Kadima Rehabilitation & Nursing At Campbelltown
Inspection history, citations, penalties and survey trends for this long-term care facility in Palmyra, Pennsylvania.
- Location
- 2880 Horseshoe Pike, Palmyra, Pennsylvania 17078
- CMS Provider Number
- 395846
- Inspections on file
- 40
- Latest survey
- March 21, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Campbelltown during CMS and state inspections, most recent first.
Surveyors identified that the facility did not employ a full-time qualified dietitian and also lacked a qualified full-time dietary services manager to oversee food and nutrition services. In an interview, the DON confirmed the absence of both a full-time dietitian and a qualified dietary manager, resulting in noncompliance with regulatory requirements for qualified dietary staff.
Surveyors observed black residue on the floors of multiple rooms and a bathroom, and two residents reported issues with cleanliness and rusty equipment. Housekeeping staff were described as only disposing of trash and not cleaning, resulting in a failure to provide a safe, clean, and comfortable environment.
A resident with a history of CHF and bradycardia was transferred to the hospital for elevated BP, but there was no documentation that the physician or responsible party were notified of the change in condition or transfer, as required by facility policy.
Three residents did not receive their scheduled medications at the times ordered by their physicians, with some medications being administered several hours late and one medication not given with meals as required. The DON and staff delayed medication administration due to staffing issues, as confirmed by the Administrator.
Licensed nursing staff did not receive in-service training or skills competency evaluations, as confirmed by facility records and staff interviews, resulting in a failure to ensure staff had the necessary competencies to meet resident needs.
The facility did not conduct required annual in-service training or skills competency evaluations for nurse aides, as confirmed by the Administrator and review of personnel files.
The facility did not have a certified dietary manager or a full-time qualified dietitian on staff, and there were no regularly scheduled consultations with a qualified dietitian in the absence of a certified dietary manager, as confirmed by staff interviews.
Surveyors found unsanitary conditions in food storage, preparation, and service areas, including debris, flies, leaking equipment, improper food storage, soiled surfaces, and improper glove use by dietary staff. Food items were undated, past use-by dates, or improperly stored, and sanitizer testing was not properly documented or performed. These deficiencies resulted in food not being stored or served in accordance with professional standards.
The Quality Assurance Committee did not meet quarterly as required, with no documentation of meetings since January 2024, as confirmed by the Administrator.
Staff did not follow infection control policies requiring Enhanced Barrier Precautions for residents with wounds or indwelling devices, as PPE was not used during high-contact care activities and no signage or PPE was available. Additionally, the facility lacked a documented water management program for Legionella, with no evidence of water testing, potentially affecting all residents.
Flies were observed in the kitchen's dishwashing and food preparation areas, as well as in multiple locations on the nursing unit, including resident rooms, the nurses station, the resident shower room, and near the food cart holding meal trays. The facility did not maintain an effective pest control program to prevent or address these pest issues.
A resident who required staff assistance for transfers was unable to get out of bed due to insufficient staffing, as confirmed by both the resident's account and a lack of documentation of the transfer. Facility staffing records showed that required nurse aide, LPN, and RN ratios, as well as minimum direct care hours per resident, were not met.
The facility did not act promptly on resident grievances, as required by its policy, with multiple residents reporting delays and a review of grievance forms showing no evidence of timely review, investigation, or written decisions provided to residents. The Administrator confirmed that grievances were not addressed.
The facility did not provide written notification about bed hold policies, transfer details, or Ombudsman information to residents and their representatives when several residents were transferred to the hospital after a change in condition. This deficiency was confirmed through clinical record review and staff interview, with no documentation found for any of the affected residents.
The facility did not consistently monitor or assess the nutritional status of several residents at risk for malnutrition, including those with diabetes, feeding difficulties, pressure ulcers, and end stage renal disease. Required weight checks and evaluations by a dietitian or qualified nutrition professional were not documented as completed, despite physician orders and facility policy.
Two residents requiring hemodialysis did not receive care consistent with professional standards, as staff failed to complete required communication with the dialysis provider, did not consistently monitor and document access sites each shift, and missed documentation of post-dialysis weights, contrary to facility policy and physician orders.
Pharmacy recommendations for medication regimen changes were not reviewed or addressed by a physician in a timely manner for four residents with complex medical conditions, despite facility policy requiring monthly pharmacist reviews and physician follow-up. The Administrator confirmed the absence of documentation showing that these recommendations were acted upon.
The facility did not consistently assess, document, or provide physician-ordered wound care for multiple residents with pressure ulcers and other wounds. Several residents with complex medical conditions, including pressure ulcers, lymphedema, and osteomyelitis, had missing documentation of wound treatments and weekly skin assessments, and some reported that wound care was not provided as ordered. Staff interviews confirmed the lack of evidence for completed treatments and assessments, resulting in a deficiency related to nursing services.
The facility did not ensure that food was served at a palatable and appetizing temperature, as required. A test tray audit found mixed vegetables served below the required temperature, and two residents reported that their food was cold. The Director of dining confirmed that hot foods should be served at 135-140°F, but this standard was not met.
A resident with severe intellectual disabilities, anxiety, and lack of coordination was observed using a wheelchair seat belt that could not be self-removed. Staff confirmed the resident's inability to remove the restraint, but there was no documentation of a physician's order, rationale, or required assessments for the restraint, nor evidence of a care plan or monthly reevaluations as per facility policy.
A resident with end stage renal disease, diabetes, and a physician's order for dialysis three times per week was not accurately assessed in the MDS, as the assessment failed to indicate dependence on renal dialysis. This inaccuracy was confirmed by the Administrator.
A resident admitted with several mental health diagnoses, such as borderline personality disorder and schizoaffective disorder, did not have evidence of a completed or obtained PASARR screening in their clinical record. The Administrator confirmed the lack of required documentation during staff interview.
A resident with significant physical limitations did not receive timely assistance with nail care or eating. The resident was observed with long, dirty nails despite expressing a preference for short nails and not refusing care. During a meal, the resident struggled to use adaptive utensils and did not receive staff assistance for over half an hour, contrary to care plan and physician orders.
Two residents with indwelling urinary catheters did not receive or have documented catheter care as required by facility policy, including perineal care and maintenance of the catheter and collection bag. One resident continued to have a foley catheter after the discontinuation of a care order without a new order in place, and another was observed with a catheter in place over several days without evidence of required care being provided or documented.
Staff did not follow physician orders for PRN oxycodone administration for a resident with pain management needs, giving the medication at pain levels below the ordered threshold and without attempting required nonpharmacological interventions.
Medications, including a tube of medicated cream and two bottles of nasal medications, were found unsecured in the rooms of two residents without any documented assessment for self-administration or bedside storage. This resulted in a failure to store drugs and biologicals in locked compartments as required.
A resident with a history of heart failure and cancer did not receive prescribed antifungal lozenges for a diagnosed oral fungal infection until five days after the specialist's order was communicated, resulting in continued mouth discomfort.
A resident with a history of suicidal ideation and suicide attempts was not provided with required supervision or behavioral health services after expressing self-harm intentions. The resident accessed a sharp object from a roommate and attempted suicide, while staff failed to implement one-to-one observation or timely assessments. Additionally, sharp objects and unlocked carts were accessible in resident areas, creating accident hazards. Staff and administration confirmed these lapses, resulting in Immediate Jeopardy.
A resident with a history of mental health disorders and prior suicide attempt repeatedly expressed feelings of depression, anxiety, and suicidal ideation, and requested psychological services. Despite these requests and clear risk factors, there was no evidence that the resident was assessed or treated by behavioral health services during their stay. The resident ultimately attempted suicide by inflicting multiple neck lacerations with scissors obtained from a roommate, following ongoing unaddressed mental health needs.
Three residents with psychiatric diagnoses did not have timely or complete behavioral health assessments documented in their medical records. Behavioral health consults and follow-up visits were either missing or not added to the records as required, despite staff confirming that such documentation should have been included.
Surveyors found that the facility failed to provide a safe, clean, and comfortable environment, with issues including a non-functioning entrance door, dirty surfaces and garbage in the dining area, stained and damaged walls, sticky floors with black residue, urine odors, dust, and garbage in resident rooms and hallways.
A resident with Parkinsonism who needed significant assistance with bathing reported in writing that two nurse aides treated her abusively and made derogatory remarks during a shower. The facility did not report this allegation to the Administrator or the State Survey Agency as required by policy.
A resident with Parkinsonism who required significant assistance with bathing reported that two aides treated her abusively during a shower, including forceful handling and derogatory remarks. The resident reported the incident both verbally and in writing, but there was no documented evidence that the facility investigated the allegation, as confirmed by the Administrator.
A resident with multiple behavioral health diagnoses did not receive a needed referral to outpatient mental health therapy, despite recommendations from a psychiatric nurse practitioner and the resident's own request. The care plan required physician notification and referral for mood changes, but staff did not notify the physician or initiate the referral, as confirmed by the DON and the resident.
The facility failed to comply with the requirement to have a credentialed Infection Preventionist (IP) as part of their Infection Prevention and Control Program. Despite the facility's policy mandating that infections be reported to the IP for routine surveillance, the Administrator confirmed that no staff members were credentialed as infection preventionists. This issue had been previously cited, indicating a recurring compliance problem.
The facility failed to employ a full-time qualified dietary services manager in the absence of a full-time dietitian, as confirmed by the Administrator. This deficiency was identified during a staff interview and was previously cited, indicating non-compliance with staffing requirements for food and nutrition services.
The facility did not meet the required nurse aide (NA) to resident ratios over a 21-day period. Specifically, the facility failed to maintain the mandated staffing levels during the day, evening, and night shifts on multiple days, as revealed by a review of nursing schedules. This indicates a consistent shortfall in staffing, failing to comply with the regulatory requirements.
The facility consistently failed to meet the required LPN to resident ratios over a 21-day period. The day shift ratio of one LPN per 25 residents was not met on one occasion, the evening shift ratio of one LPN per 30 residents was not met on eight occasions, and the night shift ratio of one LPN per 40 residents was not met on 19 occasions.
The facility did not meet the required RN to resident ratios, having less than one RN per 250 residents during all shifts on two days within a 21-day review period. This was determined through an examination of nursing time schedules.
The facility failed to meet the required RN to resident ratio and did not provide the mandated minimum of 3.2 hours of direct care per resident for 19 out of 21 days reviewed. Specific days where care hours fell short include several instances with the lowest being 1.76 care hours per resident. This deficiency was identified through a review of nursing time schedules.
The facility failed to comply with infection control regulations due to not having a credentialed Infection Preventionist (IP). The facility's policy requires staff to report infections to the IP for routine surveillance, but the Administrator confirmed the absence of a credentialed IP. This issue was previously cited, indicating a recurring compliance problem.
The facility did not employ a full-time qualified dietary services manager when there was no full-time dietitian onsite. The Administrator confirmed this during an interview, indicating a failure to meet staffing requirements for dietary services.
A resident with an open wound and lymphedema did not receive six doses of physician-ordered Oxycontin due to the medication being unavailable from the pharmacy. Despite being alert and able to communicate, the resident's pain management was compromised as the medication was not administered over three days.
The facility failed to serve meals at regularly scheduled times, with residents in the back hall receiving lunch over 30 minutes late and those in the front hall over 44 minutes late. Interviews with several residents and confirmation from the Administrator highlighted a consistent issue with meal service timing.
The facility failed to provide scheduled showers to four residents, impacting their quality of life and dignity. Residents with muscle weakness and anxiety were not given showers as per the facility's schedule, and interviews with staff and residents confirmed this lapse. The administrator acknowledged the lack of documentation for these showers.
The facility failed to implement physician's orders for two residents, resulting in missed wound care treatments and monitoring. One resident with a stage three pressure ulcer did not receive daily wound care as ordered, while another resident with a non-pressure wound and requiring hemodialysis had missed treatments and monitoring. The facility administrator confirmed the lack of evidence for the treatments being administered as ordered.
The facility did not post the required nurse staffing information. During a facility tour, it was observed that no staffing information was displayed, and this was confirmed by the Administrator.
The facility did not hold required quarterly QAPI Committee meetings for three out of four quarters from June 2023 to June 2024, and the Infection Preventionist was absent from the one meeting that was held. This was confirmed by the interim Administrator.
The facility was found deficient in its infection prevention and control program due to not having a credentialed Infection Preventionist (IP). The facility's policy required staff to report infections to the IP for routine surveillance. However, the DON admitted that no staff were credentialed as IPs, violating resident care policies and nursing services regulations.
The facility failed to maintain a clean and homelike environment in the Skilled Nursing Unit. Observations included peeling paint, a black substance on floors and grout, and stained curtains. These issues were noted in various locations, including a shared bathroom, a resident's room, and the main shower room, indicating non-compliance with safety and cleanliness standards.
Lack of Qualified Full-Time Dietary Leadership
Penalty
Summary
The facility failed to employ sufficient qualified dietary leadership staff, specifically a full-time qualified dietitian or, in the absence of such, a full-time qualified dietary services manager. During a staff interview on March 21, 2026, at 10:44 a.m., the Director of Nursing confirmed that there was no full-time dietitian employed and that the facility did not employ a qualified dietary manager to oversee the food and nutrition service. This deficiency was cited under 28 Pa. Code 201.18(b)(3) regarding management and 42 CFR §483.60(a)(2) concerning qualified dietary staff, and it had been previously cited on June 6, 2025.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment on one nursing unit, as evidenced by multiple observations of black residue present on the floors of several resident rooms and a bathroom across from the nurse's station. During interviews, one resident reported that equipment in the facility was rusty, while another resident stated that housekeeping staff only disposed of trash and did not clean. These findings were based on direct observations and resident interviews conducted by surveyors. The deficiency was cited under 28 Pa. Code 207.2(a), which pertains to the administrator's responsibility to ensure a safe and clean environment for residents.
Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician and responsible party of a change in condition, as required by facility policy and state regulation. Specifically, a resident with diagnoses including congestive heart failure and bradycardia experienced elevated blood pressure and was transferred to the hospital. Clinical record review showed no documented evidence that the resident was assessed or that the physician and responsible party were notified of the elevated blood pressure and subsequent hospital transfer. The resident, who had no cognitive impairment, confirmed the hospital transfer during an interview. This deficiency was identified through facility policy review, clinical record review, and resident interview.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
Staff failed to administer medications in accordance with physician orders for three residents. For one resident with COPD and diabetes, the Medication Administration Record indicated multiple medications were to be given at 9:00 a.m. and insulin glargine at 8:00 a.m.; however, the resident reported not receiving her morning medications by 10:50 a.m., and record review confirmed medications had not been administered as of 12:30 p.m. Another resident with end stage renal disease and diabetes was scheduled to receive several medications at 9:00 a.m., but observation showed the Director of Nursing did not administer these until 11:48 a.m. A third resident with atrial fibrillation and hypertension was to receive medications at 9:00 a.m. and midodrine with meals, but observation revealed medications were not given until 11:36 a.m., and a nurse's note indicated midodrine was not administered with breakfast as ordered. In an interview, the Administrator confirmed that the late administration of medications was due to staffing issues. The deficiencies were identified through clinical record reviews, resident and staff interviews, and direct observation, and were cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Conduct Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nursing staff demonstrated the necessary competencies and skill sets required to care for residents' needs. This deficiency was identified through a review of facility personnel files and staff interviews, which revealed that no in-service training or skills competency evaluations had been conducted for licensed nursing staff. The Administrator confirmed this lack of staff development and competency assessment during an interview.
Failure to Provide Annual Nurse Aide Training and Competency Evaluation
Penalty
Summary
The facility failed to provide annual education and training necessary for nurse aides to care for residents' needs. Review of personnel files and staff interviews revealed that no in-service training or skills competency evaluations were conducted for nurse aides. This was confirmed by the Administrator during an interview, who acknowledged the absence of required staff development activities.
Failure to Employ Qualified Dietary Services Manager or Dietitian
Penalty
Summary
The facility failed to employ a full-time, qualified dietary services manager in the absence of a full-time qualified dietitian. During staff interviews, it was confirmed that the facility did not have a certified dietary manager or a full-time qualified dietitian on staff. Additionally, there were no regularly scheduled consultations with a qualified dietitian when a certified dietary manager was not present. These findings were corroborated by both the Director of dining and the Administrator during separate interviews.
Failure to Maintain Sanitary Food Storage and Service Conditions
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions in the kitchen and on the nursing unit. In the kitchen, there was an accumulation of food debris under the dish machine, flies present in the dishwashing and food preparation areas, and a leaking hose on the back of the ice machine causing water to pool on the floor. The floor under clean dish racks was dirty, the inside of the microwave was soiled, and the juice machine's grate cover was dusty. A bin of sugar had a measuring cup stored inside in direct contact with the sugar, and open boxes of juice connected to the juice machine were either undated or past the recommended use period, with one box bulging and stained. The plastic connectors for the juice machine were soiled with dried juice and debris. In the walk-in refrigerator, raw ground beef was stored above ready-to-eat ham lunch meat, and prepared food items were found past their use-by dates or without legible dates. The refrigerator door latch was broken, causing the door to remain open unless manually closed. The walk-in freezer had significant ice accumulation, and non-food items were stored with resident food. Dirty ceiling tiles, a leaking pipe, and dust and debris on utensil storage drawers were also noted in food preparation areas. In dry storage, dented cans, undated or expired cake mix bags, and a large hole in the wall were observed. During tray line service, flies were present in areas where resident trays were assembled, and on clean cooking tools. A dietary aide was observed handling multiple food items and tasks without changing gloves or performing hand hygiene between tasks. The refrigerator door was left open for an extended period during this time. On a subsequent day, debris and moisture were found under the sink in the food preparation area, with small flies present. The dish machine sanitizer concentration log was incomplete, and the dietary aide used the incorrect test strips to check sanitizer concentration. On the nursing unit, the microwave was found to be soiled with various substances. These observations indicate a failure to store and serve food under sanitary conditions as required by professional standards.
Failure to Hold Required Quarterly Quality Assurance Committee Meetings
Penalty
Summary
The facility's Quality Assurance Committee failed to meet on a quarterly basis as required. Review of facility documentation showed no record of committee meetings since January 2024. During an interview, the Administrator confirmed that there was no documentation of the committee having met. This deficiency was cited under CFR 483.75(g) and 28 Pa code 201.18(b)(3).
Failure to Implement Infection Control Policies and Water Management Program
Penalty
Summary
The facility failed to implement and follow its own infection prevention and control policies, specifically regarding Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Observations during the survey revealed that staff did not use required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents with chronic wounds, central venous catheters, or feeding tubes. There were no signs posted to indicate PPE requirements, and PPE was not readily available for use. Specific incidents included a nurse aide providing care to a resident with a central venous catheter without a protective gown, an LPN flushing a feeding tube without a gown, and the same LPN providing wound care to a resident with a Stage 4 pressure sore without using a gown. The Infection Preventionist confirmed that the EBP policy had not been implemented or followed by staff. Additionally, the facility did not have a documented water management program for Legionella, as required by its Emergency Preparedness Plan and Infection Control Policies. There was no evidence that the facility's water had been tested for Legionella, and the Administrator confirmed the absence of a documented water management program. These deficiencies were found to have the potential to affect all residents in the facility.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of flies in multiple areas. On June 3, 2025, flies were observed in the kitchen's dishwashing and food preparation areas during two separate observations. Additionally, flies were seen on the nursing unit, including in resident rooms, at the nurses station, and in the resident shower room. Further observations on June 4, 2025, revealed flies in additional resident rooms and in the hallway by the food cart holding resident meal trays during tray service. These findings indicate that the facility did not adequately prevent or address pest issues in both food service and resident care areas.
Insufficient Staffing Resulted in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of every resident, as evidenced by clinical record review, resident interview, and facility documentation. One resident, who was alert, oriented, and required staff assistance for transfers due to difficulty walking and weakness, reported being unable to get out of bed on a Sunday because there was not enough staff available. Review of the resident's clinical record confirmed there was no documentation of a transfer out of bed on that day. Additionally, staffing records for the same day showed the facility did not meet required nurse aide, LPN, RN ratios, or minimum direct care hours per resident.
Failure to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to act promptly upon resident grievances as required by its own Grievance Policy, which states that grievances should be reviewed and a written decision issued to the resident within five days. During a confidential group interview, half of the residents interviewed reported that the facility did not respond promptly to grievances. Review of grievance forms submitted over several months showed no evidence that the facility reviewed, investigated, or determined corrective actions for the grievances, nor that written decisions were provided to residents within the required timeframe. The Administrator confirmed that there was no evidence the grievances were addressed.
Failure to Provide Required Written Notification on Bed Hold and Transfer
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding bed hold policies, transfer information, and Ombudsman contact details when residents were transferred to the hospital following a change in condition. Clinical record reviews for seven sampled residents who were transferred revealed no documentation that such notifications were given at the time of transfer. This lack of documentation was consistent across all reviewed cases, indicating a systemic issue in the facility's notification process. Additionally, staff interviews, including one with the Administrator, confirmed that there was no evidence to support that the required written notices were sent to the residents' representatives. The deficiency was identified through both clinical record review and staff interview, with all seven sampled residents affected by the same lapse in required communication during their transfer to the hospital.
Failure to Monitor and Assess Nutritional Status for Residents at Risk
Penalty
Summary
The facility failed to adequately monitor and assess the nutritional status of seven residents identified as being at nutritional risk. Facility policy required that indicators such as bilateral edema, muscle wasting, depression, dementia, and specialized diets be considered as risk factors for malnutrition. Despite this, clinical record reviews showed that multiple residents with significant medical histories, including diabetes, feeding difficulties, muscle weakness, dysphagia, pressure ulcers, end stage renal disease, and metabolic encephalopathy, did not receive required nutritional assessments or regular weight monitoring as ordered by physicians. In several cases, there was no documentation that residents were weighed according to physician orders, and no evidence that a registered dietitian or qualified nutrition professional evaluated their nutritional status within the required timeframes. For example, one resident with diabetes and feeding difficulties was not weighed for several months and had no documented dietitian evaluation. Another resident with muscle weakness, dysphagia, and pressure ulcers was not weighed as ordered and had not been assessed by a dietitian since the previous year. Additional residents with complex conditions such as end stage renal disease, major depressive disorder, and dependence on dialysis also lacked evidence of timely nutritional assessments and weight monitoring. The facility administrator confirmed that these assessments and reviews should have occurred monthly but were not completed as required.
Failure to Provide Safe and Consistent Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards for two residents requiring hemodialysis. Facility policy required the use of a communication notebook to share relevant information between the facility and the dialysis provider, as well as monitoring of the dialysis access site each shift. For one resident with end stage renal disease, there was no evidence that staff completed or obtained dialysis communication forms for multiple dialysis sessions over several weeks. Additionally, staff did not consistently monitor the resident's dialysis catheter site as ordered, with missing documentation on specific shifts, and failed to document post-dialysis weights on several required days. The resident also reported that staff did not always monitor her catheter site. For another resident with end stage renal disease and a physician's order for hemodialysis three times a week, there was no documented evidence that the access site was monitored each shift as required by facility policy. The Infection Control Nurse confirmed the lack of documentation for this monitoring. These findings indicate that the facility did not adhere to its own policies and physician orders regarding the monitoring and communication necessary for safe dialysis care.
Failure to Ensure Timely Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and addressed by a physician in a timely manner for four out of five sampled residents. According to facility policy, a licensed pharmacist is required to conduct a monthly drug regimen review for each resident and report any irregularities to the attending physician, DON, and Medical Director, with the expectation that these reports are acted upon and documented in the physician's progress notes. However, clinical record reviews revealed that for multiple residents with complex medical histories—including schizoaffective disorder, intermittent explosive disorder, major depressive disorder, anxiety, emphysema, a femur fracture, cerebral infarction, dementia, and dysphagia—pharmacist recommendations were made on several occasions but were not addressed or documented by the physician. Specifically, for one resident, pharmacist recommendations made in February and April were not addressed; for another, recommendations from January, February, and April were not acted upon; and for two additional residents, recommendations from March, January, and February were either not documented or not addressed by the physician. During an interview, the Administrator confirmed the lack of documentation regarding the pharmacy recommendations and their timely review or action by the physician.
Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to assess, document, and provide physician-ordered wound care treatments for six residents with wounds, as required by facility policy. The policy specified that residents with skin impairments should have their wound status assessed and documented in the electronic medical record by a Registered Nurse, and that physician wound progress notes should be used in addition to in-house RN assessments for those followed by wound care physicians. However, clinical record reviews revealed multiple instances where wound care treatments were not documented as completed on the Treatment Administration Record (TAR) for several residents, and there was a lack of evidence that weekly skin assessments were performed as required. For example, one resident with multiple sclerosis and a stage four sacral pressure ulcer had several days where ordered wound treatments were not documented as completed. Another resident with end stage renal disease and a stage four sacral pressure ulcer reported that wound care was not provided regularly, and there was no evidence of wound care being completed for nearly two weeks. Additional residents with conditions such as lymphedema, cellulitis, metabolic encephalopathy, and osteomyelitis also had missing documentation for wound care treatments and assessments, with some lacking any evidence of RN wound evaluation per policy. Interviews with staff, including the Infection Preventionist, confirmed that there was no documented evidence that wound treatments and weekly skin assessments were completed as ordered for the affected residents. The lack of documentation and failure to follow physician orders and facility policy led to the deficiency cited under 28 Pa Code 211.12 (d)(1)(5) Nursing services.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature on the nursing unit. According to the facility's Meal Test Tray form, hot foods were required to be served above 135 degrees Fahrenheit. However, a test tray audit revealed that mixed vegetables were served at 116.6 degrees Fahrenheit, which is below the required temperature. The Director of dining confirmed that hot foods should be served at 135-140 degrees Fahrenheit. Additionally, one resident reported that food was often served cold, and another resident specifically stated that the mixed vegetables were cold when served. These findings were based on observation, review of facility documentation, resident interviews, staff interviews, and the results of the test tray audit.
Failure to Assess and Document Physical Restraint Use
Penalty
Summary
The facility failed to properly assess and document the use of a physical restraint for one resident with severe intellectual disabilities, anxiety, and lack of coordination. Over multiple days of observation, the resident was seen in a wheelchair with a seat belt that she could not self-remove. Staff confirmed the resident's inability to remove the seat belt independently. There was no documented evidence that a physician's order or rationale for the restraint was obtained, nor was there an initial or ongoing assessment of the restraint's necessity, as required by facility policy. The interdisciplinary team did not develop a comprehensive care plan for the restraint, and monthly reevaluations were not documented.
Inaccurate MDS Assessment for Resident with Renal Dialysis
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 19 sampled residents. Clinical record review showed that the resident had diagnoses including end stage renal disease, diabetes, and was dependent on renal dialysis, with a physician's order for dialysis three times per week. However, the resident's MDS assessment did not indicate dependence on renal dialysis. This inaccuracy was confirmed by the Administrator during an interview.
Failure to Complete PASARR Screening for Mental Disorders
Penalty
Summary
The facility failed to complete or obtain a required Preadmission Screening and Resident Review (PASARR) for one resident who was admitted with multiple mental health diagnoses, including borderline personality disorder, schizoaffective disorder, intermittent explosive disorder, major depressive disorder, and generalized anxiety. Clinical record review showed no evidence of a completed or obtained PASARR for this resident. This finding was confirmed by the Administrator during an interview, who acknowledged the absence of documentation related to the required screening.
Failure to Provide Timely Assistance with Hygiene and Eating
Penalty
Summary
A resident with multiple sclerosis, muscle weakness, adult failure to thrive, and dysphagia was found to have unmet needs related to personal hygiene and eating assistance. Clinical record review and resident interview revealed that the care plan required staff to check, trim, and clean the resident's nails on bath day and as necessary, and to report any changes to the nurse. However, on two separate occasions, the resident was observed with long nails and visible dirt underneath. The resident stated she preferred short nails, had not refused nail care, and that staff had not offered to provide this care. Additionally, the resident required staff assistance with eating, as documented in a physician's order. During a meal observation, the resident struggled to obtain her utensil and had difficulty using adaptive utensils due to the foam handles sliding off, requiring her to use her mouth to adjust them. Staff did not offer or provide assistance with the meal until 36 minutes after the resident was observed with her meal tray, despite her evident difficulty.
Failure to Provide and Document Catheter Care per Facility Policy
Penalty
Summary
The facility failed to provide adequate catheter care for two residents with indwelling urinary catheters, as required by facility policy. The policy specified that perineal care should be performed every eight hours, the collection bag should be emptied at least every eight hours and as needed, the catheter should be cleansed from the insertion site outward, and the drainage tubing and bag should be checked to ensure proper drainage and that the catheter was kept off the floor. For one resident with urogenital implants, a physician's order for foley catheter care every shift was discontinued, and no new order was placed, despite the resident continuing to have a foley catheter. There was no evidence that catheter care was provided to this resident after the order was discontinued. Another resident with diabetes mellitus and urinary retention had an order for an indwelling catheter. Multiple observations over several days confirmed the presence of the catheter, but there was no documented evidence that staff provided catheter care according to facility policy. The Infection Preventionist confirmed the lack of documentation for catheter care for both residents.
Failure to Follow Physician Orders for PRN Pain Medication Administration
Penalty
Summary
Facility staff failed to administer as needed (PRN) pain medication according to the physician's orders for a resident with diagnoses including muscle weakness, low back pain, and neuropathy. The care plan required that oxycodone be given only for severe pain rated seven through ten, and that at least two nonpharmacological interventions be attempted before administering the medication. However, review of the Medication Administration Records (MAR) for May and June 2025 showed that staff administered oxycodone when the resident's pain level was less than seven on multiple occasions, and there was no evidence that nonpharmacological interventions were attempted prior to medication administration on most occasions in June. These findings were confirmed by staff interview.
Failure to Securely Store Medications and Lack of Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored as required. On multiple occasions, a tube of medicated cream was observed on the bed of one resident, and two bottles of nasal medications were found on the bedside table of another resident. Clinical record reviews for both residents showed no assessments for medication self-administration or for bedside storage of medications. These observations indicate that medications were not kept in locked compartments or carts, and there was no documentation supporting that the residents were permitted to self-administer or store medications at their bedside.
Delay in Treatment of Fungal Infection
Penalty
Summary
A deficiency was identified when a resident with a history of heart failure and cancer, who was able to communicate clearly and had no memory impairments, did not receive timely treatment for a diagnosed fungal infection in the mouth. Clinical records show that an ear, nose, and throat specialist recommended antifungal lozenges (clotrimazole) after an examination. However, there was no documentation that the medication was provided to the resident until five days after the specialist's office communicated the need for treatment. The resident reported experiencing mouth discomfort and confirmed the delay in receiving the prescribed medication.
Failure to Supervise Resident with Suicidal Ideation and Maintain Safe Environment
Penalty
Summary
The facility failed to provide necessary supervision and services for a resident with a documented history of suicidal ideation and suicide attempts. Despite the resident expressing suicidal thoughts and requesting psychological services on multiple occasions, there was no evidence that staff implemented one-to-one observation, conducted timely assessments, or ensured the resident was seen by behavioral health services as required by facility policy. The resident was able to access a sharp object from her roommate and attempted suicide while in the facility, indicating a lack of adequate supervision and failure to follow established protocols for residents at risk of self-harm. Additionally, the environment was not maintained free from accident hazards. A resident was able to keep sharp objects, including a knife and scissors, in her room, and these items were accessible to others, including a roommate with a history of suicidal ideation. Observations revealed that the key to a locked drawer was left in the lock, making it easy for anyone to access potentially dangerous items. Furthermore, unattended and unlocked treatment and medication carts containing sharp objects and button batteries were observed in resident-accessible areas, with scissors left on top of medication carts in the presence of ambulatory residents and visitors. Staff interviews confirmed that the resident with suicidal ideation was not placed on one-to-one observation and had not been seen by behavioral health services since admission. The facility administrator acknowledged the lack of evidence for implementing safety interventions or staff education following the suicide attempt. The combination of inadequate supervision, failure to follow policy, and unsafe environmental conditions led to an Immediate Jeopardy situation.
Failure to Provide Behavioral Health Services for Resident with Suicidal Ideation
Penalty
Summary
A resident with a history of suicide attempt, major depressive disorder, generalized anxiety, bipolar disorder, agoraphobia with panic disorder, and insomnia was admitted to the facility. Hospital records indicated the resident was at risk for suicide and required one-to-one supervision during a prior hospital stay. Upon admission, the care plan identified the resident as being at risk for mood problems due to previous suicide attempts, with interventions including behavioral health consultations as needed. Despite multiple documented requests from the resident for psychological services and staff notes indicating ongoing anxiety, depression, and suicidal ideation, there was no evidence that the resident was ever assessed or treated by a behavioral health provider during their stay. Staff interviews confirmed that the resident was not seen by behavioral health services since admission. On several occasions, the resident expressed feelings of wanting to hurt herself and requested to see a therapist, but there was no documentation of behavioral health follow-up or assessment. The situation escalated when the resident was found with multiple lacerations to her neck after using scissors obtained from a roommate in a suicide attempt. This incident followed repeated expressions of distress and requests for behavioral health support, which were not met with timely or documented intervention by behavioral health professionals.
Failure to Maintain Accurate Behavioral Health Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three of five sampled residents, specifically regarding behavioral health assessments and documentation. For one resident with multiple psychiatric diagnoses, there was no evidence in the medical record that behavioral health services were provided as documented by the practitioner, with a gap between the referral and the first documented behavioral health visit. Another resident, also with psychiatric diagnoses and on psychotropic medications, had a behavioral health assessment indicating a follow-up was needed in six weeks, but there was no evidence in the record of any follow-up assessment or documentation of rescheduling for over six months. A third resident with major depressive disorder had a similar lapse, with a behavioral health assessment indicating a follow-up in four to six weeks, but no documentation of follow-up or rescheduling for four months. Staff interviews confirmed that behavioral health assessments were sent electronically and were supposed to be printed and scanned into the residents' medical records, but these records were not available for the residents in question. The lack of timely and accurate documentation of behavioral health assessments and follow-up visits resulted in incomplete medical records for these residents.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and comfortable environment. The right-side swinging glass door at the facility's front entrance was not operational. In the dining room, the interior entrance door handle and windows were dirty with a white substance, and garbage was found on the floor under the exterior windows. A reddish stain was present on the door frame of the linen closet across from the nurse station. Several rooms and hallways had damaged wallboard and wallpaper, specifically at rooms 1, 3, 8, 24, 27, and 30. In various resident rooms, floors were sticky with black residue, there were urine odors, dust in corners, garbage under heaters, and damaged spots on walls. These observations were made throughout one nursing unit during the survey period.
Failure to Timely Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving a resident with Parkinsonism who required substantial to maximal staff assistance with bathing. The resident, who was not cognitively impaired, reported that two nurse aides treated her abusively during a shower by forcefully removing her clothing, shoving her under cold and then hot water, roughly scrubbing her, and making derogatory remarks about her skin. The resident reported this incident in writing to nursing staff several days after the event. Facility documentation showed no evidence that this allegation was reported to the Administrator or Abuse Prevention Coordinator as required by facility policy. Additionally, there was no documentation that the incident was reported to the State Survey Agency within the required timeframe. The Administrator confirmed during interview that the incident was not reported according to policy.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident diagnosed with Parkinsonism who required substantial to maximal staff assistance with bathing. The resident, who was not cognitively impaired, reported that two aides treated her abusively during a shower by forcefully removing her clothing, shoving her under cold and then hot water, and roughly scrubbing her while making derogatory remarks. The resident verbally reported the incident to facility staff and later submitted a written report. Despite these reports, there was no documented evidence that the facility conducted an investigation into the allegation, as confirmed by the Administrator.
Failure to Provide Behavioral Health Services for Resident with Mood and Behavior Concerns
Penalty
Summary
A deficiency was identified when a resident with diagnoses including schizoaffective disorder, borderline personality disorder, intermittent explosive disorder, and anxiety disorder did not receive necessary behavioral health services. The resident's care plan included interventions such as notifying the physician of mood changes and referring to behavioral health services as needed. Despite recommendations from a psychiatric nurse practitioner and the resident's own request for a referral to outpatient mental health therapy due to increased anxiety, there was no evidence that staff notified the physician or made the referral. The Director of Nursing confirmed that no referral had been made, and the resident reported ongoing increased anxiety and an unmet request for therapy.
Lack of Credentialed Infection Preventionist
Penalty
Summary
The facility was found to be non-compliant with the requirement to have a credentialed Infection Preventionist (IP) as part of their Infection Prevention and Control Program (IPCP). According to the facility's policy titled 'Infection Control,' which was last reviewed on August 21, 2023, staff members are required to report all infections to the IP, who is responsible for conducting routine surveillance. However, during an interview on January 25, 2025, the Administrator admitted that the facility did not have any staff members who were credentialed as infection preventionists. This deficiency was previously cited on July 18, 2024, and December 17, 2024, indicating a recurring issue with compliance in this area.
Plan Of Correction
1. A full-time Infection Preventionist has been hired and will be working with both Kadima at Campbelltown and Palmyra. She is an RN and has the required certification for the position of IP. 2. The company will also hire a second nurse to complete the Infection Preventionist course so that there will always be a backup ensuring the problem does not recur. 3. The DON or designee will monitor Infection Control credentials as well as any issues weekly for 4 weeks and then monthly for 2 months to ensure compliance compliance.
Deficiency in Dietary Staffing Requirements
Penalty
Summary
The facility was found to be non-compliant with the requirement to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. During an interview conducted on January 25, 2025, the Administrator confirmed that the facility did not have a full-time dietitian employed onsite. Additionally, the facility failed to employ a qualified certified dietary manager to fulfill the role in the absence of a full-time dietitian. This deficiency was identified based on staff interviews and was previously cited on December 17, 2024. The lack of a full-time qualified dietary services manager or dietitian indicates a failure to meet the staffing requirements outlined in CFR 483.60(a), which mandates sufficient staff with appropriate competencies to carry out the functions of the food and nutrition service, considering resident assessments and individual plans of care.
Plan Of Correction
1. The facility cannot retroactively correct. 2. The facility actively advertised for a Certified Dietary Manager and one was hired and started on February 25, 2025. The facility has hired a full-time Registered Dietitian as well. 3. NHA/designee will educate HR department/recruitment of the need for a Dietary Manager in the absence of a full-time dietician. 4. When hired, the Dietary Manager will provide the NHA with the completed class courses and testing results in attaining a Certified Dietary Manager certificate. The NHA and corporate CDM will monitor that a qualified DM is in place. Results will be reported to QUAPI committee for review and analysis.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios over a 21-day period from January 4 through 24, 2025. Specifically, the facility did not meet the required ratio of one NA per ten residents during the day shift on 15 days, one NA per 11 residents during the evening shift on 18 days, and one NA per 15 residents during the night shift on four days. This deficiency was identified through a review of nursing schedules, indicating a consistent shortfall in staffing levels across multiple shifts and days, thereby failing to meet the regulatory requirements effective from July 1, 2024.
Plan Of Correction
1. The facility is unable to retroactively ensure NA to resident ratios are met on the cited dates. 2. The facility will maintain NA to resident ratios. 3. The DON was re-educated on ensuring NA to resident ratios are met. There will be a daily staffing meeting to review the current day and future dates NA ratios. 4. The NHA or designee will complete an audit of NA to resident ratios daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Non-Compliance with LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by the regulation effective July 1, 2023. A review of nursing schedules for the period from January 4 through 24, 2025, revealed multiple instances of non-compliance. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on January 17, 2025. Additionally, the evening shift ratio of one LPN per 30 residents was not met on January 11, 12, 14, 15, 16, 17, 18, and 19, 2025. Furthermore, the night shift ratio of one LPN per 40 residents was not adhered to on January 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 24, 2025. These findings indicate a consistent failure to comply with staffing requirements over the reviewed period.
Plan Of Correction
1. The facility is unable to retroactively ensure LPN to resident ratios are met on the cited dates. 2. The facility will maintain LPN to resident ratios. 3. The DON was re-educated on ensuring LPN to resident ratios are met. There will be a daily staffing meeting to review the current day and future dates LPN ratios. 4. The NHA or designee will complete an audit of LPN to resident ratios daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Meet RN to Resident Ratios
Penalty
Summary
The facility failed to meet the minimum licensed registered nurse (RN) to resident ratios as required by regulation effective July 1, 2023. Specifically, the review of nursing schedules for a 21-day period from January 4 through 24, 2025, revealed that the facility did not have at least one RN per 250 residents during all shifts on two of those days. This deficiency was identified based on the examination of nursing time schedules.
Plan Of Correction
5540 1. The facility is unable to retroactively ensure RN to resident ratios are met on the cited dates. 2. The facility will maintain RN to resident ratios. 3. The DON was re-educated on ensuring RN to resident ratios are met. There will be a daily staffing meeting to review the current day and future dates RN ratios. 4. The NHA or designee will complete an audit of RN to resident ratios daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Meet RN Ratio and Care Hours
Penalty
Summary
The facility failed to meet the required RN to resident ratio of one RN for 250 residents on January 14 and 15, 2025. Additionally, the facility did not provide the mandated minimum of 3.2 hours of direct care per resident for 19 out of 21 days reviewed between January 4 and January 24, 2025. Specific days where the care hours fell short include January 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 24, with the lowest being 1.76 care hours per resident on January 20, 2025. This deficiency was identified through a review of nursing time schedules, indicating a consistent failure to meet the required staffing levels and care hours over the specified period.
Plan Of Correction
1. The facility is unable to retroactively ensure minimum PPD hours of Direct Care are met on the cited dates. 2. The facility will maintain minimum PPD hours of direct care. 3. The DON was re-educated on ensuring minimum PPD hours of direct care. There will be a daily staffing meeting to review the current day and future dates PPD hours of direct care. 4. The NHA or designee will complete an audit of PPD hours of direct care daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Lack of Credentialed Infection Preventionist
Penalty
Summary
The facility was found to be non-compliant with infection control regulations due to the absence of a credentialed Infection Preventionist (IP). According to the facility's policy on infection control, last reviewed on August 21, 2023, staff members are required to report all infections to the IP, who is responsible for conducting routine surveillance. However, during an interview on December 17, 2024, the Administrator admitted that the facility did not have a staff member who was a credentialed IP. This deficiency was previously cited on July 18, 2024, indicating a recurring issue with compliance to CFR 483.80 (b) and relevant state codes regarding resident care policies and nursing services.
Plan Of Correction
1. The Director of Nursing is completing the Infection Preventionist Program and will act as the interim IP until another RN is hired and completes the IP program. 2. The facility is applying for at least one other full-time employed RN to complete the infection preventionist program. 3. The Director of Nursing was re-educated on the Infection Preventionist requirements. The NHA will ensure at least two facility staff members are credentialed at all times. 4. The NHA or designee will conduct a one-time audit of each Infection Preventionist's credentials to ensure they meet the monitoring criteria. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Employ Qualified Dietary Services Manager
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. During an interview conducted on December 17, 2024, at 11:00 a.m., the Administrator confirmed that there was no full-time dietitian employed onsite at the facility. Additionally, the facility did not employ a qualified certified dietary manager to fulfill the role in the absence of a full-time dietitian.
Plan Of Correction
1. The facility cannot retroactively correct. 2. The facility is actively advertising for a dietary manager. NHA/designee will establish training for certification of a dietary manager when employed. The facility will employ a consultant Dietician and/or consultant CDM in the interim. 3. NHA/designee will educate HR department/recruitment/Dietary manager the need of a certified dietary manager in the absence of full-time dietician. 4. When hired, the Dietary Manager will provide the NHA with the completed class courses and testing results in attaining a Certified Dietary Manager certificate. The NHA and corporate CDM will monitor that a qualified DM is in place. Results will be reported to QAPI committee for review and analysis.
Medication Unavailability Leads to Missed Doses
Penalty
Summary
The facility failed to ensure the availability of a physician-ordered medication for a resident, leading to a deficiency in pharmaceutical services. Resident 1, who had an open wound on the left lower leg and lymphedema, was alert, oriented, and able to communicate her needs. On December 12, 2024, a physician ordered Oxycontin to be administered every 12 hours for pain management. However, the medication administration record for December 2024 showed that the medication was not administered on December 14, 15, and 16, resulting in six missed doses. Nursing documentation indicated that the medication was unavailable from the pharmacy, leading to the failure in administering the prescribed medication.
Plan Of Correction
1. Resident 1 was assessed for pain and administered medication. 2. A facility wide audit was completed to determine if there were any other unavailable medications. 3. The Licensed Nurses were re-educated on providing medication from the ebox and notification of the DON if medications are not available. The DON will work directly with the pharmacy to ensure medication availability. 4. The DON or designee will conduct an audit of medication availability weekly x 4 weeks then monthly x 2 months to ensure ordered medications are available. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Late Meal Service in Nursing Unit
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times in accordance with resident preferences on the nursing unit. The scheduled mealtime for the back hall of the nursing unit was 12:15 p.m., and for the front hall, it was 12:30 p.m. However, observations revealed that meals were consistently served late. Residents 4 and 5 in the back hall received their lunch trays between 12:45 and 12:59 p.m., which was over 30 minutes past the scheduled time. Similarly, in the front hall, Residents 1, 2, 3, and 6 received their lunch trays between 1:14 p.m. and 1:30 p.m., over 44 minutes past the scheduled mealtime. Interviews with Residents 1, 2, 3, 4, 5, and 6 confirmed that they usually received their meals late. The Administrator also confirmed during an interview that meals were served late, indicating a systemic issue with meal service timing in the facility.
Plan Of Correction
1. Facility cannot retroactively correct. 2. NHA/Designee will conduct a one-time whole house audit of meal delivery times for breakfast/lunch/dinner to ensure compliance with regulation. 3. Nursing home administrator/designee will in-service the dietary department on importance of adhering to meal delivery times to ensure compliance with regulation. 4. NHA/Designee will conduct an audit of tray delivery times 3 x a week x 4 weeks and once a month x 2 months to ensure ongoing compliance with regulation. Results will be reviewed at QAPI.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide scheduled showers to four residents, impacting their quality of life and dignity. Resident 1, who had difficulty walking and muscle weakness, was supposed to receive a weekly shower on Thursdays, but there was no documentation of showers being provided in November 2024. Similarly, Resident 2, with muscle weakness and anxiety, was scheduled for weekly showers on Fridays, but there was no evidence of showers being given on the scheduled dates in November 2024. Both residents confirmed in interviews that they were not offered showers as per their preferences. Residents 3 and 4, both requiring assistance for activities of daily living and having diagnoses of muscle weakness and anxiety, were also not provided showers as scheduled. Resident 3 was to receive showers on Wednesdays, and Resident 4 on Thursdays, but there was no documentation to support that these showers occurred in November 2024. Interviews with two nurse aides confirmed that residents did not receive showers as scheduled, and the facility administrator acknowledged the lack of evidence for the provision of these showers.
Failure to Implement Physician's Orders for Wound Care and Monitoring
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to deficiencies in care. Resident 3, diagnosed with protein calorie malnutrition, anemia, and muscle weakness, had a stage three pressure ulcer on her sacrum. A physician's order required daily cleansing and dressing of the wound, but the treatment administration record (TAR) showed that the treatment was not provided on six out of 24 days in November 2024. Resident 4, with diagnoses including muscle weakness, chronic kidney disease, and requiring hemodialysis, had a non-pressure wound on the left foot. The physician's order specified a detailed wound care regimen to be followed every evening shift, but the TAR indicated that the treatment was not administered on November 8, 2024. Additionally, orders for antifungal treatments and dialysis site monitoring were not consistently followed, with several instances of missed applications and checks. The facility administrator confirmed the lack of evidence for the treatments being administered as ordered.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information as required. During a tour of the facility, it was observed that there was no nurse staffing information posted. This observation was confirmed in an interview with the Administrator, who acknowledged the absence of the required posting on that date.
QAPI Committee Meeting Deficiencies
Penalty
Summary
The facility failed to ensure that all required staff were present at the quarterly Quality Assurance and Performance Improvement (QAPI) Committee meetings for the entire review period. Specifically, there was no documentation of QAPI meetings for three out of four quarters between June 2023 and June 2024. The missing quarters were the third quarter of 2023, the first quarter of 2024, and the second quarter of 2024. Additionally, during the one meeting that was held in the fourth quarter of 2023, the Infection Preventionist was absent. This was confirmed by the interim Administrator during an interview, who acknowledged that only one QAPI meeting had occurred since the last survey in 2023, and that the Infection Preventionist was not present at that meeting.
Lack of Credentialed Infection Preventionist
Penalty
Summary
The facility was found to be deficient in its infection prevention and control program due to the absence of a credentialed Infection Preventionist (IP). The facility's policy, last reviewed on August 21, 2023, required staff to report all infections to the IP, who was responsible for conducting routine surveillance. However, during an interview on July 18, 2024, the Director of Nursing admitted that the facility did not have any staff members who were credentialed as infection preventionists. This lack of a qualified IP was a violation of the facility's resident care policies and nursing services regulations as outlined in 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12 (d)(1)(3)(5).
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, homelike, and comfortable environment in the Skilled Nursing Unit. During a tour, surveyors observed several deficiencies, including peeling paint on the walls in a shared bathroom and outside a room. In one room, a black substance covered the floor from the entrance and extended under a bed, and the curtain for the bed had a large stain. At the nursing station entrance, a piece of wall molding was peeling off and protruding into the hallway. In a bathroom across from the nurses' station, a black substance was noted around the grout lines and tiles, with a large black mark on the shower tile wall. Additionally, in the main shower room, a black substance was observed on the grout at the intersections of the walls and floor, and the shower curtain had a large stain. These observations indicate a failure to maintain a safe, clean, and comfortable environment for residents, as required by CFR 483.10(i) Safe Environment and 28 Pa. Code 201.18(b)(1)(e)(2.1) Management. This deficiency was previously cited on 8/30/23.
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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