdose, and the care plan was not promptly revised. Another resident, who was incontinent and required assistance, lacked a toileting care plan. Additionally, a cognitively intact resident wishing to self-administer medications did not have a care plan to support this request.
A resident with a history of Traumatic Brain Injury and other conditions was found self-administering medications without proper authorization, due to concerns about missed doses. The facility's policy requires licensed staff to administer medications, but the resident stored pills in a bedside container, leading to a deficiency in supervision.
A resident with severe cognitive impairment was not provided with necessary postural support during meals, leading to unsafe positioning. The resident was only assessed for adapted equipment after a delay. Additionally, the facility failed to collect adequate biochemical data to assess the resident's nutritional status, despite a diagnosis of hypothyroidism and a prescription for Levothyroxine.
A facility failed to provide respiratory care according to professional standards for a resident with sepsis, COPD, and hypertension. The resident was observed receiving oxygen without a physician's order, and the oxygen tubing was not dated. Staff interviews confirmed these deficiencies, indicating non-compliance with the facility's oxygen therapy policy.
A resident with low back pain and opioid dependency did not receive accurate pain level assessments as required by physician orders. Despite being prescribed Oxycodone, the MAR showed no documented pain levels for March, and staff interviews confirmed the assessments were not completed. The resident reported severe pain, and the DON acknowledged the lapse in nursing services.
A facility failed to provide trauma-informed care for a resident with PTSD, as required by their policy. The resident, with a history of sexual trauma and aggressive behavior, was not assessed or treated for PTSD, despite being admitted to a psychiatric hospital for related issues. The Director of Nursing confirmed the oversight, acknowledging the absence of PTSD in the resident's care plan.
The facility failed to follow pharmacy recommendations for two residents' medication regimens. A resident on Atorvastatin did not receive recommended lipid studies, and another on Midodrine lacked a blood pressure limit in their order. The DON confirmed these oversights.
A facility failed to document the rationale and duration for a PRN order of Lorazepam for a resident, as required by regulations. The order was indefinite, and the clinical record lacked documentation from the prescribing practitioner. This deficiency was identified during a review of clinical records and staff interviews.
A resident with renal failure and traumatic brain injury, requiring medications via peg-tube, received them orally due to a nurse's misunderstanding. The nurse, instructed during a morning meeting, administered medications orally, contrary to physician orders. The DON confirmed the error, highlighting a significant medication administration issue.
A facility failed to timely update a resident's care plan to reflect a change in code status from full code to DNR/DNI, resulting in a discrepancy between the care plan and physician orders. The resident had a complex medical history and the change occurred during hospitalization. Difficulty in contacting the resident's out-of-country representative delayed confirmation of the code status, and a temporary verbal agreement was made until a signed POLST form could be obtained.
A resident with a language barrier was unable to communicate his needs for assistance with daily activities due to the facility's failure to assess and provide appropriate communication support. The care plan noted the language issue but lacked measures for interpreter services, and there were no documented family contacts. The Speech/Language Pathologist confirmed the lack of assessment and use of assistive devices to evaluate the resident's communication abilities.
A facility failed to follow a physician's order for a resident's tube feeding. The resident was prescribed Jevity 1.5 via PEG tube, 237 ml bolus, six times a day, but a nurse administered an extra half container due to the resident's complaints of hunger. The dietician was unaware of this additional feeding, which was not reflected in the resident's care plan or caloric intake calculations.
A resident's need for corrective lenses was not addressed after their glasses were broken during an argument. Despite the facility's policy requiring immediate notification to the vision service provider for repairs, no documentation was found indicating such action was taken. The resident was observed without glasses and unable to read a picture board, confirming the lack of corrective lenses since the incident.
A resident with decreased functional abilities did not receive necessary physical therapy services due to being classified as custodial care, despite a physical therapy evaluation indicating a need for skilled services. The facility did not inform the resident or their family about the lack of services or provide options for receiving them.
A resident with a complex medical history, including Guillain-Barre Syndrome and hyponatremia, was placed on a 1200 ml daily fluid restriction. Despite recommendations for lab monitoring, no lab work was conducted since admission, leading to a deficiency in care. The issue was confirmed by the DON, highlighting a significant oversight in the resident's care plan.
A resident with a history of mental health issues, including major depressive disorder and previous suicide attempts, was not provided with necessary behavioral health services at the facility. Despite repeated requests for non-pharmacological support, such as a grief support group, the facility did not arrange these services. Clinical notes and interviews revealed the resident's ongoing struggles with depression, self-harm, and aggression, yet the facility failed to demonstrate efforts to provide the requested support.
The facility failed to properly store and label medications in two medication rooms. An opened tube of Santyl Collagenase was found unlabeled in a treatment cart on the second floor, and an opened vial of Tuberculin lacked a date opened in the third-floor medication room. Staff confirmed these deficiencies, indicating non-compliance with storage and labeling policies.
A resident experienced significant weight loss and difficulty eating due to unresolved dental issues. Despite evaluations by an outside dental group recommending extractions and dentures, the procedures were not completed, and no schedule was documented. The resident's diet was supplemented with soft foods, but the lack of dental care persisted.
A facility failed to maintain proper infection control during tube feeding and medication administration. A nurse provided tube feeding with only one gloved hand and placed equipment on a dirty table. Another nurse handled medications without changing gloves or sanitizing hands, and stacked medication cups improperly, risking contamination.
The facility failed to maintain mechanical dietary equipment in safe operating condition. The dish machine was not dispensing sanitizer during the final rinse cycle due to malfunctioning equipment, preventing proper cleaning and sanitizing of kitchenware. Additionally, the three-compartment sink operation was compromised as staff were unable to test sanitizer concentration due to a malfunctioning device, resulting in insufficient sanitization levels. Interviews confirmed the issues with the equipment.
Failure to Ensure Availability and Administration of Ordered Antianxiety Medication
Penalty
Summary
The facility failed to ensure that an ordered antianxiety medication (lorazepam gel/Ativan gel) was available and administered as prescribed for one resident. The resident had multiple diagnoses including COPD, depression, dementia with behavioral disturbance, anxiety disorder, hypomagnesemia, and dysphagia, and was care planned for verbal/physical agitation, resistiveness to care, and behavioral symptoms related to dementia and anxiety. The care plan interventions included administering medications per physician orders, specifically Depakote, lorazepam, and Rexulti. The resident had an active order for lorazepam gel 0.5 mg/ml, 1 ml topically three times daily for generalized anxiety disorder. During an observation, the resident, who had a BIMS score of 0 indicating severe cognitive impairment, was in bed requesting potato chips. After receiving chips, the resident refused an oral medication despite the nurse’s third attempt. When asked about the lorazepam gel order, the nurse confirmed the order existed but stated it was on hold and was unaware of the reason. The nurse checked the medication cart and there was no lorazepam gel available. Record review showed a current order with instructions that the pharmacy should be called every 30 days for Ativan gel, that the pharmacy would deliver to the facility, and that the medication should not be signed out unless the facility called. The Treatment Administration Records for March showed 71 possible administrations of Ativan gel, with 28 entries marked as NA (Not Available) and 4 entries marked as 5 (Hold/see nurses notes). For February, there were 84 possible administrations, with 24 entries marked NA and 15 entries marked as 5 (Hold/see nurses notes). The DON reported that the resident’s family had been paying out of pocket for the Ativan gel because it was not covered by insurance, confirmed discrepancies with the medication not being filled timely and being signed out intermittently by nursing staff, and stated that any nurse could call for a refill when the medication was not available. The DON also confirmed that the last date the medication was obtained and administered to the resident was unknown.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the most recent Department of Health survey results were readily accessible to residents and visitors on three of three nursing floors. During a Resident Council meeting, five alert and oriented residents reported that the facility had a sign at the front desk stating survey results were available upon request, but the survey binder itself was not readily accessible and had to be requested. During a facility tour with the Administrator, staff stated that the survey binder was located only on the first floor and was available upon request. Observation showed a sleeve displaying the sign "Survey results are available upon request," but it was not positioned at a wheelchair-accessible level. The binder containing the survey results was located in the Administrator's office.
Unsafe and Unclean Environment with Inadequate Linen Supply
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment on the 2nd and 3rd floor nursing units. Observations and interviews identified a front door that stuck to the floor and required force to operate, with the receptionist confirming it was broken and not functioning properly. A resident reported that the facility did not have enough clean linens and towels available, and another resident stated that housekeeping had been notified about a brown spot on the wall near the room railing that had not been cleaned for several months. During observation with the Administrator, multiple environmental concerns were confirmed, including a dirty privacy curtain with gray dust stripes, a bedside drawer without a lock, missing drawer and closet handles, a broken wall clock, spider webs on window seals, a hanging sink pipe cover, and a patched wall that had not been painted. Additional observations showed similar conditions in other resident rooms, including missing closet and dresser handles, a missing drawer, and incomplete repairs. The front door remained nonfunctional on later observations, with the door propped open and activating the alarm. During a resident council meeting, residents reported that the facility did not have enough linens, including washcloths, towels, fitted sheets, and flat sheets, especially on the 2nd and 3rd floors. A laundry observation showed limited clean linen items available in the laundry area and in unit linen carts, and the 2nd and 3rd floor units were found to have inadequate supplies of washcloths, towels, fitted sheets, and flat sheets for the resident census on those units.
Advance Directive Not Accurately Documented
Penalty
Summary
The facility failed to ensure that one resident’s advance directives were accurately documented in the clinical record. Resident R110 was admitted with diagnoses including Cerebral Palsy and Acute Respiratory Failure. The resident’s physician orders dated December 29, 2025, listed Full Code, indicating a wish to receive all life-saving interventions in the event of cardiac or respiratory arrest. However, the resident’s Pennsylvania Orders for Life Sustaining Treatment (POLST) showed that cardio DNR/do not attempt resuscitation (allow natural death) was marked and signed by the resident. During interview, the resident stated a wish to be DNR if the heart stops beating. A nurse stated the resident was Full Code and said she would follow the Full Code status in the electronic medical record during a code, but after being shown the POLST, confirmed the resident was DNR per POLST. The DON later confirmed the resident should have been DNR and that the facility had corrected the error.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to complete and transmit MDS assessments within the required 7-day timeframe for 2 of 28 residents reviewed, including Resident R65 and Resident R76. Review of Resident R65’s quarterly MDS showed it was initiated on November 1, 2025 and completed on November 14, 2025. Review of Resident R76’s quarterly MDS showed it was initiated on October 31, 2025 and completed on November 14, 2025. During an interview on March 11, 2026, the Registered Nurse in Extended Care who was responsible for initiating, reviewing, and validating MDS assessments confirmed that the quarterly MDS assessments for both residents were not completed within the required timeframe due to a high turnover rate of staff.
Failure to Coordinate PASARR Level II Services
Penalty
Summary
The facility failed to incorporate the recommendations from the PASARR Level II determination and PASRR evaluation report into the assessment, care plan, and transitions of care for one resident. The resident was admitted with diagnoses including schizophrenia, legal blindness, and atrophy. Review of the PASARR screening dated July 16, 2024, showed the resident required a Level II evaluation, and a determination letter dated July 18, 2023, stated the resident qualified for additional services. The clinical record contained no documented evidence that the facility coordinated with the Office of Long-Term Living to ensure delivery of the PASARR Level II recommended services or that those services were obtained, coordinated, or provided. A mental health counselor stated she was unable to complete full sessions with the resident and that sessions were limited to redirection with minimal communication, with the longest session lasting about 17 minutes and interrupted. The DON confirmed the resident was identified through PASARR Level II, but the facility could not provide evidence of coordination of services or care plan implementation related to the PASARR recommendations.
Communication Board Not Available for Non-English-Speaking Resident
Penalty
Summary
The facility failed to ensure that a communication board was available for a resident who did not speak English and whose care plan identified a communication board at the bedside at all times. The resident’s clinical record showed an admission date of February 29, 2012, and the comprehensive care plan dated August 30, 2023, listed the communication device as a communication board at the bedside at all times. However, the record did not identify the language the resident spoke, and during observation on March 9, 2026, the resident was unable to speak English and stated Mandarin and Cambodian when asked what language was spoken. The resident then began speaking in another language when asked about concerns, and there was no evidence of an interpreter line or communication board in the room. Interviews confirmed the communication board was not available at the bedside when surveyed. A licensed nurse stated the resident’s language was unknown and said, "I have seen it" when asked about the communication board. The Rehabilitation Director later searched the bedside table, closet, and dresser with the resident’s permission and found no communication board present. During a later interview, the Unit Manager brought a communication board to the resident, and the resident was observed holding and reviewing the pictures. The resident also had a progress note indicating refusal to attend a cardiology appointment, and when asked without the board whether the resident would agree to reschedule, the resident shook his head no; when the surveyor used the communication board, the resident agreed to attend the appointment.
Missing Treatment Order for Left Foot Pressure Wound
Penalty
Summary
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals occurred for a resident with skin impairment. Resident R145 was admitted with diagnoses including cerebral infarction and nontraumatic intracerebral hemorrhage. The resident’s Wound Evaluation and Management Summary dated March 4, 2026, documented a stage 3 pressure wound on the left dorsal foot measuring 1.5 x 0.5 x 0.1 cm, with a care goal to decrease wound area, maintain skin integrity, and prevent infection. The dressing treatment plan listed a primary dressing of skin prep to be applied once daily and as needed if saturated, soiled, or dislodged for 9 days. Review of the physician orders showed no treatment order for the wound on the dorsal area of the left foot, and the TAR for March 2026 also showed no treatment for that wound. During wound care observation on March 18, 2026, the resident received treatment for the sacral wound, right shin wound, and left heel wound, but no treatment was performed for the wound on the dorsal area of the left foot. The licensed nurse and unit manager confirmed at the time of observation that the treatment was not done, and the unit manager further confirmed that there was no order for treatment for that wound.
Enteral Feeding Bag Not Properly Labeled
Penalty
Summary
Enteral feedings were not administered and monitored according to professional standards of practice for Resident R135, specifically related to labeling. The resident was admitted with diagnoses including cerebral infarction (stroke), muscle wasting, dysphagia, and hypertension, and had a physician order dated February 3, 2026 for Glucerna 1.5 at 60 mL/hour via PEG tube, with the feeding to be up at 5:00 p.m. and down at 3:00 p.m. for a total volume of 1300 mL and 1980 kcal. During an observation on March 9, 2026 at 10:17 a.m. with an LPN, the resident was observed in bed receiving enteral feeding, and the feeding bag was not labeled with the time of initiation, the rate of the feed, or the initials of the nurse administering the feed.
Undated Open Tubersol Vial in Unit 2 Medication Room
Penalty
Summary
The facility failed to ensure medications were properly dated when opened in one of two medication rooms, specifically the Unit 2 medication room. Review of the manufacturer's recommendations for Tubersol, a medication used for tuberculosis testing, showed that once a vial is opened it should be discarded after 30 days. During observation of the Unit 2 medication room refrigerator on March 09, 2026 at approximately 10:25 a.m., surveyors found an open vial of Tubersol without an open date, so staff could not determine the discard date. At the time of the observation, an LPN confirmed that the Tubersol vial did not have an open date and stated it should have been dated when opened so it could be properly discarded after 30 days.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services. During an interview, the Food Service Director stated that her duties included oversight of ordering, receiving, storing, preparation, and service of food. She also confirmed that she was not a certified dietary manager, certified food manager, or nationally certified in food service management and safety, and that she did not have an associate's or higher degree in food service management or hospitality from an accredited institution. She further stated that she had not received frequently scheduled consultations from a qualified dietitian. Review of the employee's credentials showed that she did not meet the statutory qualifications for a director of food and nutrition services, and the Nursing Home Administrator acknowledged that the Food Service Director did not have the required qualifications to provide operational oversight of the dietary department.
Facility Assessment Lacked Required Input
Penalty
Summary
The facility assessment dated July 28, 2025, did not show that direct care staff, resident representatives, and/or family members were involved in the assessment process. The deficiency was identified during review of the facility assessment and staff interview, which found no indication that the facility included input from direct care staff, residents, resident representatives, and/or family members when determining the resources needed to care for residents competently during day-to-day operations and emergencies. During an interview on March 12, 2026, the DON confirmed that no direct care staff, resident representatives, and/or family members were included in the facility assessment.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed across three nursing units. On multiple occasions, residents were found without access to locked drawers to secure their personal belongings, leading to grievances such as the one filed by a resident regarding missing money. Additionally, the facility did not address maintenance issues, such as broken heating units and beds, which affected residents' comfort and safety. For instance, a resident was observed lying in a fetal position due to a broken bed and non-functional heating unit, which was confirmed by a Certified Nursing Assistant. Further observations revealed significant housekeeping and maintenance lapses, including unmaintained and leaking windowsills, thick dust, dried clumps of patching plaster, and multiple soiled ceiling tiles in resident rooms and common areas like the dining room. These conditions were confirmed by the Maintenance Director, who acknowledged the lack of locked drawers and the presence of soiled ceiling tiles. The resident council meeting also highlighted the absence of locks on drawers, indicating a widespread issue affecting multiple residents.
Failure to Protect Residents from Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to protect three residents from inappropriate sexual behaviors by another resident, leading to a deficiency in resident safety and care. The resident in question, who has a history of bipolar disorder and moderate cognitive impairment, was observed engaging in inappropriate sexual behaviors towards other residents. Despite being placed on one-to-one supervision, the resident was able to move unsupervised throughout the facility, entering other residents' rooms and common areas, and engaging in inappropriate conduct. Interviews with staff and volunteers revealed multiple instances where the resident was caught inappropriately touching other residents, including removing a resident's underwear and touching another resident's breast. These incidents were reported to the facility's management, including the Director of Nursing and Nursing Home Administrator, but there was no documented evidence of these reports in the residents' clinical records. Additionally, the facility's documentation of the resident's whereabouts and supervision was incomplete, with no evidence of regular checks being conducted as required. The facility's failure to adequately supervise the resident and document incidents of inappropriate behavior resulted in a lack of protection for the affected residents. The nursing staff assignments did not explicitly include duties to supervise the resident, and there was no documentation of corrective actions taken to address the resident's behavior. This deficiency highlights a significant lapse in the facility's responsibility to ensure the safety and well-being of its residents.
Failure to Conduct Background Checks and Implement Abuse Policy
Penalty
Summary
The facility failed to perform criminal history background checks for two volunteers, identified as Employees E10 and E11, who had been conducting religious activities at the facility for several years. This oversight was confirmed during interviews with the Human Services Director and the Nursing Home Administrator, who acknowledged that the criminal records for these volunteers were neither conducted nor available for review. This failure to adhere to the facility's policy of screening all employees and volunteers for convictions of abuse represents a significant deficiency in ensuring the safety and protection of residents. Additionally, the facility did not implement its established abuse policy to protect residents from abuse. Resident R44, who has a history of bipolar disorder, HIV, and moderate cognitive impairment, was involved in multiple incidents of inappropriate sexual behavior. Despite a psychology note indicating concerns about Resident R44's hypersexual thoughts and behaviors, and a nursing aide's report of witnessing Resident R44 engaging in inappropriate conduct with another resident, the facility's abuse coordinators were unaware of these reports. This lack of awareness and action by the facility's administration highlights a failure to follow through on the policy requiring immediate reporting and investigation of abuse allegations. The facility's policy mandates that all staff, including management and volunteers, receive training on recognizing, reporting, and preventing abuse. However, the interviews with the Nursing Home Administrator and Director of Nursing revealed a disconnect between the policy and its implementation, as they were unaware of the reported incidents involving Resident R44. This deficiency in communication and enforcement of the abuse policy underscores a critical lapse in the facility's responsibility to protect its residents from abuse and neglect.
Failure to Update PASRR with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that revisions were made to the Pre-Admission Screening and Resident Review (PASRR) applications to include updated mental health diagnoses for three residents. Resident R108's PASRR, completed on January 31, 2024, did not reflect the mental health diagnoses of a mental disorder obtained on May 2, 2024, and an anxiety disorder obtained on April 4, 2024. Similarly, Resident R10's PASRR, completed on February 24, 2023, did not include a mood disorder due to a known physiological condition diagnosed on July 24, 2023, despite already listing schizophrenia and altered mental status. Resident R90's PASRR, completed on October 11, 2024, included a diagnosis of bipolar disorder but failed to update the diagnosis of schizophrenia obtained on October 28, 2024. The facility's social worker, Employee E3, confirmed during an interview that the PASRR forms were not updated for residents unless they were a target for level 2. This oversight resulted in the PASRR forms for Residents R108, R10, and R90 not being updated with their additional mental health diagnoses. The failure to update these forms was a violation of the facility's resident care policies and medical records requirements as outlined in 28 PA Code 211.10 (c) and 28 PA Code 211.5(f)(viii).
Failure to Train Volunteers on Abuse and Neglect
Penalty
Summary
The facility failed to provide required training on abuse, neglect, and exploitation to two volunteer staff members, Employee E10 and Employee E11. According to the facility's policy, all employees, including volunteers, must receive training upon orientation and annually. However, a review of personnel records and interviews revealed that the volunteer Pastor, Employee E10, and his wife, Employee E11, who have been conducting religious activities at the facility for several years, did not receive this training. The Human Services Director, Employee E12, stated she was not responsible for volunteer training, and both the Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2, confirmed that the required training for these volunteers was neither conducted nor available for review.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The interdisciplinary care planning team at the facility failed to assess a resident, identified as Resident R94, for the ability to self-administer medications, which is a right outlined in the facility's policy. The policy mandates that each resident should be evaluated to determine if they can safely manage their own medications. Despite Resident R94 being cognitively intact, having no swallowing issues, and possessing adequate vision and functional upper extremities, the facility did not conduct the necessary assessment to determine if self-administration was clinically appropriate and safe. Resident R94, a retired pharmacist, expressed a desire to self-administer medications and understood the need for a secure storage solution, such as a locked bedside cabinet. However, the facility did not develop a care plan to accommodate this request. An LPN, identified as Employee E24, confirmed that the resident had been requesting to self-administer medications since admission, yet no assessment or care plan was created to address this request, leading to a deficiency in resident rights and care planning.
Failure to Document and Resolve Grievances Related to Missing Personal Belongings
Penalty
Summary
The facility failed to properly document and resolve grievances related to missing personal belongings for residents. One resident reported missing money, and although the facility investigated, they did not issue a refund due to the absence of documentation on the inventory sheet. Additionally, the facility failed to provide a promised locked drawer for the resident's personal items. Another resident's family reported missing clothing, which was not documented on the inventory sheet, and the facility did not provide a written resolution as requested by the resident. The grievance process was not effectively communicated to residents, and there was a lack of documentation and follow-up on grievances. The facility's process for managing residents' personal belongings was inadequate, as evidenced by the lack of proper labeling and inventory documentation. The Social Worker Director and other staff members confirmed that there was no clear process for tracking clothing when families handled the laundry, leading to unresolved grievances. The facility's failure to educate residents and their families about the inventory process and the lack of a consistent method for documenting and resolving grievances contributed to the deficiency. The report highlights the facility's inability to ensure residents' rights to voice grievances without discrimination or reprisal, as required by regulations.
Failure to Assess and Document Use of Restraints
Penalty
Summary
The facility failed to properly identify and assess the use of physical restraints for two residents, leading to deficiencies in care. Resident R108, who was admitted with difficulty in walking and encephalopathy, was observed in a wheelchair with a locked seatbelt that the resident could not release. This restraint was not ordered by a physician, and the unit manager was unaware of the reason for its use. This indicates a lack of proper assessment and documentation regarding the necessity and appropriateness of the restraint. Similarly, Resident R26, who has diabetes mellitus, morbid obesity, and difficulty walking, was found with their bed placed against the wall, restricting their ability to exit the bed from the left side. The resident confirmed that this was not their preference, and there was no physician assessment or care plan addressing the bed's placement. The unit manager suggested the bed's position might be due to space constraints, but this was not documented or assessed as a restraint. These oversights demonstrate a failure to evaluate and document the use of restraints, compromising resident autonomy and safety.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. Resident R30, who had a history of substance-seeking behavior, experienced an overdose requiring Narcan administration. Despite this incident, the care plan was not revised until three days later to address potential substance abuse and related complications. The revised care plan lacked interventions to monitor behavioral changes or signs of drug use after the resident's leave of absence. Resident R36, who was moderately cognitively impaired and incontinent, did not have an individualized care plan for toileting. The resident relied on staff assistance for transfers and toileting hygiene but used an incontinent brief for bowel and bladder episodes. There was no evidence of a prompted toileting program or trial of toileting equipment, such as a bedpan or bedside commode, to address the resident's needs. Resident R94, a cognitively intact individual with no functional limitations, expressed a desire to self-administer medications. Despite being aware of this request, the facility did not develop a care plan to support the resident's self-administration of medications. The resident, a retired pharmacist, understood the need for a secure storage solution for medications but was not provided with a care plan to facilitate this process.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to properly supervise a resident, identified as Resident R57, during medication administration. The facility's policy requires that only licensed or permitted individuals administer medications and that medications should never be left unattended in a resident's room. However, Resident R57, who was admitted with a diagnosis of Traumatic Brain Injury, Hypokalemia, Hypertension, Depression, and Anxiety, was found to be self-administering medications without an order in place. The resident's comprehensive care plan indicated a risk for self-harm and harm to others, yet there was no documented evidence of an order allowing self-administration of medications. During an interview, Resident R57 expressed concerns about not receiving medications on time and admitted to storing medications in a bedside container to self-administer when doses were missed. Observations confirmed the presence of multiple pills in a container at the resident's bedside, which were later identified and counted by staff. The pills included Hydrochlorothiazide, Amlodipine, and Potassium Chloride, with a total of 52 pills found. The facility's failure to ensure proper supervision and adherence to medication administration policies led to this deficiency.
Failure to Provide Postural Support and Nutritional Assessment
Penalty
Summary
The facility failed to provide a resident with the necessary devices to optimize posture during dining and did not collect additional nutritional biochemical data related to the resident's nutritional status. The resident, who was severely cognitively impaired, was observed during a meal service sitting in a wheelchair with her head tilted to the side and chin positioned on her chest. The nursing staff confirmed that the resident had not been evaluated for adapted equipment to ensure upright positioning during meals and safe swallowing until March 26, 2025, when she was finally assessed and supplied with a high back wheelchair for postural alignment. Additionally, the facility did not collect adequate biochemical data to assess the resident's nutritional status. The resident had been prescribed Levothyroxine for hypothyroidism since December 29, 2024, but the only available biochemical data was from August 30, 2024, showing a low thyroid-stimulating hormone level, indicative of probable hyperthyroidism. No further nutritional-related biochemical studies were available for review, as confirmed by a licensed practical nurse.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for Resident R23. The resident was readmitted with diagnoses including sepsis, chronic obstructive pulmonary disease, and hypertension. On March 24, 2025, it was observed that Resident R23 was receiving 2 liters of oxygen, but the oxygen tubing was not dated, and there was no physician order for the oxygen administration. Interviews with facility staff confirmed the absence of a physician order and the lack of a date on the oxygen tubing, indicating a failure to adhere to the facility's policy on oxygen therapy.
Failure to Conduct Pain Assessments for Resident
Penalty
Summary
The facility failed to ensure accurate pain level assessments for Resident R30, who was admitted with diagnoses of low back pain and opioid dependency. The resident had physician orders for pain assessments every shift and was prescribed Oxycodone for pain management. Despite these orders, the Medication Administration Report (MAR) for March 2025 showed no documented pain levels, indicating a lack of compliance with the prescribed pain assessment protocol. Interviews with the resident and staff revealed that the pain assessments were not being completed. The resident reported experiencing severe pain, with a level of 9-10, and expressed dissatisfaction with the effectiveness of the pain medication. Staff members, including a licensed unit manager and a licensed nurse, confirmed the absence of pain assessments, with the nurse attributing it to the resident not communicating her pain levels. The Director of Nursing also acknowledged the failure to complete pain assessments, highlighting a significant lapse in nursing services as per 28 Pa Code 211.12(d)(1).
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident diagnosed with PTSD, as required by professional standards and the facility's own policy. The policy mandates that upon admission, residents should be assessed for trauma and PTSD, with a questionnaire used to identify triggers and gather detailed information about traumatic events. However, the clinical record of a resident with a history of sexual trauma and PTSD showed no evidence of such an assessment, education, or treatment for PTSD. This oversight was confirmed by the Director of Nursing, who acknowledged that the resident's PTSD was not included in their care plan. The resident, who was moderately cognitively impaired, had a history of aggressive behavior and was admitted to a psychiatric hospital due to psychosis triggered by PTSD. Despite this, the facility did not incorporate the PTSD diagnosis into the resident's care plan, nor did they provide the necessary behavioral health care and services to address the resident's mental health needs. This lack of appropriate care planning and intervention for the resident's PTSD represents a failure to adhere to the facility's policy and professional standards of practice.
Failure to Implement Pharmacy Recommendations for Medication Regimen
Penalty
Summary
The facility failed to ensure timely adherence to medication regimen reviews for two residents, resulting in deficiencies. Resident R30, diagnosed with atherosclerotic heart disease and cerebral infarction, was prescribed Atorvastatin Calcium. A pharmaceutical review recommended lipid studies, but there was no documented evidence that these were completed. The Director of Nursing confirmed that the recommendations for lipid labs were not followed on two separate occasions. Resident R61, with a diagnosis of necrotizing fasciitis, amputation, and hypotension, had a physician order for Midodrine to manage low blood pressure during dialysis. A pharmacy review recommended including a blood pressure limit in the order, but this was not incorporated into the physician orders from January to March 2025. The Director of Nursing confirmed that the pharmacy's recommendation was not followed, indicating a lapse in implementing necessary medication regimen adjustments.
Failure to Document Rationale and Duration for PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of as-needed anti-anxiety medication for a resident. Specifically, a physician's order for Lorazepam, intended to be given every twelve hours as needed for agitation, was found to have an indefinite end date. The clinical record for the resident did not contain documentation from the attending prescribing practitioner that provided a rationale for the use of the medication or indicated the duration for the PRN order. This oversight was identified during a review of clinical records and staff interviews, highlighting a deficiency in the facility's medication administration regimen for one of the eight residents reviewed.
Significant Medication Error Due to Incorrect Administration Route
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the prescribed route of medication administration. Resident R116, who was admitted with diagnoses including renal failure and traumatic brain injury, is on a therapeutic diet with a feeding tube. The physician's orders for Resident R116 included medications such as Propranolol, Lansoprazole, and a multivitamin to be administered via peg-tube. However, during a medication pass observation, it was noted that a licensed nurse, Employee E21, crushed the pills and administered them orally to the resident, contrary to the physician's orders. Interviews conducted with Resident R116 and Employee E21 revealed that the resident usually received medications orally, and Employee E21 confirmed that she had always administered the medications in this manner, as instructed during a morning meeting. The Director of Nursing, Employee E2, confirmed that the current orders required the medications to be administered via peg-tube. This discrepancy between the physician's orders and the actual administration method constitutes a significant medication error, as the facility did not adhere to the prescribed route of administration.
Failure to Update Care Plan and Code Status
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan in a timely manner for a resident, leading to a discrepancy between the care plan and physician orders regarding the resident's code status. The resident, who had a complex medical history including Meniere's Disease, cancer, hypertension, and other serious conditions, was admitted with a care plan indicating a full code status. However, physician orders documented the resident's code status as DNR/DNI, which was not reflected in the care plan. The discrepancy arose when the resident's code status was changed to DNR/DNI during a hospitalization due to an intracranial hemorrhage. The facility experienced difficulty contacting the resident's representative, who lived out of the country, to confirm the correct code status upon readmission. Eventually, contact was made, and a temporary verbal agreement was reached to maintain the DNR/DNI status until a signed POLST form could be obtained. However, the care plan was not updated to reflect this change, and the POLST form was not current, leading to the deficiency.
Failure to Address Language Barrier for Resident
Penalty
Summary
The facility failed to assess and address the communication needs of a resident, identified as Resident R10, who was unable to articulate his needs for assistance with activities of daily living due to a language barrier. Observations revealed that Resident R10 required help with bathing, dressing, and grooming, and was speaking his native language, Cambodian, which the nursing staff could not understand. The clinical record indicated a care plan noting the resident's language barrier and communication problem, but it lacked measures to provide an interpreter for assessing cognitive ability and quality of life enrichment. Additionally, there were no documented contacts with family or friends for Resident R10. An interview with the Speech/Language Pathologist confirmed the absence of an assessment and the use of assistive devices, such as a language line or interpreter, to evaluate Resident R10's communication abilities in his preferred language. The interdisciplinary care team also failed to determine if the resident wanted an interpreter to communicate with healthcare staff or the doctor.
Failure to Follow Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to ensure that the physician's order related to tube feeding was followed for Resident R14. The physician's order, dated June 9, 2024, specified that Resident R14 was to receive Jevity 1.5 via PEG tube, 237 ml bolus, six times a day, totaling 1422 ml per 24 hours, and was also under an NPO order. However, during an observation on June 10, 2024, it was noted that a licensed nurse, Employee E13, administered more than the prescribed amount by giving an extra half container of Jevity to Resident R14, who complained of hunger. Employee E13 admitted to consistently providing this extra feeding without a change in the physician's order. The dietician, Employee E18, was unaware of the additional feeding and confirmed that the resident's caloric intake was calculated based on the existing physician's orders. Employee E18 stated that any weight changes in Resident R14 would have been attributed to the prescribed feeding regimen, not the unauthorized extra feeding. This lack of communication and adherence to the physician's orders led to a deficiency in the care provided to Resident R14.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices to maintain vision for a resident, identified as Resident R10. According to the facility's policy on vision services, it is the staff's responsibility to assist residents in obtaining necessary vision care and to notify the vision service provider immediately in cases of emergent problems, such as broken or damaged glasses. Resident R10 was evaluated by an optometrist and prescribed corrective lenses on December 12, 2023. However, during a comprehensive quarterly assessment on April 21, 2024, it was noted that the resident required corrective lenses for adequate vision. On June 12, 2024, observations revealed that Resident R10 was not wearing glasses, and the licensed nurse, Employee E6, confirmed that the glasses had been broken since an argument with another resident on April 24, 2024. The resident was observed holding a pair of broken glasses with a cracked frame and a missing left lens, and was unable to read a printed Vietnamese picture board. A review of the clinical records showed no documentation indicating that the vision service provider was notified about the broken glasses. Employee E6 confirmed that the resident had no corrective lenses available since April 24, 2024.
Failure to Provide Necessary Physical Therapy Services
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as Resident R14, who exhibited a new onset of decreased functional abilities. During an observation, it was noted that Resident R14 was unable to fully open his right hand, with fingers remaining in a flexed position. The resident reported not having a splint and not receiving physical or occupational therapy services. A review of the resident's clinical record showed that a significant assessment was conducted, and a physical therapy evaluation dated May 3, 2024, indicated a need for skilled physical therapy services due to decreased strength, mobility, and other functional abilities. However, there was no documented evidence that restorative skilled services were provided to Resident R14. Interviews with facility staff revealed that Resident R14 was not picked up for restorative physical therapy because he was considered to be on custodial care, which the facility would not be reimbursed for. The Rehab Director confirmed that the resident could benefit from restorative physical therapy but was not placed on it due to the custodial care status. Additionally, there was no documented evidence that the resident or their next of kin was informed about the lack of necessary services or provided with options to receive them. The resident's payor source was identified as Medicaid, and there was no documentation supporting the custodial care classification.
Failure to Monitor Labs for Resident on Fluid Restrictions
Penalty
Summary
The facility failed to monitor laboratory results for a resident on fluid restrictions, leading to a deficiency in care. The resident, who was admitted from the hospital, had a complex medical history including Guillain-Barre Syndrome, Myoneural Disorder, and other conditions. The resident was placed on a 1200 ml daily fluid restriction due to a history of hyponatremia, potentially linked to hyperproteinemia from IVIG treatment. Despite dietary progress notes recommending lab monitoring on multiple occasions, there was no evidence that lab work had been conducted since the resident's admission. The deficiency was confirmed during an interview with the Director of Nursing. The resident's clinical records did not indicate whether the continuation of fluid restrictions was necessary, and the lack of lab monitoring could have impacted the resident's health management. The failure to perform necessary lab work and reassess the need for fluid restrictions represents a significant oversight in the resident's care plan.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care services for Resident R82, who has a history of paranoid personality disorder, psychophysiological insomnia, and major depressive disorder. The resident had previously been involuntarily admitted to a psychiatric unit for a suicide attempt. Despite repeated requests for non-pharmacological support, specifically a grief support group, the facility did not arrange for these services. Interviews and clinical notes indicate that the resident expressed a strong desire for group therapy to address unresolved grief and loneliness, which were contributing to her depressive symptoms and passive death wishes. Observations and documentation from the facility's nurse practitioner and social worker highlighted the resident's ongoing struggles with depression, self-harm, and aggression towards others. Despite these documented needs and the resident's clear preference for group therapy, the facility did not provide evidence of attempts to arrange such services or explore alternative options. The unit manager acknowledged the resident's preference for a specific facility for outpatient treatment but failed to demonstrate efforts to provide the requested support. This lack of action resulted in the facility not meeting the resident's behavioral health care needs, as required to ensure her highest practicable physical, mental, and psychosocial well-being.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to professional standards in two medication rooms. During an observation of the second-floor medication room, a treatment cart was found inside the room containing an opened tube of Santyl Collagenase without a label indicating the resident's name. A licensed nurse confirmed the presence of the unlabeled tube and acknowledged that it should have been labeled. In the third-floor medication room, an opened 5 ml vial of Tuberculin, Purified Protein Derivative, was found in the medication refrigerator without a date opened affixed to either the vial or its box. The unit manager confirmed the absence of the date opened on the vial and its packaging. These findings indicate a failure to adhere to the facility's policy on medication storage and labeling, as outlined in the facility's policy and state regulations.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as R36, who was observed refusing to eat due to dental issues. The facility's policy required staff to assist residents in obtaining routine and emergency dental care, but this was not adhered to in the case of R36. Observations revealed that R36 had obvious dental issues, such as cavities or broken teeth, which made it difficult for him to chew harder foods. As a result, softer food alternatives were provided. Despite an evaluation by an outside dental group in March 2024, which recommended extractions and dentures due to periodontal disease, these procedures had not been completed by June 2024. The clinical records for R36 showed a significant weight loss over several months, dropping from 124 pounds to 116 pounds, indicating a 10.8% weight loss. The dietitian's assessment noted that R36 was below his usual and ideal body weight, and a nutritional care plan was implemented to supplement his diet with soft foods and liquid supplements. However, the necessary dental procedures to address his chewing difficulties were not scheduled or documented, as confirmed by the Director of Nursing. This lack of action contributed to the resident's ongoing dental and nutritional issues.
Infection Control Lapses in Tube Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during tube feeding and medication administration. During an observation on the second-floor unit, a licensed nurse was seen providing tube feeding to a resident using a bolus method. The nurse wore a glove only on her right hand while using both hands to handle the feeding equipment, including a large syringe and cups. Additionally, the over-bed table where the feeding equipment and cups were placed was dirty and lacked a clean covering. In another instance, a licensed nurse was observed preparing medication for a resident. The nurse placed a bottle of ophthalmic solution into a medication cup containing oral medications, then removed it and administered the oral medications without changing gloves or sanitizing her hands. The nurse proceeded to administer the ophthalmic solution to the resident's eye without changing gloves or sanitizing hands. Furthermore, during medication administration for another resident, the nurse stacked medication cups on top of each other, causing the bottoms of the cups to touch the medications underneath, before administering them to the resident.
Deficiency in Dietary Equipment Maintenance
Penalty
Summary
The facility failed to maintain all mechanical dietary equipment in safe operating condition, as observed in the food and nutrition department. The dish machine was not dispensing any chemical sanitizer during the final rinse cycle due to a malfunctioning mechanical device and tubing, preventing proper cleaning and sanitizing of dishes, bowls, cups, mugs, utensils, pots, and pans. This was confirmed through observations and interviews with dietary staff, who acknowledged the issue with the dish machine's dispensing mechanics. Additionally, the three-compartment sink operation was compromised as dietary staff were unable to test the sanitizer concentration due to a malfunctioning mechanical device connected to the chemical dispenser unit. The sanitizer used was producing a white foam, and the concentration reported by staff was below the manufacturer's recommended levels for effective cleaning and sanitizing. Interviews with the director of dietary services and dietary aides confirmed the malfunctioning equipment, which hindered the proper sanitization process.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,830 citations issued within 25 miles in the last 12 months — including the 25 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Liberty Center For Rehabilitation And Nursing | 0.9 mi | ★★★★★ | 1 | 0 |
| Wyndmoor Hills Rehabilitation And Nursing Center | 1.4 mi | ★★★★★ | 10 | 0 |
| Accela Rehab And Care Center At Springfield | 1.6 mi | ★★★★★ | 18 | 0 |
| Chestnut Hill Lodge Health And Rehab Ctr | 1.6 mi | ★★★★★ | 18 | 0 |
| Fairview Rehab And Care Center | 1.7 mi | ★★★★★ | 35 | 0 |
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