Kadima Rehabilitation & Nursing At Lakeside
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Pennsylvania.
- Location
- 245 Old Lake Road, Dallas, Pennsylvania 18612
- CMS Provider Number
- 395730
- Inspections on file
- 34
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Lakeside during CMS and state inspections, most recent first.
The facility did not maintain the required NA-to-resident staffing ratios on multiple reviewed shifts, as shown by weekly staffing records and staff interviews. For a census of 28 residents, the facility was required to staff specific minimum NA levels on day and evening shifts but instead scheduled fewer NAs than mandated, and no additional higher-level staff were present to offset the shortfall. The NHA acknowledged that the required NA-to-resident ratios were not met on the identified shifts.
The facility did not maintain the required LPN-to-resident staffing ratios on several shifts, as shown by a review of weekly staffing records and staff interviews. On four of twenty-one shifts reviewed, the number of LPNs on duty was below the mandated minimum based on the census, including day shifts where LPN coverage was slightly under the required level and a night shift with no LPN coverage at all. No additional higher-level nursing staff were present to offset these shortages, and the administrator acknowledged that required LPN-to-resident ratios were not met on the identified shifts.
The facility did not meet the required minimum RN-to-resident ratio on multiple night shifts, as staffing records showed that no RN was on duty while the census was between 27 and 28 residents, despite regulations requiring at least one RN per 250 residents on all shifts. The Nursing Home Administrator confirmed that the required RN coverage was not provided on these nights.
Surveyors identified multiple deficiencies in food storage and sanitation, including undated frozen food items, lack of a trash can at the handwashing station, improper closure of the dry storage exit door, damaged flooring, missing floor molding, and unsanitary storage of cleaning items in the janitor closet. The FSD confirmed these practices did not meet required standards.
Surveyors identified that three residents did not have accurate MDS assessments completed, including one with dementia who was incorrectly documented as having pneumonia, another with Parkinson's Disease whose range of motion limitations were not properly recorded, and a third with dementia whose antipsychotic medication dose reduction date was inaccurately entered. Staff interviews and record reviews confirmed the MDS inaccuracies.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences.
A resident with Parkinson's Disease, who was cognitively intact, experienced two disruptive incidents involving a family member, including one that required law enforcement intervention and led to the family member being barred from the facility. The facility did not update the resident's care plan to address or assess the resident's psychosocial needs following these events, despite policy requiring care plan revisions after significant changes.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as evidenced by surveyor findings that care was not consistent with the established care plan.
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. The current food service director is not yet certified, and the part-time registered dietitian works remotely without providing in-person oversight. The facility has been without an onsite registered dietitian since early 2024, leading to the deficiency findings.
The facility failed to conduct a comprehensive facility-wide assessment, leading to deficiencies in staffing and service provision. The assessment did not accurately reflect the current staffing situation, with key personnel such as a Director of Rehabilitation and registered dietitian absent. The facility's Resident Matrix indicated residents requiring specific services, but the necessary staff were not available to provide these services. Interviews confirmed the lack of essential rehabilitative and nutrition services, contributing to the deficiency.
The facility failed to comply with regulations requiring a designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program. The previous IP left, and the facility has not appointed a new qualified IP, as confirmed by the Nursing Home Administrator.
A resident with bilateral below-the-knee amputations was not provided with a wheelchair upon admission, preventing participation in activities and therapy. Despite a physical therapy evaluation indicating the need for anti-tipper devices on the wheelchair, the maintenance work order was not completed, leaving the resident without necessary mobility support for five days.
The facility failed to assess and monitor nutritional needs for two residents and deter weight loss for another. A resident with diabetes and dementia did not receive a timely nutritional assessment. Another resident with dysphagia and malnutrition experienced significant weight loss despite tube feeding, with no reweight or evaluation. A third resident with dysphagia and dementia had delayed weight monitoring and significant weight loss without timely notification to the physician or responsible party.
A facility failed to implement physician's orders for a resident with a PEG tube, who was admitted with dysphagia and malnutrition. The resident was to receive continuous tube feeding and dysphagia therapy to transition to a mechanical soft diet. However, there was no evidence that the ordered therapy was provided, and the resident's spouse's inquiry about decreasing tube feeding was met with the need for nutritional gains first.
The facility failed to serve meals at safe and palatable temperatures, as required by federal guidelines. Residents reported that food was frequently cold, and a test tray confirmed that hot meal items were served below the required temperature. The nursing home administrator acknowledged the deficiency.
The facility did not provide routine evening snacks to residents, resulting in a 14.25-hour gap between supper and breakfast, contrary to its policy. Residents expressed a desire for snacks, but they were not routinely offered, and some were unable to access them due to mobility issues. The Nursing Home Administrator could not explain the lack of snack provision.
Two residents did not receive prescribed occupational and speech therapy services due to the absence of key therapy staff at the facility. One resident, with bilateral below-the-knee amputations, did not receive occupational therapy, while another resident with dysphagia and other conditions did not receive continued occupational and speech therapy. The facility lacked an occupational therapist and a speech therapist, leading to the deficiency.
A resident with a history of morbid obesity and mobility issues exhibited repeated abusive behavior towards other residents, including verbal abuse and derogatory language. Despite multiple documented incidents, the facility failed to report these to the State Survey Agency, as confirmed by the NHA.
The facility failed to investigate and report multiple instances of verbal abuse by a resident, Resident M1, towards other residents. Despite documented incidents of yelling, taunting, and derogatory language, the facility did not complete investigations or submit required reports to the State Survey Agency within the mandated timeframe. The Nursing Home Administrator confirmed these failures, indicating a breach of the facility's abuse protection policy.
The facility failed to provide necessary social services following incidents of abuse by a resident with a history of verbal altercations. Despite multiple documented instances of abusive behavior, there was no evidence of social service interventions to support affected residents. Interviews confirmed the lack of assessments and interventions, indicating non-compliance with regulatory requirements for resident well-being.
A facility failed to accommodate a bariatric resident's needs by providing a wheelchair with a maximum weight capacity of 500 pounds, despite the resident weighing 528.6 pounds. The issue was not addressed since the resident exceeded the weight limit in February, as confirmed by the NHA.
A facility failed to refund a resident's personal funds within 30 days of their discharge or death due to departmental miscommunications. The resident's financial account showed a credit balance, but the refund was delayed, violating state regulations on resident rights.
Failure to Maintain Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet required nurse aide (NA) to resident staffing ratios on three of twenty-one reviewed shifts, as identified through a review of weekly staffing records and staff interviews. State regulations effective July 1, 2024, require a minimum of 1 NA per 10 residents on the day shift, 1 NA per 11 residents on the evening shift, and 1 NA per 15 residents on the night shift. For a census of 28 residents, the facility was required to staff 2.8 NAs on the day shift and 2.55 NAs on the evening shift. On one evening shift, the facility staffed 2.13 NAs instead of the required 2.55, and on a separate day shift, the facility staffed 2.53 NAs instead of the required 2.8. On another evening shift, the facility again staffed 2.13 NAs instead of 2.55. The records also showed that there were no additional higher-level staff available on those dates to compensate for the NA shortfalls. In an interview, the Nursing Home Administrator confirmed that the facility did not meet the required NA-to-resident ratios on the identified dates. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency is based solely on staffing levels compared to regulatory requirements for the facility’s census.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to CNAS for 3 shifts. 2.A facility wide audit was completed to ensure ratios were met. CNA sign on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Failure to Maintain Required LPN-to-Resident Staffing Ratios on Multiple Shifts
Penalty
Summary
The facility failed to meet state-required LPN-to-resident staffing ratios on multiple shifts, as identified through review of weekly staffing records and staff interviews. On four of twenty-one shifts reviewed, the number of LPNs scheduled and working did not meet the minimum required ratios of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility’s census. Specifically, on April 8, 2026, the day shift had 1.02 LPNs instead of the required 1.08 for a census of 27 residents. On April 10, 2026, the day shift had 1.03 LPNs instead of the required 1.12 for a census of 28 residents, and the night shift had 0.00 LPNs instead of the required 1.00 for the same census. On April 12, 2026, the day shift had 1.00 LPN instead of the required 1.12 for a census of 28 residents. On these dates, there were no additional higher-level staff available to compensate for the LPN shortfall. In an interview on April 14, 2026, at 2:00 PM, the nursing home administrator confirmed that the facility had not met the required LPN-to-resident ratios on the identified dates. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency is based solely on staffing levels relative to the resident census and regulatory requirements.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to LPNs for 4 shifts. 2.A facility wide audit was completed to ensure ratios were met. LPN sign on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Failure to Provide Required RN Coverage on Night Shifts
Penalty
Summary
The facility failed to meet the regulatory requirement, effective July 1, 2023, to provide a minimum of one RN per 250 residents on all shifts, as evidenced by staffing records and staff interview. A review of the weekly staffing records showed that on four separate night shifts, when the facility census ranged from 27 to 28 residents, there were no RNs scheduled or present, despite the requirement for at least one RN on duty. Specifically, on four identified nights, the RN count was zero against the required minimum of one RN for the existing census. During an interview on April 14, 2026, at 2:00 PM, the Nursing Home Administrator confirmed that the facility did not meet the required RN-to-resident ratio on those dates and shifts. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were documented in the report.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to RNS for 4 shifts. 2.A facility wide audit was completed to ensure ratios were met. RN on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Deficient Food Storage and Sanitation Practices in Dietary Department
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness in the food and nutrition services department. During an initial tour of the dietary department, surveyors observed that the handwashing area lacked a trash can for disposing of paper towels after handwashing. In the freezer, four bags of frozen vegetables and one bag of tater tots were found on the shelf without any date markings. In the dry storage room, the exit door to the outside could not close properly because the metal locking latch was folded back in the door jam, and the floor area in front of the door was worn, soiled, and had cracked floor tiles. Additionally, a six-inch piece of floor molding was missing from the wall near the exit door. Further observation in the janitor closet within the dietary department revealed a sink containing a plastic bin filled with microfiber cloths, aprons, and a container of cleaning wipes. The food service director confirmed at the time of the observations that the dietary department should be maintained in a sanitary manner, and that all food items should be properly dated to ensure safety and quality. These findings indicate that the facility did not follow acceptable practices for food storage and sanitation, as required by professional standards and state regulations.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with dementia, the quarterly MDS inaccurately documented pneumonia in the infection section, despite no evidence in the clinical record that the resident had pneumonia during the seven-day look-back period. The Registered Nurse Assessment Coordinator (RNAC) confirmed the inaccuracy. For another resident with Parkinson's Disease, the initial MDS indicated no impairment in range of motion, while occupational therapy documentation identified functional limitations and a goal to increase shoulder flexion. Observation revealed joint deformities in both hands, and the resident expressed a need for adaptive devices to eat. The RNAC and Director of Rehabilitation could not confirm the accuracy of the MDS coding and entered a correction during the survey. A third resident with moderate dementia and agitation had a quarterly MDS assessment that documented a gradual dose reduction of antipsychotic medication on a specific date. However, physician orders and nursing documentation showed the dose reduction occurred earlier, and the RNAC could not confirm the accuracy of the MDS coding. The Director of Nursing was also unable to provide documentation supporting the accuracy of the MDS for two of the residents. These findings were based on clinical record reviews, resident observations, and staff interviews.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to ensure the resident's readiness and safety during the transition were not followed, resulting in a deficiency related to the transfer/discharge process.
Failure to Update Care Plan After Psychosocial Incident Involving Family Member
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with Parkinson's Disease, despite significant psychosocial events involving the resident's son. The resident, who was cognitively intact as indicated by a BIMS score of 13, experienced two incidents where his son displayed disruptive and hostile behaviors, including verbal aggression and vulgar language toward staff in the resident's presence. On one occasion, law enforcement was required to intervene, resulting in the son being handcuffed and removed from the facility, after which he was prohibited from entering the building. Despite these events, a review of the resident's care plan revealed no evidence that the resident's psychosocial well-being had been evaluated or addressed in relation to the incidents or the subsequent restriction of his son's visitation. Interviews with the Social Worker and the Director of Nursing confirmed that the care plan was not updated to include ongoing assessment of psychosocial needs or related goals following these incidents. This failure was not consistent with the facility's policy, which requires individualized care plans to be revised as information about the resident and their condition changes.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established care plan or the expressed wishes and clinical needs of the resident involved.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian, as required by federal regulatory guidance. The current food service director (FSD), who has been in the position since March 8, 2024, is not yet a certified dietary manager but is enrolled in a class to become one. The facility has a part-time registered dietitian who works remotely and does not provide in-person oversight to the department. Additionally, a regional certified dietary manager provides some oversight support. The facility's assessment indicated the need for two dietitians or other qualified nutrition professionals to serve as the director of food and nutrition services. The facility has been without an onsite registered dietitian since January 5, 2024, and without a full-time qualified director of food and nutrition services since March 8, 2024. The nursing home administrator confirmed these staffing deficiencies and acknowledged that the part-time registered dietitian does not provide in-person oversight or consultation. The lack of a full-time qualified director and the absence of frequent consultations from a qualified dietitian or other clinically qualified nutrition professional led to the deficiency findings.
Facility-Wide Assessment and Staffing Deficiencies
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that accurately reflected the specific resources necessary to care for its resident population. The assessment did not evaluate the diseases, conditions, and limitations of the residents, nor did it inform staffing decisions or the competencies required by staff to deliver necessary care. The facility's assessment, last reviewed on September 30, 2024, did not accurately reflect the current staffing situation, as it failed to account for the absence of key personnel such as a Director of Rehabilitation, Speech Therapist, Occupational Therapist, and Occupational Therapy Assistant. Additionally, the facility has been without an onsite registered dietitian since January 5, 2024, with the current part-time dietitian working remotely without face-to-face interaction with residents. The facility's Resident Matrix indicated a census of 26 residents, including one resident requiring enteral feeding and two new residents needing rehabilitation services. However, the facility lacked the necessary staff to provide these services as outlined in their assessment. Interviews with the Nursing Home Administrator confirmed the absence of essential rehabilitative and nutrition services, which were supposed to be provided according to the facility's assessment. The Food Service Director, who is not yet a certified dietary manager, also highlighted the lack of oversight in the nutrition services department, further contributing to the deficiency.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility was found to be non-compliant with the Centers for Medicare and Medicaid Services regulation S483.80(b)(3), which requires the designation of one or more individuals as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program. The regulation mandates that the IP must work at least part-time onsite at the facility and have primary professional training in relevant fields such as nursing, medical technology, microbiology, or epidemiology. During an interview with the Nursing Home Administrator (NHA), it was confirmed that the facility did not have a designated IP since the previous IP left on October 17, 2024. Additionally, the NHA acknowledged that there was no qualified staff member currently credentialed as an IP at the facility.
Failure to Provide Wheelchair Accommodation for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident, identified as Resident 180, who required safe wheelchair equipment. Resident 180 was admitted with bilateral below-the-knee amputations, diabetes, peripheral vascular disease, and a history of falls. The care plan indicated the need for assistance with mobility and transfers, including the use of a mechanical full-body lift. Despite these needs, the resident reported not having been out of bed since admission due to the lack of a wheelchair, which prevented participation in activities, dining, and therapy. The deficiency was further highlighted by the absence of a wheelchair or specialized seating equipment in the resident's room. Interviews with staff revealed that a physical therapy evaluation determined the need for front and rear anti-tipper devices on the wheelchair to ensure stability. Although a maintenance work order was submitted, it was not completed, and the resident remained without a wheelchair for five days. The Director of Nursing confirmed that the facility did not provide the necessary accommodations in a timely manner, as the maintenance staff had not been present to fulfill the work order until after surveyor inquiry.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to assess, evaluate, and monitor nutritional parameters and develop and implement individualized nutritional interventions for two residents, and deter weight loss for another resident. Resident 1 was admitted with diagnoses including diabetes and dementia, but there was no documented evidence of a nutritional assessment completed within 72 hours of admission. This lack of timely assessment meant that individualized nutritional goals were not established for Resident 1. Resident 22, who was admitted with dysphagia and malnutrition, required a feeding tube for nutritional support. Despite having a physician order for continuous tube feeding and water flushes, Resident 22 experienced significant weight loss of 10.5% over 24 days. There was no evidence of a reweight upon admission or after the significant weight loss, nor was there documentation that the resident's nutritional requirements were evaluated or that the physician and family were informed of the weight loss. Resident 17, who had dysphagia and dementia, was readmitted to the facility but did not have a weight obtained upon readmission. The resident experienced an 8.6% weight loss over 50 days, and a reweight was delayed. Although a dietary note later identified the significant weight loss and recommended health shakes, there was no evidence that the physician or responsible party was notified. The facility's failure to timely identify and address Resident 17's weight loss was confirmed by the Nursing Home Administrator.
Failure to Implement Physician's Orders for Resident with Feeding Tube
Penalty
Summary
The facility failed to implement physician's orders and provide appropriate treatment and services to a resident with a feeding tube. Resident 22, who was admitted with diagnoses including dysphagia, surgical aftercare following surgery for a ruptured appendix, and malnutrition, had a PEG tube placed during hospitalization. The physician ordered a continuous tube feeding of Osmolite 1.5 Cal at 55 ccs per hour with 200 ccs of sterile water every four hours for hydration, along with a puree diet with thin liquids. Additionally, dysphagia therapy was ordered to be provided 3 to 5 times a week for 4 weeks to help the resident transition to a mechanical soft diet. However, the facility did not provide evidence that the ordered dysphagia therapy was administered to advance the resident's diet. Despite the resident's spouse inquiring about decreasing the tube feeding, the physician indicated that nutritional gains were necessary before considering such a change. An interview with the Nursing Home Administrator confirmed the lack of evidence for the provision of treatment and services aimed at restoring oral eating skills for the resident receiving tube feeding.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve meals at safe and palatable temperatures, as required by federal regulatory guidance. According to the facility's Food Temperature Recording Policy, hot foods should be served and held at or above 135 degrees Fahrenheit, while cold foods should be held and served at or below 41 degrees Fahrenheit. However, during a group interview with seven alert and oriented residents, all participants reported that food temperatures were frequently cold. One resident expressed a desire for meals to be at least warm, indicating dissatisfaction with the current food service. A test tray conducted on the Nursing Unit revealed that the hot meal items, including Swedish meatballs, mashed potatoes, mixed vegetables, and coffee, were served at temperatures significantly below the required 135 degrees Fahrenheit. Specifically, the Swedish meatballs and mashed potatoes were at 115 degrees Fahrenheit, mixed vegetables at 105 degrees Fahrenheit, and coffee at 107 degrees Fahrenheit. These temperatures were confirmed to be cold and not palatable, as acknowledged by the nursing home administrator. This deficiency was documented under F801.
Failure to Provide Routine Evening Snacks
Penalty
Summary
The facility failed to ensure the provision of a nourishing evening snack when more than 14 hours elapsed between the supper meal and breakfast the next day for several residents. The facility's policy, last reviewed in February 2024, mandates that there should not be more than a 14-hour span between the evening meal and breakfast unless a nourishing bedtime snack is provided. However, the scheduled mealtimes revealed a 14.25-hour gap between the evening meal and the next day's breakfast. Interviews with residents indicated that snacks were not routinely offered in the evenings, and some residents had to rely on family members to bring them food. During interviews, several residents expressed that they would like to receive an evening or bedtime snack, but these were not routinely offered. One resident mentioned that snacks were available at the nurse's station, but not all residents were able to access them, especially those who could not self-propel their wheelchairs. The Nursing Home Administrator was unable to explain why the residents were not routinely offered and provided with a bedtime snack, indicating a lapse in adherence to the facility's policy and resident care needs.
Failure to Provide Specialized Therapy Services
Penalty
Summary
The facility failed to provide specialized occupational therapy and speech therapy services according to professional standards of practice for two residents. Resident 180, admitted with diagnoses including bilateral below-the-knee amputations and a history of falls, did not receive occupational therapy services as the facility lacked an occupational therapist. Despite a physician's order for occupational therapy, the resident reported not receiving therapy and had not been out of bed since admission. Interviews with staff confirmed the absence of an occupational therapist and a speech therapist at the facility. Resident 22, admitted with conditions such as peritonitis and dysphagia, also did not receive the prescribed occupational and speech therapy services. Although initial evaluations were conducted, there was no documented evidence of continued therapy sessions. The resident's care plan included orders for therapy to address functional decline and swallowing difficulties, but the facility failed to provide these services as prescribed. Interviews with the Nursing Home Administrator confirmed the facility's failure to adhere to its admission agreement and assessment, resulting in the lack of specialized therapy services for both residents. The absence of key therapy staff contributed to the deficiency, as the facility had not had a speech therapist since early November and an occupational therapist since shortly thereafter.
Failure to Report Resident Abuse by a Resident
Penalty
Summary
The facility failed to report multiple instances of resident abuse perpetrated by Resident M1 to the State Survey Agency, as required by their abuse prohibition policy. The policy mandates that any accident or incident, regardless of severity, must be reported to the department supervisor immediately, followed by an investigation and completion of an accident or incident form. However, despite several documented incidents of verbal abuse and aggressive behavior by Resident M1 towards other residents, these were not reported to the appropriate state authorities. Resident M1, who was admitted with diagnoses including morbid obesity, GERD, and mobility issues, exhibited a pattern of abusive behavior. Incidents included yelling at and mocking other residents, using derogatory language, and engaging in loud and argumentative behavior. These behaviors were documented in nursing and behavior notes over several months, yet the facility did not fulfill its obligation to report these incidents to the State Survey Agency. The Nursing Home Administrator confirmed the failure to report during an interview.
Failure to Investigate and Report Resident Abuse
Penalty
Summary
The facility failed to investigate and report multiple instances of resident abuse perpetrated by Resident M1. The facility's policy on abuse protection mandates that all incidents, regardless of severity, must be investigated, and findings reported to the State Survey Agency within five working days. However, the facility did not adhere to this policy. Resident M1, who has diagnoses including morbid obesity, GERD, and mobility issues, was involved in several incidents of verbal abuse towards other residents. These incidents were documented in nursing and behavior notes, detailing instances where Resident M1 yelled, taunted, and used derogatory language towards other residents, causing distress and disruption. Despite the documentation of these incidents, the facility did not provide evidence of completed investigations or submission of the required PB-22 forms to the State Survey Agency within the stipulated timeframe. The Nursing Home Administrator confirmed the failure to investigate and report these incidents as required. The deficiency highlights a significant lapse in the facility's responsibility to protect residents from abuse and comply with state regulations.
Failure to Provide Social Services After Resident Abuse
Penalty
Summary
The facility failed to provide necessary therapeutic social services to assess and address the psychosocial needs of residents following incidents of abuse by Resident M1. The regulatory guidance under S483.40(d) requires facilities to provide or arrange for mental and psychosocial counseling services and to identify non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. However, the facility did not adhere to these guidelines in the case of Resident M1, who was involved in multiple incidents of verbal abuse and altercations with other residents. Resident M1, who was admitted with diagnoses including morbid obesity, GERD, and mobility issues, was documented in several instances of abusive behavior towards other residents. These incidents included yelling, taunting, and using derogatory language, which caused distress among other residents. Despite these repeated occurrences, there was no documented evidence of the facility's efforts to identify the affected residents or provide supportive social service interventions to assist them in coping with the abuse. Interviews with the Director of Social Services and the Nursing Home Administrator confirmed the lack of documented social service assessments and interventions following the episodes of abuse by Resident M1. This deficiency highlights the facility's failure to comply with the regulatory requirements to maintain the mental and psychosocial well-being of its residents, as outlined in the relevant state codes and federal regulations.
Failure to Provide Appropriate Wheelchair for Bariatric Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a bariatric resident, identified as Resident M1, who required safe wheelchair equipment. Resident M1 was admitted with diagnoses including morbid obesity and polyosteoarthritis, and weighed 528.6 pounds as of May 13, 2024. During a facility tour on May 16, 2024, Resident M1 was observed using a bariatric wheelchair with a maximum weight capacity of 500 pounds, which was insufficient for the resident's weight. The resident had exceeded the wheelchair's weight capacity since February 8, 2024, when they weighed 508.2 pounds. The facility was unable to provide documented evidence that the weight capacity issue of the wheelchair had been identified and addressed. An interview with the Nursing Home Administrator confirmed that the resident's weight exceeded the wheelchair's maximum capacity, and the facility had not provided appropriate wheelchair equipment to meet the needs of the bariatric resident. This deficiency was noted under 28 Pa. Code 205.75 Supplies.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to return the personal funds of a resident within 30 days of their discharge or death, as required by regulations. The clinical record review showed that the resident was admitted to the facility and later expired. A financial account statement revealed a credit balance of $9,520, which was later adjusted to $6,584. However, the refund was not issued due to miscommunications within the facility's departments. This was confirmed by a letter from the Principal of the organization and an interview with the Nursing Home Administrator, who acknowledged that the funds were not refunded to the resident's family within the stipulated time frame. The deficiency was identified during a review of clinical records, financial account records, and staff interviews, highlighting a lapse in the facility's management of resident funds. The failure to refund the resident's personal funds within the required timeframe was a violation of the resident's rights as per the applicable state codes.
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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