Kadima Rehabilitation & Nursing At Lititz
Inspection history, citations, penalties and survey trends for this long-term care facility in Lititz, Pennsylvania.
- Location
- 125 South Broad Street, Lititz, Pennsylvania 17543
- CMS Provider Number
- 395590
- Inspections on file
- 26
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 51
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Lititz during CMS and state inspections, most recent first.
A resident who was cognitively intact and required assistance with toileting had multiple documented periods of several consecutive days without a bowel movement, yet nursing staff did not document implementation of the facility’s bowel protocol or use of PRN constipation medications ordered by the physician. Nursing notes during these no-BM periods lacked abdominal and bowel sounds assessments, and when the resident later reported nausea and diarrhea, the nurse was unsure of the number of recent BMs and did not complete a comprehensive assessment to determine if the diarrhea represented fecal seepage from constipation. The DON stated that EMR alerts are generated when a resident has no BM for two days and should trigger the bowel protocol, but confirmed there was no documentation that this protocol was followed for this resident.
A resident with depression, anxiety, and altered mental status developed neck marks that led staff to initiate suicide precautions and obtain crisis and psychiatry evaluations, with psychiatry recommending Hydroxyzine and PRN follow-up. Family later reported that the resident admitted to cutting their neck with glass from a picture frame and trying to kill themselves, and the DON confirmed reports of self-harm and damage to the resident’s belongings, but there was no documented follow-up behavioral health consult at that time. Days later, the resident was sent to the ER for abdominal pain, where records documented fecal impaction, suicidal ideations, and the resident’s admission of attempting self-harm with glass and a cord, prompting an ER behavioral health consult that recommended PCP follow-up and counseling. After return, facility notes described delusions, paranoia, increased anxiety, wandering, and medication refusal, yet there was no documentation that the PCP was notified of these escalating behaviors or that behavioral health services were engaged until weeks later.
A resident on hospice care with multiple serious diagnoses did not receive several scheduled doses of morphine and lorazepam as ordered for pain and terminal restlessness. The assigned agency nurse withheld the medications, citing a lack of observed symptoms, and the facility's investigation confirmed the missed doses, resulting in a finding of neglect.
A resident with multiple medical conditions developed skin impairments on both ankles that were not promptly reported to a physician or treated according to facility policy. Although skin issues were identified and documented, there was a delay in notifying the physician and in starting the wound care ordered by the wound NP, resulting in a lapse in timely pressure ulcer management.
A resident with dementia, PVD, and osteoarthritis experienced a fall resulting in severe pain and a femur fracture. Despite clear signs of distress and repeated notifications to the DON and Nursing Home Administrator, there was a 14-hour delay in obtaining an x-ray and providing effective pain management, with only minimal intervention attempted during this period. The resident's pain remained unmanaged, resulting in actual harm.
The facility did not notify the State Long-Term Care Ombudsman of transfers or discharges for four residents and failed to provide written bed-hold policy information to three residents or their representatives at the time of transfer or within 24 hours for emergency transfers. Additionally, one resident was discharged without medication reconciliation. These deficiencies were confirmed through record review and staff interviews.
The facility did not have a Licensed Dietitian available to review or monitor residents' nutritional status, as confirmed by both clinical record review and interview with the Nursing Home Administrator.
The facility did not ensure that a licensed pharmacist completed monthly drug regimen reviews for a resident over several months, and failed to document that physicians addressed medication irregularities or pharmacy recommendations for multiple residents.
Three residents received as-needed opioid pain medications without documented attempts at non-pharmaceutical interventions, and two residents were not monitored for side effects of pain or anti-depressant medications. The facility's records did not reflect required documentation or monitoring, as confirmed by interviews with the administrator and DON.
Surveyors found a large build-up of ice in the walk-in freezer, with food boxes so covered in ice that their contents were unidentifiable. Staff acknowledged that this had been an ongoing problem, resulting in a failure to store food according to professional standards.
Surveyors found that dirty laundry was stored in large trash bags on the floor near clean items, with maintenance tools also present in the laundry area. No PPE was available for staff handling contaminated items, and staff reported that PPE was only used for items from rooms on transmission-based precautions.
The facility did not have a certified Infection Preventionist on staff, as required. Documentation review and administrator interview confirmed that the DON was still completing the necessary training and certification, and no other staff member was certified for this role.
A resident requested $700.00 from their personal funds, but due to the Business Office Manager's lack of access and authority to disburse funds, the resident did not receive the money until 14 days after the initial request. Staff confirmed that access to resident funds required corporate office involvement, resulting in the delay.
Two residents experienced deficiencies in their living environment, including a bedside table with a broken lock and door, and a room floor that was dull and faded after staff attempted to scrape it, removing wax. Staff confirmed the need for further floor maintenance but had not completed it.
A resident reported that about $65 was missing from a wallet that should have been locked in the supervisor's office while the resident was hospitalized. Although the missing money was reported to staff, no investigation was conducted, as confirmed by the NHA.
A resident alleged being physically abused by a facility employee, but the facility failed to conduct a thorough investigation as required by policy. Statements were only obtained from two nurses, with no input from the resident, other staff, or the alleged perpetrator, and no investigation conclusion or required reporting was documented.
A resident with a history of left femur fracture, shoulder dislocation, and obesity was not weighed weekly as ordered by the physician, and was administered Hydrocodone for pain despite a documented pain level of 0. These failures were confirmed by facility leadership.
A resident with an unstageable pressure ulcer did not receive the wound care recommended by a consultant, as the treatment orders were not updated or followed according to professional standards. This was identified during a review of clinical records and confirmed with facility staff.
Two residents were not weighed according to facility policy, with one only having an admission weight and the other lacking any post-admission weight documentation, despite one being identified as at risk for malnutrition.
A resident with End Stage Renal Disease missed a dialysis session and required emergency transport for dialysis due to the facility's failure to arrange appropriate transportation, as required by its own policy.
A certified nurse aide employed for at least one year did not complete the required 12 hours of annual in-service education, as confirmed by facility documentation and interviews with the administrator and DON.
Kadima Rehabilitation & Nursing at Lititz failed to provide an updated all-hazards risk assessment as required for emergency preparedness. During a survey, document review and interviews with the DON and Director of Maintenance confirmed that the facility did not have current documentation of this assessment, affecting the entire facility.
Surveyors found that the facility did not have documentation to verify that required semi-annual inspections and annual testing of the fire alarm system had been completed, as confirmed by the DON and Director of Maintenance.
Surveyors identified that the facility lacked required documentation for multiple scheduled inspections and maintenance activities on its automatic sprinkler systems, including quarterly, semi-annual, annual, and 3-year tests. Interviews with the DON and Director of Maintenance confirmed the absence of these records, and no evidence was provided to verify that a previously reported dry system air leak deficiency was repaired.
Surveyors found that the facility lacked documentation for both the annual 90-minute and three-year 4-hour load bank tests required for the emergency generator. During review and interviews, the DON and Director of Maintenance confirmed the absence of these records.
A stairtower door near the South Nurses' Station was found not to latch properly because of incorrectly mounted magnet hardware. This deficiency was confirmed by the DON and Director of Maintenance during the survey.
A faulty door closure was observed on the South Nurses' Station and Food Storage Room, resulting in the door failing to automatically close and latch as required for hazardous area enclosures. This deficiency was confirmed by the DON and Director of Maintenance.
The facility installed carbon monoxide detectors on its fire alarm system and placed the system into service without obtaining prior plan approval or completing an occupancy inspection, as confirmed by interviews with the DON and Director of Maintenance. No documentation of approval or completion was provided.
Surveyors found that the facility lacked an updated smoking policy for staff, failed to provide noncombustible ashtrays and self-closing metal containers in the designated smoking area, and had discarded cigarette butts on the ground in multiple locations, as confirmed by the DON and Director of Maintenance.
Surveyors found that the facility did not have documentation verifying that its emergency preparedness plan was reviewed by the EPP committee within the required annual timeframe. This was confirmed by both the DON and Director of Maintenance during the exit conference.
Surveyors found that the facility did not provide updated life safety floor plans, lacked documentation of annual carbon monoxide alarm inspections per manufacturer instructions, and could not verify evacuation and alarm protocols as required by state law. Facility leadership confirmed these documentation deficiencies during interviews.
The facility did not provide documentation to verify that required monthly and annual tests of battery-powered emergency lighting were performed, as confirmed by both document review and interviews with the DON and Director of Maintenance.
Surveyors found that the facility did not have documentation to verify that monthly visual inspections of exit signs were completed over the past year. This was confirmed by the DON and Director of Maintenance during the survey.
A deficiency was identified when the facility did not have a fire watch policy in place for periods when the fire alarm system was out of service for more than four hours. This was confirmed through document review and interviews with the DON and Director of Maintenance.
A review of facility documentation and staff interviews revealed the absence of a fire watch policy for periods when the sprinkler system is impaired or out of service for more than ten hours. This deficiency was confirmed by the DON and Director of Maintenance.
Surveyors found that the facility did not have a policy to ensure egress routes to the public way are kept clear of snow or ice. This was confirmed by both the DON and the Director of Maintenance during interviews.
A resident with cognitive impairment and extensive care needs experienced a fall and later developed new severe pain and hypotension. Despite these changes, there was no documented assessment by an RN after the onset of new symptoms, even though the RN supervisor and DON were notified. The DON confirmed that an RN assessment and documentation were required but not completed.
A resident who required maximum staff assistance with daily care needs did not receive scheduled showers on multiple occasions, as confirmed by the DON and clinical records.
Three residents who required frequent turning and repositioning did not have complete or accurate documentation in their clinical records to show that this care was provided as required by their care plans. Interviews with residents and the DON confirmed the lack of documentation for these interventions.
The facility did not provide quarterly financial statements to residents, as required by regulations. During interviews, residents reported not receiving these statements, and the Nursing Home Administrator confirmed that no statements had been sent in 2024 or 2025.
The facility did not meet the required nurse aide staffing ratios over several days, failing to provide one nurse aide per 10 residents during the day, one per 11 residents in the evening, and one per 15 residents overnight. This was identified through a review of staffing data.
The facility did not meet the required 3.20 PPD of direct resident care on four days, with PPDs ranging from 2.83 to 3.19. This was identified through a review of staffing data and communicated to the Nursing Home Administrator.
The facility failed to maintain required nurse aide staffing levels during specific shifts over a period, with deficiencies in the day, evening, and night shifts. This was confirmed through a review of staffing data and a discussion with the Nursing Home Administrator.
The facility did not meet the required 3.2 PPD of direct resident care on two days within a ten-day period. Staffing data showed that on two days, the facility provided less than the required hours of care, with 2.83 and 2.93 hours recorded. This was confirmed with the Nursing Home Administrator.
The facility did not meet the required LPN staffing ratios during specific shifts in November and December 2024. The day shift requirement of one LPN per 25 residents was not met on several dates, and the evening shift requirement of one LPN per 30 residents was also not met on multiple occasions. This was confirmed through staffing data review and an interview with the Nursing Home Administrator.
The facility failed to maintain proper sanitation during dishwashing, as the sanitizer level was found to be 10 ppm, below the required level. The facility's policy mandates checking sanitizer levels at each meal cycle, but the log lacked documentation of sanitizer strength. An employee noted that checks were done daily or every other day, with usual levels at 200 ppm. The NHA confirmed the log was updated incorrectly, omitting sanitizer recording, and acknowledged the improper sanitizer level.
A facility failed to follow physician orders for a resident, leading to a deficiency. The resident was ordered to wear dermal sleeves on their lower extremities for skin protection, but the care plan indicated tubigrips instead. The resident sustained a skin tear on the right lower leg, with exposed adipose tissue and sanguineous drainage, and reported pain during dressing changes. It was confirmed that the resident was not wearing the prescribed tubigrips during transfers.
A resident with a stage 4 pressure ulcer and an unstageable ulcer on the right heel did not receive a wound culture as ordered by the physician. Despite recommendations and orders for a wound culture to rule out osteomyelitis, the facility failed to obtain the culture, as confirmed by the Nursing Home Administrator.
A facility failed to implement enhanced barrier precautions for a resident with an in-dwelling catheter, ileostomy, and severe pressure ulcers. Observations showed no evidence of such precautions, and staff interviews revealed a lack of awareness about the requirement. The Nursing Home Administrator confirmed the absence of these precautions.
Failure to Monitor and Treat Constipation per Bowel Protocol and Physician Orders
Penalty
Summary
The facility failed to monitor and manage a cognitively intact resident’s bowel function in accordance with its bowel protocol and the physician’s PRN constipation orders. The facility’s bowel protocol required the 11–7 nursing supervisor to monitor bowel movements (BM) daily, identify residents without a BM for 2 days as at risk for constipation, and then implement a stepwise regimen including prune juice, Milk of Magnesia, Dulcolax suppository, and Fleet enema, with assessment and physician notification if there were no results or if pain or absent bowel sounds were present. The physician’s orders for the resident included PRN prune juice, magnesium hydroxide suspension, bisacodyl suppository, and Fleet enema for constipation. The resident’s admission MDS showed they were cognitively intact, required supervision with toilet transfers and partial/moderate assistance with toilet hygiene, and were coded as having an ostomy or no BM for seven days, while the admission assessment documented that the resident did not have an ostomy. Facility documentation showed that the resident had no documented BM for multiple extended periods: four consecutive days, then five days, and another five days without a BM. During these periods, there was no documented evidence that the bowel protocol steps were implemented, that the resident’s bowel status was assessed, or that the ordered PRN constipation medications were administered. Nursing progress notes on two of the days without a BM did not include an abdominal exam or bowel sounds assessment to determine constipation. A later nursing note documented the resident’s complaint of nausea and diarrhea, with vitals checked, but the nurse was unsure how many BMs the resident had, and there was no comprehensive assessment to determine whether the reported diarrhea represented fecal seepage related to constipation. The DON reported that the EMR generates alerts when a resident has no BM for two days and that supervisors are to communicate these alerts so staff can implement the bowel protocol, but confirmed there was no documentation that the protocol was followed for this resident.
Failure to Provide Timely Behavioral Health Services After Self-Harm and Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to timely and appropriately provide behavioral health services to a resident with depression, anxiety, and altered mental status. The resident was cognitively intact on admission. On one date, nursing notes documented that therapy staff reported several marks on the resident’s neck. The resident denied self-harm and suicidal ideation, but the facility initiated suicide precautions, including 15-minute checks and removal of cords and other potentially harmful items, and contacted crisis intervention. Crisis intervention assessed the resident and determined the resident was not in crisis, and a psychiatry consult documented a linear scratch on the neck, no concerns, and no suicidal or homicidal ideation or hallucinations. The psychiatrist recommended starting Hydroxyzine and follow-up in 4–6 weeks or PRN. Later that same day, nursing notes documented that the resident’s son reported the resident had admitted to using a picture frame in the room to hurt themselves and feeling depressed due to health issues, loss of independence, and increased confusion. The next day, social services documented that the granddaughter reported the resident told the son they had tried to kill themselves by grabbing glass from a picture frame and cutting their neck. The DON confirmed that the resident had informed the son they tried to hurt themselves with glass from a picture frame and that slashes were observed in the resident’s reading book sleeves. The picture frame was never found. Despite these reports and the psychiatrist’s recommendation for PRN follow-up, there was no documentation that a follow-up behavioral health consult was requested after the resident’s admission of self-harm with glass. Subsequently, the resident requested hospitalization for abdominal pain and was sent to the ER, where hospital records documented fecal impaction and suicidal ideations, along with a behavioral health consult. ER documentation indicated the resident admitted attempting to kill themselves a few days earlier by scratching their neck with glass and attempting to wrap a cord around their neck. The ER behavioral health consult recorded similar statements and recommended follow-up with the primary care physician and restarting counseling. After return to the facility, nursing notes documented delusional statements, increased anxiety, paranoia, wandering, refusal of medications, and statements about impending death and religiously themed thoughts involving judgment and the devil. There was no documented evidence that the primary physician was notified of the resident’s increased anxiety, paranoia, and delusions after the hospital transfer, and no documented evidence that behavioral health followed the resident until several weeks later, despite the ER behavioral health recommendations and the resident’s repeated reports of suicidal ideation and self-harm attempts.
Failure to Administer Prescribed Pain and Anxiety Medications
Penalty
Summary
A deficiency occurred when a resident with chronic lymphocytic leukemia, congestive heart failure, and generalized anxiety, who was on hospice care due to declining health, did not receive prescribed medications for pain and terminal restlessness. Following a fall that resulted in a left femur fracture, the resident was ordered morphine sulfate and lorazepam to manage pain and restlessness. However, clinical records and the Medication Administration Record (MAR) showed that several scheduled doses of morphine and one dose of lorazepam were not administered as ordered over a specified period. The agency nurse assigned to the resident reported discomfort with administering both medications together, citing an assessment that did not show signs of restlessness, and therefore withheld the medications. The Director of Nursing's investigation confirmed that multiple scheduled doses were missed. The Nursing Home Administrator acknowledged that the medication orders were not followed, and the agency nurse was not permitted to return to the facility. This failure to administer prescribed medications as ordered constituted neglect, as the resident was not protected from the willful withholding of necessary care.
Delayed Wound Care and Physician Notification for Pressure Ulcers
Penalty
Summary
The facility failed to provide timely wound care and physician notification for a resident who developed skin impairments on both ankles. The resident, admitted after a fall and with diagnoses including rhabdomyolysis, left quadricep injury, and right peroneal nerve compression, initially had no skin impairments noted on admission. The care plan included interventions such as frequent repositioning, use of a pressure reduction mattress, and monitoring for skin issues. On November 30, a small open area was observed on the left ankle and redness on the right ankle; the area was cleaned and dressed, but there was no documentation that the physician was notified of these findings at that time. Further review showed that the physician was not notified of the skin impairments until December 3, and no wound treatments were documented for the bilateral ankles on December 1, 2, or 3. On December 3, a wound NP assessed the resident and identified a deep tissue pressure injury on the left ankle and an unstageable pressure ulcer with eschar on the right ankle, ordering specific wound care. However, the ordered treatment was not initiated until December 5, two days after the order was made. Staff interviews confirmed the delays in both physician notification and initiation of wound care treatment.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident with diagnoses including dementia, peripheral vascular disease, and osteoarthritis, who was identified as being at risk for falls and experiencing both acute and chronic pain, suffered a fall resulting in severe pain and a subsequent fracture. Following the fall, the resident was found on the floor, assessed, and neuro checks were initiated. Although the resident was noted to be in visible pain, with swelling and deformity of the right leg, there was a significant delay in obtaining an x-ray and providing effective pain management. The resident repeatedly exhibited signs of distress, including grimacing, holding the affected leg, and verbalizing pain, but only received PRN Tylenol after several hours, which was initially declined. Morphine was not administered until much later, and the x-ray confirming a comminuted and displaced femur fracture was not completed until 14 hours post-fall. Throughout this period, documentation shows that responsible parties, including the DON and Nursing Home Administrator, were informed of the resident's ongoing severe pain, but no additional assessments, treatments, or emergency interventions were initiated until after the x-ray was completed. The DON did not assess the resident or follow up on the x-ray order despite being aware of the situation. Interviews confirmed that no appropriate action was taken to address the resident's severe pain for 14 hours, resulting in prolonged unmanaged pain and actual harm.
Failure to Notify Ombudsman and Provide Bed-Hold Policy at Transfer/Discharge
Penalty
Summary
The facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of four residents. Additionally, the facility did not provide written information about the bed-hold policy to three residents or their representatives at the time of transfer, or within 24 hours in cases of emergency transfer. These deficiencies were identified through clinical record reviews and staff interviews, which revealed a lack of documentation for both the required notifications and the provision of bed-hold policy information. Specific instances included residents being transferred to hospitals for various medical reasons, such as scheduled surgical procedures, urinary tract infection, encephalopathy, and sepsis, without evidence that the bed-hold policy was communicated or that the Ombudsman was notified. In one case, a resident was discharged to home without medication reconciliation being completed prior to discharge. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the absence of required documentation and notifications for these events.
Failure to Employ Licensed Dietitian for Nutritional Oversight
Penalty
Summary
The facility failed to employ a Licensed Dietitian to oversee and provide nutritional services to residents. Review of clinical records showed no evidence that a Licensed Dietitian was reviewing or monitoring the nutritional status of residents. During an interview, the Nursing Home Administrator confirmed that the Licensed Dietitian, who was supposed to be employed by the facility, was unavailable and had not been providing required nutritional services or monitoring residents' nutritional status.
Failure to Complete and Document Monthly Pharmacy Reviews and Physician Follow-Up
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly drug regimen reviews, including review of the medical chart, as required by policy. For one resident, there was no evidence that pharmacy consultant reviews were completed for multiple consecutive months. Additionally, for several residents, the consultant pharmacist identified medication irregularities or made recommendations, but there was no documented evidence that these irregularities were recorded or that the attending physician addressed the pharmacist's recommendations. Specifically, one resident's record lacked pharmacy consultant reviews for several months, while other residents' records showed that identified medication irregularities or recommendations for gradual dose reduction were not documented as addressed by the physician. An interview with the Nursing Home Administrator confirmed the absence of documentation for both the pharmacy reviews and physician follow-up on pharmacy recommendations.
Failure to Use Non-Pharmaceutical Pain Interventions and Monitor Medication Side Effects
Penalty
Summary
The facility failed to implement non-pharmaceutical interventions prior to administering as-needed pain medications for three residents and did not monitor for side effects of pain and anti-depressant medications for two residents. Clinical record reviews for residents with orders for pain medications such as Oxycodone HCl, Hydrocodone-Acetaminophen, and Percocet did not show evidence that non-pharmacological interventions were attempted before medication administration. Additionally, there was no documentation of ongoing monitoring for medication side effects as required by the facility's pain management policy. Specifically, one resident with a history of moderate to severe pain and another with diagnoses including a left femur fracture and left shoulder dislocation received as-needed opioid pain medications without documented attempts at non-pharmaceutical pain management. The records also lacked evidence of side effect monitoring for both pain and anti-depressant medications. These findings were confirmed in interviews with the Nursing Home Administrator and DON, who acknowledged that non-pharmaceutical interventions and side effect monitoring were not performed.
Improper Food Storage Due to Excessive Ice Build-Up in Freezer
Penalty
Summary
During a kitchen tour, surveyors observed a significant accumulation of ice in the walk-in freezer, with boxes of food so heavily covered in ice that their contents could not be identified. Staff confirmed that this ice build-up had been an ongoing issue. The deficiency was identified as a failure to store food in accordance with professional standards for food service safety, as required by regulations.
Infection Control Deficiency in Laundry Handling and Storage
Penalty
Summary
Surveyors observed that the facility failed to properly handle, store, and process laundry to prevent the spread of infection. Large trash bags containing dirty items were found on the floor in front of the dryer, and the folding table with clean items was located approximately four feet from these dirty items. Shelves in the laundry area also contained various maintenance items, such as tools and small hardware, which were stored in the same space. Additionally, there was no personal protective equipment (PPE) available for staff to use while sorting and handling contaminated items. Staff interviews confirmed that PPE was only used when handling items from rooms on transmission-based precautions, and that PPE was not available in the laundry area.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure that a qualified staff member was certified as an Infection Preventionist, as required for the infection prevention and control program. Review of facility documentation did not provide evidence of a certified Infection Preventionist on staff. During an interview, the Nursing Home Administrator confirmed that the DON was in the process of taking the required classes but had not yet completed them or obtained certification. It was further confirmed that there was no Infection Preventionist currently on staff at the facility.
Delay in Disbursement of Resident Personal Funds
Penalty
Summary
The facility failed to ensure that a resident received personal funds upon request in a timely manner. On June 24, 2025, a resident requested $700.00 from their personal funds. The Business Office Manager was unable to access or disburse the funds, as they did not have authority to write checks or access the accounts. As a result, the resident did not receive the requested funds until July 15, 2025, which was 14 days after the initial request. Interviews with both the resident and an employee confirmed the delay and the lack of access to resident funds at the facility level, requiring requests to be made to the corporate office for disbursement.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents. For one resident, the bedside table's locked drawer could not be closed and therefore could not be locked, and the bottom door of the bedside table was falling off its hinges. For another resident, the floor in the room and bathroom had large areas that appeared dull and faded, and staff had attempted to scrape the floor, which resulted in the removal of some of the wax. An employee confirmed that the floor needed to be stripped but had not had the time to complete the task. These deficiencies were identified through observations and interviews with residents and staff, and were presented to the Nursing Home Administrator.
Failure to Investigate Missing Resident Property
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when approximately $65 belonging to the resident went missing from a wallet that was supposed to be secured in the supervisor's office during the resident's hospitalization. The resident reported the missing money to staff but was not informed of any investigation into the incident. The Nursing Home Administrator confirmed awareness of the allegation but acknowledged that no investigation had been conducted. This failure was identified during a review of facility policy and interviews with the resident and staff.
Failure to Complete Thorough Abuse Investigation
Penalty
Summary
The facility failed to ensure a thorough investigation was completed following an allegation of physical abuse involving one resident. According to facility policy, all reports and allegations of abuse, including injuries of unknown origin, must be promptly reported, evaluated, and thoroughly investigated, with witness statements obtained and a conclusion documented. In this case, a resident alleged being hit in the mouth by a facility employee. The facility obtained statements from two nurses present at the time but did not obtain statements from the resident, other staff members present, or the alleged perpetrator. Additionally, there was no evidence in the facility documentation of a conclusion to the investigation, and no PB 22 form was filed for the alleged perpetrator as required. An interview with the Nursing Home Administrator confirmed that the investigation was not thoroughly completed and that the necessary documentation and reporting steps were not followed.
Failure to Follow Physician Orders for Weights and Pain Medication
Penalty
Summary
The facility failed to follow physician orders for a resident with diagnoses including a left femur fracture, shoulder dislocation, and obesity. The resident's care plan required adherence to a prescribed diet and weekly weights for four weeks, but documentation showed the resident was only weighed once during that period, not weekly as ordered. Additionally, the resident had a physician order for Hydrocodone 7.5 mg to be administered every four hours as needed for severe pain, but records indicated the medication was given when the resident's pain level was documented as 0. These deficiencies were confirmed by interviews with the Nursing Home Administrator and Director of Nursing.
Failure to Implement Recommended Pressure Ulcer Treatment
Penalty
Summary
A resident with an unstageable pressure ulcer on the right medial ankle was evaluated by a wound consultant, who recommended specific wound care treatments including cleansing with normal saline solution, application of medical grade honey and calcium alginate, securing with bordered foam, and changing the dressing daily and as needed. Despite these recommendations, a review of the resident's physician orders and treatment administration record for the month showed that the recommended treatment had not been implemented or updated as advised. This lapse was confirmed during a review and brought to the attention of the Director of Nursing.
Failure to Monitor Resident Weights as Required
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two of five residents reviewed. According to facility policy, all residents are to be weighed on admission, readmission, and at least monthly. For one resident, an admission weight and a mini nutritional assessment were completed, which identified the resident as being at risk for malnutrition, but no subsequent weights were obtained. For another resident, the only documented weight was recorded prior to admission, with no further weights obtained after admission. These findings were confirmed through review of clinical records and interviews with staff.
Failure to Provide Transportation for Dialysis Services
Penalty
Summary
The facility failed to provide transportation for a resident with End Stage Renal Disease who required dialysis services. According to the facility's policy, all transportation arrangements to and from the dialysis center were to be made by the facility. Clinical record review showed that the resident was sent to a hospital emergency department via ambulance to receive dialysis on one occasion, and on another occasion, the resident missed a dialysis session due to a transportation issue. These events were confirmed through review of progress notes and interviews with facility leadership.
Failure to Complete Annual In-Service Training for Nurse Aide
Penalty
Summary
The facility failed to ensure that a certified nurse aide who had been employed for at least one year completed the required 12 hours of annual in-service education. Review of facility documentation did not provide evidence that the nurse aide had fulfilled this annual training requirement. This was confirmed during an interview with the Nursing Home Administrator and the DON, who acknowledged that the nurse aide had not completed the mandated in-service hours.
Failure to Maintain Updated All-Hazards Risk Assessment
Penalty
Summary
Kadima Rehabilitation & Nursing at Lititz was found to be non-compliant with federal emergency preparedness requirements during a Medicare/Medicaid Recertification Survey. Specifically, the facility failed to provide an updated all-hazards risk assessment as required by regulation. This assessment is a critical component of the emergency preparedness plan and must be reviewed and updated at least annually for LTC facilities. The deficiency was identified through document review, which revealed the absence of an updated risk assessment for the facility. During the exit conference, both the Director of Nursing and the Director of Maintenance confirmed that they could not provide documentation of an updated all-hazards risk assessment. The lack of this documentation affected the entire facility component, as the risk assessment is necessary to identify and plan for potential emergency events, including missing residents and other hazards relevant to the facility's operation.
Plan Of Correction
1. We cannot retroactively correct. 2. The Hazard Risk Assessment will be updated. 3. Administration will be educated on the need for updating the Hazard Risk Assessment. 4. The EPP committee will review the updated risk assessment.
Failure to Document Fire Alarm System Inspections and Testing
Penalty
Summary
The facility failed to provide documentation verifying that required semi-annual inspections and annual testing of the fire alarm system had been performed within the previous twelve months. During a document review, surveyors were unable to locate records confirming that these inspections and tests had occurred as mandated by NFPA 70 and NFPA 72 standards. This lack of documentation was confirmed in an interview with the Director of Nursing and the Director of Maintenance, who acknowledged that the records for the semi-annual inspection and annual testing of the fire alarm system were not available.
Plan Of Correction
The facility has received documentation of the semi-annual and annual tests of the fire alarm system. The facility will ensure that all verifying documentation is received and on premises of any inspections that are completed. The Environmental Services Director has been re-educated on the requirements of regulation K0345. The NHA or designee will complete an annual audit of the tests of the fire alarm system in July x 2 years. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Missing Documentation for Sprinkler System Maintenance and Testing
Penalty
Summary
The facility failed to provide required documentation for the inspection, testing, and maintenance of its automatic sprinkler systems as mandated by NFPA 25. During a document review, it was found that records were missing for several critical maintenance activities, including semi-annual valve supervisory switches and pressure switch waterflow alarm checks, 1st and 3rd quarterly inspections, annual main drain/control valve tests, annual dry system partial trip tests, and the 3-year dry system full trip test. These deficiencies were confirmed during interviews with the Director of Nursing and Director of Maintenance, who acknowledged the absence of the necessary documentation for the facility's installed sprinkler systems. Additionally, a review of records and interviews revealed that the previous sprinkler company, Johnson Controls, had reported a 3-year air leak failure during an inspection, but the facility could not provide documentation confirming that the 3-year leak test was performed or that the identified deficiency in the dry sprinkler system was repaired. The lack of documentation for these required maintenance and testing activities affected the entire sprinkler system component.
Plan Of Correction
1 The facility is unable to retroactively perform this testing. 2 Testing will be completed for the wet/dry valve system. Three-year leak tests will be performed. The facility will ensure that all verifying documentation is received and on the premises of any inspections that are completed. 3 The Environmental Services Director was re-educated on the requirements of K0353. 4 The NHA or designee will complete an annual audit of the tests of the wet/dry valve system in August x 2 years. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.
Missing Emergency Generator Testing Documentation
Penalty
Summary
The facility failed to provide documentation of required annual and three-year testing for the emergency generator that serves the entire facility. During a document review, it was found that records for the annual 90-minute load bank test and the three-year 4-hour load bank test were missing. These tests are mandated to ensure the generator and associated equipment can supply power within the required timeframe and are maintained according to NFPA standards. At the time of the exit conference, both the Director of Nursing and the Director of Maintenance confirmed that the facility was unable to supply the necessary test results for the emergency generator. The deficiency was identified solely through document review and staff interview, with no mention of specific residents or patient conditions related to the deficiency.
Plan Of Correction
1. The facility is unable to retroactively perform this testing. 2. Testing will be completed for the annual, 90-minute load bank and the 3-year, 4-hour load bank. 3. The Environmental Services Director was re-educated on the requirements of K0918. 4. The NHA or designee will complete an annual audit of the annual testing yearly in August. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.
Stairtower Door Failed to Latch Due to Improper Hardware
Penalty
Summary
A deficiency was identified when the first floor stairtower door, located by the South Nurses' Station, failed to latch properly in its frame. This issue was observed during a facility inspection and was attributed to improperly mounted magnet hardware on the door. The failure of the door to positively latch was confirmed during an interview with the Director of Nursing and the Director of Maintenance at the time of the exit conference. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1. The first floor stair tower door's hardware was adjusted to ensure positive latch. 2. A facility-wide audit was completed to ensure positive latch of required doors. 3. The Environmental Services Director was re-educated on the requirements of K0225. Monthly door latch audits will occur. 4. The NHA or designee will complete a random audit of facility doors weekly x 4 weeks then monthly x 2 months to ensure positive latch. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Deficient Fire Barrier Door Closure in Hazardous Area
Penalty
Summary
The facility failed to maintain the required fire safety standards for hazardous area enclosures in one of five smoke compartments. During an observation, it was found that the door to the South Nurses' Station and Food Storage Room did not automatically close and latch within the door frame due to a faulty door closure. This deficiency was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged that the door failed to function as required.
Plan Of Correction
1. The South Nurses Station and Food Storage Room door closure was adjusted to ensure positive latch. 2. A facility-wide audit was completed to ensure positive latch of required doors. 3. The Environmental Services Director was re-educated on the requirements of K0321. Monthly door latch audits will occur. 4. The NHA or designee will complete a random audit of facility doors weekly x 4 weeks then monthly x 2 months to ensure positive latch. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring. K 0321
Fire Alarm System Altered Without Required Plan Approval or Inspection
Penalty
Summary
The facility failed to obtain required plan approval and conduct an occupancy survey before making changes to its fire alarm system. Specifically, carbon monoxide detectors were installed on the existing fire alarm system without prior plan review or approval from the Department of Health. No documentation was provided to show that the necessary approvals were sought or granted before these modifications were made. Additionally, the facility placed the altered fire alarm system into service without completing an occupancy inspection or providing a record of completion for the changes. Interviews with the Director of Nursing and Director of Maintenance confirmed that the fire alarm system was altered and put into use without the required approval from the Pennsylvania Department of Health.
Plan Of Correction
K 0341 1. The facility cannot retroactively correct. 2. All new plans related to the fire alarm system will undergo both a formal plan review and an occupancy survey prior to implementation. 3. The Environmental Services Director has been re-educated on the requirements of regulation K0341. 4. The Nursing Home Administrator (NHA) or their designee will review all proposed changes to the fire alarm system to ensure full compliance with applicable codes and regulations.
Failure to Maintain Smoking Safety Standards and Updated Policy
Penalty
Summary
The facility failed to comply with NFPA 101 smoking regulations as evidenced by several deficiencies identified during document review, observation, and interviews. The facility did not have an updated smoking policy available for staff, as confirmed by both the Director of Nursing and the Director of Maintenance. Additionally, observations revealed discarded cigarette butts on the ground in multiple locations, including the back area by the dumpster and the rear parking area designated as a smoking area. Further inspection of the designated smoking area showed the absence of required safety equipment, specifically a noncombustible ashtray and a self-closing metal container for ash disposal. These deficiencies were confirmed by facility leadership during the exit conference. No information was provided regarding specific patients or their medical conditions in relation to these deficiencies.
Plan Of Correction
1. The facility has a Smoking Policy that is available for review. Kadima at Lititz is a no smoking campus. All ashtrays have been removed from around the facility. 2. The Smoking Policy will be placed in the Safety and Disaster Policy & Procedure Manual. 3. All staff will be educated on the smoking policy. 4. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly, every July.
Lack of Annual Review Documentation for Emergency Preparedness Plan
Penalty
Summary
The facility failed to provide documentation verifying that its emergency preparedness plan was reviewed within the previous twelve months. During a document review on July 1, 2025, surveyors were unable to locate evidence that the emergency preparedness plan had been reviewed by the Emergency Preparedness Plan (EPP) committee as required. An interview conducted at the exit conference with the Director of Nursing and the Director of Maintenance confirmed the absence of documentation showing that the emergency preparedness plan had been reviewed in the past year. No additional information regarding specific residents or patient conditions was provided in the report.
Plan Of Correction
1. We can not retroactively correct. 2. The Emergency Preparedness plan will be reviewed by the EPP committee. 3. The Environmental Services Director will be educated on the need for EPP review. 4. The EPP plan review will be audited yearly in July.
Failure to Maintain Life Safety Documentation and Carbon Monoxide Alarm Protocols
Penalty
Summary
Surveyors identified several deficiencies related to the facility's compliance with general requirements for life safety and state regulations. The facility failed to provide updated and accurate life safety floor plans when requested during the survey. Both the Director of Nursing and the Director of Maintenance confirmed at the exit conference that the facility could not produce these required documents. Additionally, the facility did not have documentation verifying that annual testing and inspection of installed carbon monoxide alarms had been performed according to the manufacturer's instructions, as required by the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. A Nighthawk battery-operated carbon monoxide detector was observed at the main desk, but no supporting documentation was available. Further, the facility lacked documentation verifying the existence and implementation of evacuation and alarm protocols related to carbon monoxide alarms, also in accordance with the 2016 Act 48. This was confirmed during interviews with facility leadership, who acknowledged the absence of required documentation for both annual inspections and evacuation/alarm protocols. No information about specific residents or their conditions was included in the report.
Plan Of Correction
1. Life Safety floor plan drawings have been updated and are available for review. Carbon monoxide alarms throughout the facility will receive their annual testing per the manufacturer's instructions. Evacuation and alarm protocols are available for review. 2. The facility has updated its floor plan drawings and made available its evacuation and alarm protocols. These items are posted in the Emergency Preparedness Manual. 3. The Environmental Services Director was re-educated on the requirements of K0100. The carbon monoxide alarms will be tested annually in July. The Emergency Preparedness Manual will be reviewed quarterly and PRN for accuracy. 4. The NHA or designee completed a one-time audit of the Emergency Preparedness Manual to ensure that floor plan drawings and evacuation/alarm protocols were available. The NHA or designee will complete an annual audit of the Carbon Monoxide alarm testing in July x 2 years. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Lack of Documentation for Emergency Lighting Testing
Penalty
Summary
The facility failed to provide documentation verifying that monthly and annual testing of battery-powered emergency lighting had been performed, as required by NFPA 101 standards. During a document review, it was found that there was no record of these required tests for the emergency lighting sources. This was confirmed in an interview with the DON and Director of Maintenance, who acknowledged that documentation for the testing of installed back-up emergency lighting could not be provided. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
1. The facility is unable to retroactively perform this testing. 2. Monthly and annual battery-powered emergency lighting tests were completed in July. 3. The Environmental Services Director was re-educated on the requirements of K0291. Monthly battery-powered emergency lighting tests are scheduled. Annual testing will occur in July of each year. 4. The NHA or designee will complete an audit of the battery-powered emergency lighting testing monthly x 6 months. Annual testing will be confirmed in July. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Lack of Documentation for Monthly Exit Sign Inspections
Penalty
Summary
Surveyors determined that the facility failed to provide documentation verifying that monthly visual inspections of exit signs had been conducted over the past 12 months. During a document review, it was found that there was no record of these required inspections. This finding was confirmed in an interview with the DON and the Director of Maintenance, who acknowledged that the facility could not produce the necessary documentation for exit sign inspections. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
1. The facility is unable to retroactively perform this testing. 2. A monthly exit sign inspection was completed in July. 3. The Environmental Services Director was re-educated on the requirements of K0293. Monthly exit sign inspections are scheduled. 4. The NHA or designee will complete an audit of exit sign inspection documentation monthly x 6 months. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Lack of Fire Watch Policy During Fire Alarm System Outage
Penalty
Summary
The facility failed to maintain a full and accurate fire watch policy for situations when the fire alarm system is out of service for more than four hours, as required by NFPA 101. During a document review, it was found that there was no fire watch policy in place to address the impairment or outage of the fire alarm system for extended periods. This deficiency was confirmed during interviews with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of such a policy. The lack of a fire watch policy affected the entire component of the fire alarm system and was identified through both documentation review and staff interviews. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The facility has a Fire Watch Policy that is available for review. The Fire Watch Policy will be placed in the Safety and Disaster Policy & Procedure Manual. The Environmental Services Director will be educated on the Fire Watch Policy. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly, every July.
Lack of Fire Watch Policy for Sprinkler System Outage
Penalty
Summary
The facility failed to maintain a complete and accurate fire watch policy for situations when the sprinkler system is impaired or out of service for more than ten hours. During a document review, it was found that there was no policy in place addressing the procedures to follow in the event of a sprinkler system impairment or extended outage. This deficiency was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of such a policy. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Plan Of Correction
The facility has a Fire Watch Policy that is available for review. The Fire Watch Policy will be placed in the Safety and Disaster Policy & Procedure Manual. The Environmental Services Director will be educated on the Fire Watch Policy. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly, every July.
Lack of Snow Removal Policy for Egress Routes
Penalty
Summary
Surveyors determined that the facility failed to provide a policy ensuring that egress routes to the public way remain free and clear in the event of snow or ice. During a document review, it was found that there was no existing snow removal policy in place. This finding was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of such a policy.
Plan Of Correction
1. The facility has a Snow Removal Policy that is available for review. 2. The Snow Removal Policy will be placed in the Safety and Disaster Policy & Procedure Manual. 3. The Environmental Services Director will be educated on the Snow Removal Policy. 4. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly every July.
Failure to Complete Timely RN Assessment After Change in Condition
Penalty
Summary
A deficiency occurred when a registered nurse failed to complete and document a timely assessment following a significant change in a resident's condition. The resident, who was cognitively impaired and required extensive assistance with daily care, was initially found on the floor with a minor leg injury and no complaints of pain. Later the same day, the resident began to experience new severe pain and exhibited a markedly low blood pressure of 70/44, along with increased respirations. Although the RN supervisor and Director of Nursing were notified of these changes, there was no documented evidence that a registered nurse assessed the resident at that time. The facility's failure to ensure a registered nurse performed and documented an assessment after the resident's change in condition was confirmed through review of clinical records, investigative documents, and staff interviews. The Director of Nursing acknowledged that an RN assessment should have been completed and recorded in the medical record, as required by professional standards and state regulations.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a dependent resident by not administering scheduled showers. Clinical record reviews showed that a resident, who was cognitively intact but required maximum staff assistance with daily care needs, was scheduled to receive showers twice weekly on Mondays and Thursdays. However, documentation revealed that the resident did not receive showers on several scheduled dates in May. This was confirmed by the Director of Nursing, who acknowledged that the resident missed these scheduled showers.
Incomplete Documentation of Resident Repositioning
Penalty
Summary
The facility failed to ensure that clinical records for three residents were complete and accurately documented, specifically regarding the required turning and repositioning of residents. For one resident, the care plan required turning and repositioning every two hours, but clinical records lacked documentation of this intervention on multiple days and shifts throughout the month. Another resident's care plan also required turning and repositioning every two hours, yet there was no documented evidence of this being performed for the entire month. A third resident, with a diagnosis of femur fracture and stroke, had a care plan specifying turning and repositioning every two hours as tolerated, but no documentation was found for these interventions during the review period. Interviews with the residents and the Director of Nursing confirmed the absence of documentation for the required care. One resident stated she could self-reposition but needed extra help at times, while the DON acknowledged that the documentation should have been present but was not. The findings were based on reviews of clinical records, care plans, and staff interviews, and were cited under relevant state regulations for clinical records and nursing services.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide quarterly statements regarding personal funds to residents, as required by 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities. During an interview conducted on April 29, 2025, three residents reported not receiving these statements. Additionally, no documentation was provided to support that the facility had sent quarterly statements to residents. The Nursing Home Administrator confirmed via telephone on April 30, 2025, that neither the facility nor the corporate offices had sent quarterly statements to any residents during 2024 or 2025.
Plan Of Correction
1. Facility will send retro quarterly statements to residents affected. 2. Resident records that should receive quarterly statements will be audited by NHA or designee to ensure that an updated and accurate list is available of all residents that receive quarterly statements. 3. Re-education will be completed by NHA or BOM regarding distribution of quarterly statements. Statements will be sent to POA via certified mail or if the resident is cognitive and does own finances a quarterly statement receipt will be signed by the resident to document that residents received necessary paperwork. 4. Audits will be conducted monthly x4 by NHA or designee and will be submitted to QAPI for review and analysis of need for ongoing monitoring.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the period from March 28 through April 6, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift on six occasions, one nurse aide per 11 residents during the evening shift on eight occasions, and one nurse aide per 15 residents during the night shift on four occasions. These deficiencies were identified through a review of facility staffing data and were communicated to the Nursing Home Administrator during a telephone interview on April 14, 2025.
Plan Of Correction
1. All residents will receive care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler will review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from the internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All nursing leadership staff have been educated on Nursing staffing Ratios and HPPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required Per Patient Day (PPD) of 3.20 hours of direct resident care for each resident on four specific days between March 28 and April 6, 2025. A review of the facility's staffing data revealed that on March 29, 2025, the PPD was 3.19, on March 30, 2025, it was 2.83, on April 4, 2025, it was 2.96, and on April 6, 2025, it was 2.97. This deficiency was identified during a review of the facility's staffing data and was communicated to the Nursing Home Administrator during a telephone interview on April 14, 2025.
Plan Of Correction
1. All residents will receive care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler will review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from the internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All nursing leadership staff have been educated on Nursing staffing Ratios and HPPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during specific shifts over a period from December 31, 2024, through January 9, 2025. Specifically, the facility did not maintain a minimum of one nurse aide per 10 residents on the day shift for five days, one nurse aide per 11 residents on the evening shift for two days, and one nurse aide per 15 residents on the night shift for five days. These deficiencies were identified through a review of facility staffing data and were confirmed with the Nursing Home Administrator during a telephone interview on January 15, 2025. The specific dates of non-compliance included December 31, 2024, January 1, 2025, January 2, 2025, January 5, 2025, and January 6, 2025, for the day shift; December 31, 2024, and January 1, 2025, for the evening shift; and December 31, 2024, January 1, 2025, January 4, 2025, and January 7, 2025, for the night shift.
Plan Of Correction
1. Facility can not retroactively correct. 2. All of the residents had the potential to be affected; however, there were no adverse resident outcomes as a result of this deficient practice. 3. Licensed staff have been re-educated on staffing requirements by the DON and/or designee. An ongoing systemic change put in place is the review of staffing in daily meeting. 4. Administrator/Director of Nursing and/or designee will audit the schedule for four weeks and then monthly for two months to ensure appropriate coverage.
Facility Staffing Deficiency
Penalty
Summary
The facility failed to meet the required Per Patient Day (PPD) of 3.2 hours of direct resident care for each resident on two specific days within a ten-day period. A review of the facility's staffing data from December 31, 2024, through January 9, 2025, revealed that on December 31, 2024, the facility provided only 2.83 hours of care, and on January 1, 2025, it provided 2.93 hours of care. This deficiency was confirmed with the Nursing Home Administrator during a telephone interview on January 15, 2025.
Plan Of Correction
1. Facility can not retroactively correct. 2. All residents had the potential to be affected; however, there were no adverse resident outcomes as a result of the deficient practice. 3. Licensed staff have been re-educated on staffing requirements by the DON or designee. An ongoing systemic change put in place is the review of staffing in daily meeting. 4. The Administrator/Director of Nursing/and/or designee will audit the schedule weekly for four weeks and then monthly for two months to ensure appropriate coverage is in place.
LPN Staffing Deficiency in November and December 2024
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) during specific shifts in November and December 2024. Specifically, the facility did not maintain the minimum staffing of one LPN per 25 residents during the day shift on November 23, December 6, and December 12, 2024. Additionally, the evening shift staffing requirement of one LPN per 30 residents was not met on November 19, November 22, December 4, December 5, December 9, and December 13, 2024. This deficiency was confirmed through a review of facility staffing data and an interview with the Nursing Home Administrator on December 18, 2024, who acknowledged the failure to meet the staffing ratios on the specified dates.
Plan Of Correction
1. Facility can not retroactively correct. 2. All of the residents had the potential to be affected; however, there were no adverse resident outcomes as a result of this deficient practice. 3. Licensed staff have been re-educated on staffing requirements by the DON and/or designee. An ongoing systemic change put in place is the review of staffing in daily meeting. 4. Administrator/Director of Nursing and/or designee will audit the schedule for four weeks and then monthly for two months to ensure appropriate coverage.
Sanitation Deficiency in Dishwashing Process
Penalty
Summary
The facility failed to maintain appropriate sanitation during dishwashing, as observed during a survey. The facility's policy requires that sanitizer levels be checked at each meal cycle using a chlorine test strip, with results recorded on a monitoring log. During an observation, the sanitizer strip showed a value of 10 ppm, which is below the required level. Additionally, the log for June 2024 showed recorded water temperatures but lacked documentation of sanitizer strength. An interview with an employee revealed that sanitizer checks were performed daily or every other day, with usual levels at 200 ppm. The Nursing Home Administrator confirmed that the log had been updated incorrectly, omitting the space for recording sanitizer levels, and acknowledged that the sanitizer level should not have been 10 ppm.
Failure to Follow Physician Orders for Skin Protection
Penalty
Summary
The facility failed to adhere to physician orders for a resident, identified as Resident 28, which resulted in a deficiency. The physician's order, dated February 29, 2024, required the use of dermal sleeves on the resident's bilateral lower extremities for skin protection, with instructions to remove them only for skin assessment or during care/showers. However, the active plan of care indicated the use of tubigrips instead. On March 1, 2024, documentation revealed that Resident 28 sustained a skin tear on the right lower leg, measuring 9 cm x 4 cm, with exposed adipose tissue and sanguineous drainage. The resident reported pain during dressing changes but not afterward. It was noted that the resident did not have tubigrips on during transfers, contrary to the physician's order. An interview with the Director of Nursing and Nursing Home Administrator confirmed the resident was not wearing the prescribed tubigrips during the transfer.
Failure to Obtain Wound Culture for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary services for a resident with pressure ulcers, as evidenced by the clinical record review and staff interview. The resident was admitted with a stage 4 pressure ulcer on the sacral region and an unstageable pressure ulcer on the right heel. A wound consult recommended an x-ray and a wound culture of the right heel to rule out osteomyelitis. Despite physician's orders on two separate occasions to obtain a wound culture, there was no evidence in the clinical record that the culture was obtained. The Nursing Home Administrator confirmed that the wound culture was not performed as ordered.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident requiring such measures. Observations during the survey revealed that there was no evidence of enhanced barrier precautions in the resident's room. The resident had significant medical needs, including an in-dwelling catheter, ileostomy, a stage 4 pressure ulcer in the sacral region, and an unstageable pressure ulcer on the right heel. Despite these conditions, staff interviews indicated a lack of awareness regarding the necessity of enhanced barrier precautions. The Nursing Home Administrator confirmed that these precautions were not in place for the resident.
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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