Kadima Rehabilitation & Nursing At Palmyra
Inspection history, citations, penalties and survey trends for this long-term care facility in Palmyra, Pennsylvania.
- Location
- 341 North Railroad St, Palmyra, Pennsylvania 17078
- CMS Provider Number
- 395506
- Inspections on file
- 39
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 48 (2 serious)
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Palmyra during CMS and state inspections, most recent first.
The facility failed to follow its accident and incident policy requiring completion of incident reports and witness statements to investigate falls and determine causes. A resident with muscle weakness and prior craniotomy experienced two falls, including an unwitnessed fall between beds and another during shower preparation, without a thorough documented investigation. Another resident with anoxic brain damage, respiratory failure with hypoxia, persistent vegetative state, and contractures was found with his head on the floor and feet on the bed after an unwitnessed fall, with no complete investigation documented. A third resident with a history of cerebral infarction, anxiety, and seizures, dependent on staff for toileting and dressing, was found on the floor near the bathroom door, and no investigation was documented. The Regional Clinical Director confirmed that one fall had no investigation and the others had incomplete investigations, despite the expectation for full fall investigations.
Surveyors found that the facility did not respond to grievances raised by a resident group regarding inadequate chairs for visitors and missing laundry. The facility’s grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet resident council minutes showed that concerns about insufficient visitor seating and missing laundry had been reported previously, and residents again reported the same issues during a confidential group interview. There was no evidence that the facility had taken action to address these ongoing concerns, resulting in a deficiency related to resident/family group rights and facility response.
The facility did not ensure that a resident’s DNR status was clearly and consistently documented. Facility policy required a physician’s order to accompany any advance directive and presumed CPR unless a DNR order was written. One resident’s care plan listed CPR as needed, while the resident’s POLST specified DNR/allow natural death. Review of the chart showed no physician order reflecting the DNR status documented on the POLST, and leadership confirmed the inconsistency between the care plan and the POLST.
A resident with a history of stroke and hemiplegia was repeatedly observed in bed and in a wheelchair wearing an abdominal binder, a device that restricts access to the stomach area, without documented evidence of an initial restraint evaluation or ongoing restraint assessments as required by facility policy. The policy defined physical restraints as devices attached to or adjacent to the body that the resident cannot easily remove and required assessment on admission/readmission and at least quarterly. The Regional Clinical Director reported it was unknown whether the resident could remove the abdominal binder without assistance, and no documentation showed that the need for this restraint had been evaluated or reassessed.
The facility did not follow its abuse reporting and investigation policy requiring investigation of injuries of unknown origin to rule out potential abuse. A resident with anoxic brain damage, respiratory failure with hypoxia, persistent vegetative state, contractures, cognitive impairment, and dependence on staff for bed mobility was found by nursing staff to have an abrasion on the left knee of unknown origin. There was no documentation that any investigation was completed to determine the cause of the injury or to rule out abuse, which was confirmed by the Regional Clinical Director during interview.
Two residents did not receive care according to physician orders. One resident with severe neurological impairment and contractures had orders for Derma Savers to be applied to the right hand and leg, but surveyors repeatedly observed the resident without these skin protectors and there was no documentation they were applied. Another resident with CHF, diabetes, and depression had orders for daily weights and cardiologist notification for specified weight gains; records showed multiple qualifying weight increases, missed daily weights, and no documentation that the cardiologist was notified.
A resident with anoxic brain damage, respiratory failure, persistent vegetative state, and contractures had documented bilateral ROM limitations and required assistance with ADLs. OT discharge instructions called for use of orthotics to maintain ROM and skin integrity, and a physician ordered a Posey soft elbow extension splint to be applied during daytime hours, alternating between upper extremities. Surveyor observations on multiple days found the resident without the splint, and the clinical record contained no documentation that the device had been applied as ordered. The OT director later documented that the resident had not been wearing the splint and that staff could not locate it, confirming the splint was supposed to be in use.
A resident with a history of dehydration, cognitive impairment, and a need for moderate assistance with eating had a care plan requiring that water be kept at the bedside at all times due to dehydration risk. Surveyors observed on multiple occasions that no fluids were present at the bedside despite this care plan intervention. A regional clinical director confirmed that water was supposed to be available at the bedside, supporting the finding that staff failed to provide sufficient fluids to maintain proper hydration.
An RN was observed retrieving medication cups labeled in black marker from a medication cart, and confirmed that medications had been pre-poured into the cups rather than being prepared and administered immediately as required by the facility’s Medication Administration policy. This occurred on one nursing unit and represented a failure to ensure medications/biologicals were securely stored and handled in accordance with professional standards and facility policy.
Surveyors determined that the facility did not ensure all required members attended a quarterly QAPI meeting. Review of QAPI minutes showed that the DON and the Medical Director were not present at one of the two reviewed quarterly meetings, and the Regional Clinical Director confirmed there was no documentation of their attendance. This failure to include required leadership in the QAPI meeting was cited under federal quality assessment and assurance regulations and related state management requirements.
A resident with a history of stroke, anxiety, and seizures, who was dependent on staff for toileting and dressing, did not have access to a working call system in the bathroom/bathing area. The care plan identified the resident as at risk for falls and directed staff to keep the call light within reach and encourage its use. However, multiple observations over two days showed that no call bell was available in the bathroom/bathing area, constituting a failure to provide the required call system.
A resident with iron deficiency anemia and diabetes had a consultant appointment where epoetin alfa was recommended once weekly to support red blood cell production. The consultant’s recommendation was not documented as being reviewed with the physician for an extended period, and this delay in physician involvement in the resident’s care was confirmed by the Regional Clinical Director. This constituted a failure to ensure timely physician supervision of care as required by regulation.
A resident with diabetes, dementia, chronic kidney disease, and a history of sepsis was evaluated by an endocrinology NP after a physician ordered a specialty consult. The endocrinologist documented diabetes with hyperglycemia and neuropathy and Stage IV chronic kidney disease, and recommended specific lab tests, including blood work for blood sugar and thyroid function, as well as a nephrology consult. Record review showed that the recommended labs were not ordered or completed and that no nephrology consult was ordered. The Administrator confirmed that the endocrinologist’s recommendations were not acted upon or addressed by the attending physician, resulting in a deficiency related to quality of care and nursing services.
A resident with a history of traumatic brain injury, seizures, stroke, dysphagia, and memory impairment had a physician order for a scopolamine transdermal patch every three days to manage increased secretions, with staff directed in the care plan to administer medications as ordered. During a review of the MAR, surveyors found multiple dates where the scopolamine patch was not applied and was marked on hold, with nursing notes stating it was not available from the pharmacy. In an interview, the DON confirmed that the ordered scopolamine patches were not administered on those dates because the medication was not available from the pharmacy.
Surveyors found that the facility did not have documentation verifying a functional inspection of the fire alarm system within the required twelve-month period, as confirmed by the Administrator. This deficiency affected the entire fire alarm system component.
Surveyors found that the facility did not provide documentation of required quarterly sprinkler system inspections, and observed both an obstructed sprinkler head in the walk-in freezer and a wire supported by the sprinkler system in the basement Activities Room. The Administrator confirmed these deficiencies during interviews.
Surveyors found that the facility did not have documentation to verify that staff participated in required quarterly fire drills over the past year. The Administrator confirmed that records of fire drills prior to a certain date were not available.
Surveyors found that the facility did not provide documentation verifying that required weekly inspections, monthly testing, and annual testing of the emergency generator were performed in the past year. The Administrator confirmed the absence of these records, affecting the entire emergency electrical system.
The facility did not provide documentation confirming that basement portable fire extinguishers were inspected monthly as required, with no records available for several months. This was confirmed by the Administrator during the survey.
Surveyors found that a surge suppressor was supplying power to another surge suppressor in the basement Maintenance Office, a practice known as daisy-chaining, which does not comply with NFPA 101 and related standards. This was confirmed by the Administrator during the inspection.
Surveyors observed that the headroom in a basement corridor was approximately 6 feet 2 inches, which is below the required 6 feet 8 inches for means of egress. This was confirmed by the Administrator and affected one of two smoke compartments.
A surveyor observed that the basement had only a single exit, and the Administrator confirmed the lack of at least two remote exits, resulting in noncompliance with NFPA 101 requirements for exit accessibility in smoke compartments.
A required smoke barrier was not present on a resident sleeping floor with 30 or more beds, as observed and confirmed by the Administrator. This resulted in the floor lacking the necessary subdivision into at least two smoke compartments.
The facility did not provide enough support personnel to ensure the safe and effective operation of the food and nutrition service, resulting in a deficiency related to inadequate staffing in this department.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Six residents with complex medical conditions experienced significant weight changes without required reweighs or evaluation by a dietitian, despite facility policy. Documentation of weights and follow-up assessments was lacking, and some required monthly weights were missed without explanation.
The facility did not provide enough nursing staff to meet resident needs, as all interviewed residents reported long delays in staff response to call bells due to low staffing. Documentation showed that required nurse aide, LPN, and RN staffing ratios, as well as direct care hours per resident, were not met on multiple days during the review period.
The facility did not employ a qualified dietitian or clinically qualified nutrition professional to oversee food and nutrition services, as confirmed by the Administrator during an interview. This staffing deficiency was previously cited and remains unaddressed.
The facility did not inform residents when applesauce was substituted for apple crisp on the lunch menu, and residents reported they are generally unaware of what food will be served. A resident with depression, anxiety, and protein calorie malnutrition received applesauce instead of the listed dessert and stated she often does not get what is on her tray ticket or the menu, with no notification of changes.
The facility did not employ a registered dietitian or physical therapist, resulting in residents not being evaluated for nutrition or offered physical therapy services, as confirmed by clinical record review and staff interview.
The facility did not complete a thorough facility-wide assessment to identify the specific needs and services required by its resident population, nor did it evaluate the necessary staffing levels and competencies to meet those needs. The assessment was incomplete and lacked critical information, as confirmed by the Administrator.
The Quality Assurance Committee failed to meet quarterly as required, with no documented meetings since January 2025, as confirmed by both facility records and the Administrator.
Three residents experienced a lack of respect for their dignity and preferences, including the absence of visitor chairs, inaccessible television remotes, and televisions positioned out of view. Additionally, residents reported not knowing their meal options, and posted menus were not updated to match actual meals served.
The facility did not ensure that residents had reasonable access to mail services, as all interviewed residents reported that mail was not delivered or available on Saturdays. Interviews with the NHA and DON confirmed that, despite mail arriving at the facility six days a week, the business office only distributed mail during their work hours, leading to a lack of mail service for residents on Saturdays.
The facility did not provide required written notifications about bed-hold policies, transfer reasons, or Ombudsman information to residents and their representatives when several residents were transferred to the hospital after a change in condition. Documentation confirming that these notices were sent was not present, as confirmed by the Administrator.
Two residents with a history of falls did not receive timely or appropriate fall prevention interventions as required by their care plans. One resident was repeatedly observed without non-skid footwear after a serious fall, and another experienced multiple falls without new interventions, incident reports, or physician/family notification. The DON and Infection Preventionist confirmed these deficiencies.
Staff did not document daily weights for a resident with end stage renal disease receiving dialysis, as required by facility policy and the resident's care plan. The absence of daily weight records was confirmed through clinical record review and staff interview.
Pharmacy recommendations made during monthly drug regimen reviews for five residents were not reviewed or addressed by the physician, and there was no documentation of follow-up in the medical records. The DON confirmed the lack of timely action or documentation regarding these recommendations.
A resident's responsible party was not informed about an increase in the resident's sertraline dosage or offered alternative treatment options. The DON confirmed that the responsible party was not notified of the medication change.
Residents reported that call bells were not answered promptly and that there had been no hairdresser available for months. Multiple resident council meetings documented these concerns, but there was no evidence that the facility addressed the issues raised by the resident group.
A resident with dementia and hypertension received carvedilol for high blood pressure even when their heart rate was below the physician-ordered threshold. Staff administered the medication outside of the specified parameters on multiple occasions, as confirmed by the DON.
A resident with muscle weakness developed new open areas on the sacrum, but staff did not adequately assess or measure these wounds as required by facility policy. Weekly skin assessments lacked documentation of complete evaluations, and the DON confirmed that proper assessment and measurement were not performed.
A resident with an indwelling urinary catheter was observed multiple times with the catheter drainage bag either above bladder level or on the floor, contrary to facility policy requiring the bag to be kept below bladder level and off the floor. The resident had significant medical conditions including sepsis, hematuria, kidney failure, and urinary retention.
A resident requiring enteral nutrition via feeding tube did not receive Jevity 1.5 at the rate recommended by the dietitian, as the physician's order lacked a specified rate and staff administered the formula at an incorrect rate. The DON confirmed the order was transcribed without the necessary rate, resulting in the resident not receiving nutrition as needed.
A resident with congestive heart failure and other conditions experienced significant weight increases over two months, but staff did not notify the physician as required by the care plan. Clinical records lacked documentation of physician awareness, and staff confirmed the physician was not informed.
Two residents with dysphagia and physician orders for mechanically altered diets were not provided food in the required texture. One resident received large pieces of meat instead of a ground diet, and another was served a regular texture meal instead of a pureed diet, resulting in vomiting. Staff confirmed the meals did not meet the prescribed dietary modifications.
A resident with tremor and muscle weakness, who was care planned and ordered to use red foam handles on silverware, was not provided with the required adaptive equipment during meals. The DON confirmed the omission.
The facility did not maintain complete and accurate clinical records for three residents, each with significant medical conditions, by failing to document wound consultant assessments as required. According to the Administrator, these assessments should have been included in the residents' records, but evidence of the visits was missing.
A resident with multiple medical and psychiatric diagnoses was transferred to the hospital for suicidal behavior and, after being cleared for return by a psychiatrist, was not readmitted by the facility as confirmed by the Regional Director of Operations.
Kadima Rehabilitation and Nursing at Palmyra failed to post current nurse staffing information as required. During a survey, it was found that the facility displayed outdated staffing data, with the information dated the previous day. This deficiency violates federal and state regulations that mandate daily updates of nurse staffing data, including details on registered nurses, LPNs, and certified nurse aides, as well as the resident census.
Failure to Complete Required Fall Investigations for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to investigate resident falls in accordance with its own accident and incident policy, which required staff to report all accidents or injuries to a supervisor, complete an Accident or Incident Report Form, and obtain witness statements from the resident and any staff present or first to find the resident. The Regional Clinical Director stated that these reports and witness statements were used to investigate falls, determine their cause, and prevent recurrence. However, for three sampled residents, the required investigations were either not completed or were incomplete, despite documented falls and existing care plans identifying them as being at risk for falls. For one resident with muscle weakness and a history of craniotomy, who was cognitively intact and partially dependent for ADLs, the record showed two falls—one unwitnessed fall between beds in the room and another fall when the resident stood from a wheelchair while a nurse aide was preparing for a shower—without documented evidence of a thorough investigation. Another resident with anoxic brain damage, respiratory failure with hypoxia, persistent vegetative state, and contractures, who was cognitively impaired and dependent for bed mobility, was found with his head on the floor and feet still on the bed after an unwitnessed fall, again without documented evidence of a thorough investigation. A third resident with cerebral infarction, anxiety, and seizures, who was dependent on staff for toileting and dressing, was found on the floor near the bathroom door, with no documented evidence that any investigation was completed. The Regional Clinical Director confirmed that there was no investigation for the third resident’s fall and that the investigations for the first two residents’ falls were incomplete, despite the expectation that full investigations should have been conducted.
Failure to Address Resident Council Grievances on Visitor Seating and Laundry
Penalty
Summary
Surveyors determined that the facility failed to address grievances raised by the resident group regarding visitor seating and missing laundry. The facility’s Grievance Policy, dated November 2025, 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 March 4, 2026, all four participating residents reported there were not enough chairs available in the facility for visitors, and two of the four residents reported missing laundry. Review of resident council meeting minutes from February 17, 2026, showed that residents had previously reported not enough chairs around the building for loved ones to sit during visits and that two residents had reported missing laundry. There was no evidence that the facility had addressed these ongoing concerns about inadequate visitor seating and missing laundry, resulting in a deficiency under 42 CFR 483.10(f)(5)(i)-(iv)(A)(B) related to resident/family group and response, previously cited on July 3, 2025. The deficiency was further supported by the lack of documentation or other proof that the facility had acknowledged, investigated, or resolved the grievances identified in the resident council minutes and reiterated during the group interview. The cited regulation and state code (28 Pa. Code 201.14(a)) were referenced as the standards against which the facility’s inaction was measured, emphasizing that the residents’ expressed concerns about chairs for visitors and missing laundry remained unaddressed over time.
Failure to Ensure Consistent DNR Orders with Resident’s POLST
Penalty
Summary
The facility failed to ensure that a resident’s advance directive and code status were clearly and consistently established in the medical record. Facility policy stated that all residents are presumed to have consented to CPR unless there is documentation in the medical record specifying that a DNR order be written, and that any advance directive must be accompanied by a physician’s order. For one resident, the care plan documented a presumed advance directive that CPR would be performed as needed, in line with the default presumption of full code. However, a Pennsylvania Orders for Life-Sustaining Treatment (POLST) form for this same resident indicated that in the event the resident had no pulse and was not breathing, staff were to not attempt resuscitation and to allow natural death (DNR). Review of the resident’s current physician orders revealed no documented physician order addressing the resident’s DNR status as indicated on the POLST. The Regional Clinical Director confirmed that there was no physician’s order for the resident’s DNR directive and that the care plan and POLST were inconsistent. The resident had been admitted with diagnoses including a pressure ulcer of the left buttock, severe protein-calorie malnutrition, and schizophrenia.
Failure to Assess and Monitor Use of Abdominal Binder as a Physical Restraint
Penalty
Summary
The facility failed to assess and conduct ongoing assessments for the use of a physical restraint for one resident, as required by its restraint policy. The facility’s policy, last reviewed in November 2025, defined physical restraints as any device attached to or adjacent to the resident’s body that the resident cannot easily remove and that restricts access to the body, and required restraint use to be assessed on admission/readmission and at least quarterly for elimination, reduction, or continued need. Clinical record review showed that the resident had diagnoses including cerebral infarction (stroke) and hemiplegia. On multiple observations over two days, the resident was seen in bed and in a wheelchair wearing an abdominal binder, a wide elastic compression belt that restricts access to the stomach area. In an interview, the Regional Clinical Director stated it was unknown whether the resident could remove the abdominal binder without assistance. There was no documented evidence that the facility completed an initial restraint evaluation or ongoing restraint assessments to determine the need for this restraint in accordance with facility policy and applicable state regulations (28 Pa. Code 201.12(d)(1) and 211.8(e)(f)).
Failure to Investigate Injury of Unknown Origin for Dependent Resident
Penalty
Summary
The facility failed to follow its Abuse Reporting and Investigation policy, dated November 2025, which required that injuries of unknown origin be investigated to rule out potential abuse. Clinical record review for Resident 7, who had diagnoses including anoxic brain damage, respiratory failure with hypoxia, persistent vegetative state, and contractures, and who was cognitively impaired and required staff assistance for bed mobility per a recent MDS assessment, showed that on January 29, 2026, a nurse documented an abrasion on the resident’s left knee measuring 2.3 cm by 1.3 cm with an unknown origin. There was no documented evidence that any investigation was conducted to determine the cause of this injury or to rule out potential abuse. In an interview on March 5, 2026, the Regional Clinical Director confirmed that there was no documentation of an investigation related to this injury of unknown origin, resulting in a deficiency under 28 Pa. Code 211.10(d) and 211.12(d)(1)(5).
Failure to Implement Physician Orders for Skin Protection and CHF Weight Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders and provide treatment and care according to residents’ clinical needs and documented orders. For one resident with anoxic brain damage, respiratory failure with hypoxia, a persistent vegetative state, and contractures, the physician ordered Derma Savers (skin protectors) to be applied to the right hand and right leg as tolerated. The MDS indicated this resident was cognitively impaired and dependent on staff for dressing. On multiple observations over two days, the resident was seen in a reclining chair and in bed without the ordered Derma Savers on the right hand or right lower extremity. Clinical record review and staff interview confirmed there was no documented evidence that the Derma Savers were applied as ordered. The facility also failed to follow physician orders for another resident with diabetes mellitus, congestive heart failure, and major depressive disorder. The care plan included an intervention to report changes to the provider as necessary, and a physician’s order directed staff to weigh the resident daily and call the cardiologist if the resident gained more than 2 lbs overnight or 5 lbs in one week. Clinical records showed multiple instances of weight gains exceeding these thresholds, including a 2.6 lb gain from one day to the next, a 4.2 lb gain from one day to the next, and a 6.2 lb gain over several days. There was no documented evidence that the resident was weighed daily as ordered on specific dates, and no documentation that the cardiologist was notified of the weight changes. The Regional Clinical Director confirmed the lack of documentation for both the application of Derma Savers and the required daily weights and cardiologist notification.
Failure to Implement Ordered Elbow Splint for ROM Maintenance
Penalty
Summary
The facility failed to implement ordered interventions to maintain or improve range of motion for a resident with significant contractures and neurological impairment. The resident had diagnoses including anoxic brain damage, respiratory failure with hypoxia, persistent vegetative state, and contractures, and a Minimum Data Set assessment showed limitations in ROM in both upper and lower extremities on both sides. The care plan indicated the resident required assistance with ADLs such as personal hygiene, transferring, and bed mobility. An occupational therapy discharge summary specified that the resident should use orthotics to maintain ROM and skin integrity. A physician order dated January 13, 2026, directed staff to apply a Posey Soft elbow extension splint as tolerated and to alternate upper arm use during daytime hours. Observations on March 3 and March 4, 2026, showed the resident was not wearing the Posey Soft elbow extension splint during the observed time periods. Review of the clinical record revealed no documentation that the splint had been implemented as ordered. On March 4, 2026, the Director of OT documented that the resident had not been wearing the splint and that staff were unable to locate it. The Director of OT confirmed in an interview that the splint was supposed to be in use as ordered.
Failure to Maintain Ordered Bedside Hydration for a Dehydration‑Risk Resident
Penalty
Summary
The facility failed to provide sufficient fluid intake to maintain proper hydration for one sampled resident. The resident had diagnoses that included dehydration, had cognitive impairment, and required moderate assistance with eating per the Minimum Data Set assessment. The resident’s current care plan identified a risk for dehydration and included an intervention directing staff to keep water available at the bedside at all times. However, observations on multiple occasions showed that the resident had no fluids at the bedside: on March 3, 2026, at 10:53 a.m., and on March 4, 2026, at 9:30 a.m., 10:45 a.m., 11:51 a.m., and 12:30 p.m. In an interview, the Regional Clinical Director confirmed that the resident was supposed to have water at the bedside according to the care plan. This deficiency was cited under CFR 483.25(g)(2) for failure to ensure sufficient fluid intake to maintain proper hydration and referenced a previous citation on 7/3/25, as well as 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Improper Pre-Pouring and Storage of Medications in Medication Cart
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored and administered in accordance with facility policy and professional standards. The facility’s Medication Administration policy, last reviewed in November 2025, required that medications be administered at the time they are prepared. During a medication pass observation on March 4, 2026, at 8:47 a.m., a surveyor observed an RN retrieving medication cups with labels written in black marker from a medication cart on one nursing unit. In an interview at that time, the RN confirmed that she had pre-poured the medications into the medication cups, rather than preparing and administering them immediately as required by policy. This practice occurred in a medication cart on one of one nursing units and was cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services. No additional information was provided in the report regarding specific residents, their medical histories, or their conditions at the time of the deficiency.
Required QAPI Committee Members Absent from Quarterly Meeting
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assurance and Performance Improvement (QAPI) committee attended a quarterly meeting, as required by regulation. Review of the QAPI committee minutes for the meeting held on February 18, 2026, showed that the Director of Nursing (DON) and the Medical Director were not present. During an interview on March 3, 2026, at 12:10 p.m., the Regional Clinical Director confirmed there was no documented evidence that the DON and Medical Director attended that QAPI meeting. This deficiency was cited under 42 CFR 483.75(g) for quality assessment and assurance and 28 Pa. Code 201.18(e)(1)(2)(3) related to management. No residents or specific clinical events were referenced in the report, and the deficiency is based solely on documentation review and staff interview regarding required QAPI committee membership and attendance.
Failure to Provide Working Call System in Resident Bathroom/Bathing Area
Penalty
Summary
The facility failed to ensure a working call system was available in a resident’s bathroom and bathing area. Clinical record review showed that Resident 10 had diagnoses including cerebral infarction (stroke), anxiety, and seizures, and a Minimum Data Set assessment indicated the resident was dependent on staff for toileting and dressing. The resident’s care plan identified a risk for falls and included an intervention for staff to ensure the call light was within reach and to encourage its use. However, during observations conducted on March 3, 2026, at 10:50 a.m. and 12:39 p.m., and on March 4, 2026, at 9:46 a.m., 10:35 a.m., and 11:52 a.m., no call bell was available in the resident’s bathroom/bathing area, resulting in noncompliance with 28 Pa. Code 201.18(b)(3)(e)(2.1) Management and 28 Pa. Code 211.12(d)(5) Nursing services. These findings were based on clinical record review and repeated observations that confirmed the absence of a call bell for Resident 10 despite the resident’s dependence on staff for activities of daily living and the documented care plan requirement that a call light be accessible.
Failure to Timely Communicate Consultant Medication Recommendation to Physician
Penalty
Summary
The facility failed to ensure timely physician supervision of care for one of 14 sampled residents when a consultant’s medication recommendation was not promptly communicated to the attending physician. The resident had diagnoses including iron deficiency anemia and diabetes. On January 13, 2026, a consultant documented a recommendation that the resident receive epoetin alfa once every seven days to help produce red blood cells. Clinical record review showed no documented evidence that this recommendation was reviewed with or acted upon by the physician until March 4, 2026. In an interview on March 5, 2026, at 9:15 a.m., the Regional Clinical Director confirmed that the consultant’s recommendation had not been reviewed with the physician in a timely manner, resulting in noncompliance with physician supervision requirements under 42 CFR 483.30(a) and 28 Pa. Code 211.2(d)(3). This deficiency was previously cited on July 3, 2025, under the same regulatory requirements for physician supervision and medical director responsibilities.
Failure to Implement Endocrinologist Recommendations for Complex Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement consultant physician recommendations for a resident with multiple complex medical conditions. The resident had diagnoses including diabetes, history of sepsis, resistance to multiple antimicrobial drugs, dementia, and Stage IV chronic kidney disease, with documented memory impairment on a recent Minimum Data Set assessment. A physician ordered an endocrinology evaluation, and a nurse practitioner endocrinologist subsequently assessed the resident and documented diabetes with hyperglycemia and neuropathy and Stage IV chronic kidney disease. The endocrinologist recommended specific laboratory tests, including blood work to assess blood sugar levels and thyroid function, and also recommended a nephrology consultation. Clinical record review showed no evidence that the recommended lab tests were ordered or completed, and no evidence that a nephrology consultation was ordered. In an interview, the Administrator confirmed that the endocrinologist’s recommendations had not been acted upon or addressed by the resident’s attending physician. This failure to follow through on the consultant endocrinologist’s recommendations for labs and a nephrology consult for a resident with serious comorbidities formed the basis of the cited deficiency under 42 CFR 483.25 (Quality of Care) and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services, and was noted as previously cited on 7/3/25.
Failure to Provide Ordered Scopolamine Patch Due to Pharmacy Unavailability
Penalty
Summary
The facility failed to ensure that a physician-ordered medication was available and administered as prescribed for one resident. The resident had a history of traumatic brain injury, seizures, stroke, dysphagia, and memory impairment, and was care planned for altered neurological status with an intervention for staff to administer medications as ordered. On July 23, 2023, a physician ordered a scopolamine transdermal patch every three days for increased secretions, with removal per schedule. Review of the January 2026 MAR showed that on January 3, 6, and 30, 2026, the scopolamine patch was not applied and was coded as on hold with directions to see nursing notes. Nursing notes for those dates documented that the patch was not applied because it was not available from the pharmacy. In an interview on February 4, 2026, the Director of Nursing confirmed that the ordered scopolamine patches were not administered on those dates due to unavailability from the pharmacy. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee, 28 Pa. Code 201.18(1)(3) Management, and 28 Pa. Code 211.12(d)(3)(5) Nursing services.
Lack of Documentation for Fire Alarm System Inspection
Penalty
Summary
The facility failed to provide documentation verifying that a functional inspection of the fire alarm system had occurred within the previous twelve months. During a review of records, surveyors were unable to locate any documentation confirming that the required inspection and testing of the fire alarm system had been completed as mandated by NFPA 70 and NFPA 72 standards. This was confirmed in an interview with the Administrator, who acknowledged the absence of such documentation. The deficiency affected the entire fire alarm system component within the facility. 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 cannot retroactively conduct the fire alarm system inspections for 2024. 2) The facility placed the fire alarm system inspections on a calendar schedule with a contracted vendor. The annual inspection will take place on 8/21/2025. 3) The facility re-educated the maintenance director on ensuring vendor completion of scheduled inspections. 4) The NHA or designate will complete a sprinkler fire alarm system inspections audit quarterly for 1 year, then semi-annually for 1 year. The results will be submitted to the QAPI committee for review and analysis of the need for ongoing monitoring.
Failure to Maintain and Document Sprinkler System Inspections and Obstructions
Penalty
Summary
The facility failed to provide documentation verifying that quarterly sprinkler system inspections had been conducted within the previous twelve months. During a document review, no records were available to confirm that these required inspections had taken place, and this was acknowledged by the Administrator during an interview. Additionally, observations revealed that the sprinkler head in the walk-in freezer was obstructed by boxes, and a white wire in the basement Activities Room was being supported by the sprinkler system. Both issues were confirmed by the Administrator during interviews at the time of observation. These findings indicate that the facility did not maintain the sprinkler system in accordance with required standards, specifically regarding unobstructed sprinkler heads and ensuring the system was free from extraneous weight.
Plan Of Correction
1) A quarterly sprinkler system inspection was completed on 12/13/2024 and 4/25/2025. The obstructed sprinkler head in the walk-in freezer was cleared, and the wire supported by the sprinkler system in the basement Activities Room was removed. 2) The NHA reached out to SA Comunale to confirm the next quarterly sprinkler inspection was scheduled. The Maintenance Director will complete facility rounds to ensure sprinkler heads are free of obstruction, and that sprinkler pipes are free of obstruction. 3) The maintenance director was reeducated on quarterly sprinkler inspection requirements, on ensuring that sprinkler heads are free of obstruction, and that sprinkler pipes are not obstructed. 4) The NHA or designee will complete weekly rounds ×4 weeks then monthly ×2 months to ensure sprinkler heads and pipes are free of obstruction.
Lack of Documentation for Quarterly Fire Drills
Penalty
Summary
The facility failed to provide documentation verifying that staff participated in required quarterly fire drills within the previous twelve months. During a document review, it was found that there was no documentation available to confirm that fire drills were conducted prior to June 2, 2025. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of records verifying the completion of fire drills before that date. 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 facility could not retroactively perform the missing fire drills for 2024. 2) A fire drill was conducted for the month of August to ensure the facility is back into compliance. 3) The maintenance director was re-educated on the quarterly fire drill schedule per shift. 4) The NHA or designee will conduct an audit of the fire drills quarterly for 1 year to ensure fire drills are being completed. The results will be submitted to the QAPI committee for review and analysis of the need for ongoing monitoring.
Failure to Document Emergency Generator Maintenance and Testing
Penalty
Summary
The facility failed to provide documentation verifying that weekly inspections, monthly testing, and annual testing of the emergency generator were conducted within the previous twelve months. During a document review, surveyors were unable to locate records confirming that these required maintenance and testing activities had taken place as specified by NFPA 101, NFPA 110, and related standards. An interview with the Administrator confirmed the absence of documentation for the emergency generator's weekly inspections, monthly testing, and annual testing for the past year. This lack of records affected the entire emergency electrical system component, as there was no evidence to demonstrate compliance with the required maintenance and testing protocols.
Plan Of Correction
1) The facility cannot retroactively complete an annual, monthly, and weekly generator check. 2) The weekly generator check was completed, the monthly generator check was completed, and the annual generator was completed by Penn Power on 8/8/2025. Records were placed in the life safety binder. 3) The maintenance director was re-educated on monthly, weekly, and annual generator inspections. 4) The NHA or designee will conduct a quarterly audit for 1 year monthly, then for 3 years, to ensure generator inspections are completed. The results will be submitted to the QAPI committee for review and analysis of the need for continued monitoring.
Failure to Document Monthly Fire Extinguisher Inspections
Penalty
Summary
The facility failed to provide documentation verifying that portable fire extinguishers located in the basement had been inspected on a monthly basis as required. During a document review, it was found that there was no documentation of monthly inspections for these extinguishers since January 3, 2025. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of inspection records for the specified period. No information regarding residents or their medical conditions was included in the report, and the deficiency pertains solely to the lack of required fire extinguisher inspection documentation.
Plan Of Correction
1) The facility is unable to retroactively conduct monthly fire extinguisher inspections. The basement fire extinguisher was added to the master list of fire extinguishers and inspected. 2) The maintenance director conducted a monthly audit to ensure all fire extinguishers were inspected and are on the master list. 3) The maintenance director was re-educated on ensuring that monthly fire extinguisher inspections are completed. 4) The NHA or designee will conduct an audit quarterly × 1 year to ensure that monthly fire extinguisher inspections are completed and on the master list. Results will be submitted to QAPI for review and analysis to determine need of ongoing monitoring.
Improper Use of Surge Suppressors in Maintenance Office
Penalty
Summary
Surveyors observed that within the basement Maintenance Office, a surge suppressor was supplying electrical power to another surge suppressor, a practice known as 'daisy-chaining.' This was identified during an inspection and confirmed through an interview with the Administrator. The report specifies that this arrangement failed to comply with NFPA 101 and related standards, which prohibit such use of surge suppressors and require proper monitoring of electrical equipment and power cords within the facility. No information was provided regarding any residents or their medical conditions in relation to this deficiency.
Plan Of Correction
1) The surge suppressor in the maintenance office was removed. 2) A facility-wide audit was completed to ensure there were no other surge suppressors in the facility. 3) The maintenance director was reeducated on monitoring usage of surge suppressors. 4) The NHA or designee will conduct an audit of facility surge suppressors weekly ×4 weeks then monthly ×2 months. The results will be submitted to the copy committee for review and analysis of the need for ongoing monitoring.
Insufficient Headroom in Basement Corridor
Penalty
Summary
The facility failed to maintain the required headroom clearance in a basement corridor, as observed during a survey. On July 29, 2025, it was noted that the headroom in the basement corridor measured approximately 6 feet 2 inches, which is less than the required 6 feet 8 inches above the finished floor. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the headroom did not meet the standard specified by NFPA 101 for means of egress. The deficiency affected one of two smoke compartments within the component.
Failure to Provide Required Number of Exits in Basement
Penalty
Summary
During an observation conducted on July 29, 2025, at 11:50 AM, it was found that the basement of the facility had only a single exit. This was confirmed in an interview with the Administrator at the same time, who acknowledged that the basement did not have at least two exits remote from each other. The deficiency affects one of two smoke compartments within the component, as the facility failed to provide not less than two exits, remote from one another, for each floor as required by NFPA 101 standards.
Lack of Required Smoke Barrier on Resident Sleeping Floor
Penalty
Summary
The facility failed to provide at least two smoke compartments on each resident sleeping floor containing 30 or more resident beds, as required by NFPA 101. During an observation, it was found that the resident sleeping floor did not have a smoke barrier, which was confirmed by the Administrator during an interview. This deficiency affects one of two floors within the component and was identified through direct observation and staff confirmation. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Insufficient Food and Nutrition Service Staffing
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. This deficiency was identified based on observations and findings that indicated inadequate staffing levels within the food and nutrition department, which impacted the department's ability to fulfill its responsibilities.
Failure to Follow Approved Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. No additional details regarding specific actions, inactions, or individuals involved are provided in the report.
Failure to Monitor and Assess Nutritional Status of At-Risk Residents
Penalty
Summary
The facility failed to adequately monitor and assess the nutritional status of six residents identified as being at nutritional risk. Facility policy required reweighs within 72 hours for weight changes of 3% or greater in one month, and for all weights, including reweighs, to be documented in the electronic medical record. Additionally, the policy identified muscle wasting, depression, dementia, and the need for therapeutic or mechanically altered diets as risk factors for malnutrition. Despite these policies, there was no evidence that reweighs were performed or that residents experiencing significant weight changes were evaluated by a dietitian or qualified nutrition professional. In some cases, required monthly weights were missed without documented refusals. The residents involved had complex medical histories, including muscle weakness, dementia, dysphagia, polyneuropathy, congestive heart failure, cirrhosis, pressure ulcers, diabetes, edema, metabolic encephalopathy, anemia, and end stage renal disease. Several residents experienced significant weight loss or gain over a one-month period, yet there was no documentation of follow-up assessments or interventions by nutrition professionals as required by facility policy. These deficiencies were identified through facility policy review, clinical record review, and staff interviews.
Failure to Maintain Sufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by both resident interviews and review of staffing documentation. During a group interview, all seven residents reported that staff response to call bells was significantly delayed due to low staffing levels. Facility records from June 11, 2025, through July 1, 2025, showed that the minimum nurse aide to resident ratios were not met on 17 out of 21 days, the minimum licensed practical nurse ratios were not met on 18 out of 21 days, and the minimum registered nurse ratio was not met on nine out of 21 days. Additionally, the minimum direct care hours per resident were not met on three out of 21 days. These findings indicate a consistent pattern of insufficient staffing during the reviewed period.
Failure to Employ Qualified Dietitian for Food and Nutrition Services
Penalty
Summary
The facility failed to employ a qualified dietitian or clinically qualified nutrition professional to provide food and nutrition services. During an interview, the Administrator confirmed that there was no qualified dietitian or clinically qualified nutrition professional employed by the facility. This deficiency was identified under CFR 483.60(a)(2) Staffing and 28 Pa. Code 201.18(b)(3) Management, and it was previously cited on a prior survey.
Failure to Notify Residents of Menu Substitutions and Accommodate Preferences
Penalty
Summary
The facility failed to accommodate resident food preferences and did not notify residents of menu substitutions. On July 1, 2025, the planned lunch menu included apple crisp for dessert, but due to a lack of ingredients, nurse aide 1 reported that applesauce was served instead. Seven residents interviewed stated they typically do not know what food will be served with each meal. Review of a resident's clinical record showed she had depression, anxiety, and protein calorie malnutrition, with no cognitive impairment. During lunch, this resident received applesauce instead of the apple crisp listed on her tray ticket and stated she often does not receive what is indicated on her tray or the menu, and is not informed of substitutions. There was no evidence that residents were notified about the substitution of applesauce for apple crisp.
Failure to Employ Nutrition and Physical Therapy Staff
Penalty
Summary
The facility failed to employ nutrition and physical therapy staff necessary to promote the wellbeing of its residents. Clinical record reviews showed there was no documentation indicating that residents were evaluated by a registered dietitian or offered physical therapy services. During an interview, the Administrator confirmed that the facility did not employ a registered dietitian or physical therapist, and that the services typically provided by these professionals were not being offered or provided to residents.
Incomplete Facility-Wide Assessment of Resident Care Needs and Resources
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources required to care for its resident population during both routine operations and emergencies. The assessment, last reviewed on April 30, 2025, was found to be incomplete after the first page and did not accurately identify the specific needs and services required by the various subsets and characteristics of the residents. Additionally, the assessment lacked an evaluation of the overall number of staff and the capabilities needed to ensure a sufficient and competent workforce to meet each resident's needs. During an interview, the Administrator confirmed that the facility assessment did not contain all required information.
Failure to Hold Quarterly Quality Assurance Committee Meetings
Penalty
Summary
The facility's Quality Assurance Committee did not meet on a quarterly basis as required. Review of facility documentation showed no evidence of committee meetings since January 2025. During an interview, the Administrator confirmed that there was no documentation of quarterly meetings prior to January 2025 or between January 2025 and June 2025. This failure was identified through both documentation review and staff interview.
Failure to Honor Resident Dignity and Preferences
Penalty
Summary
The facility failed to provide care and services in a manner that respected the dignity and preferences of three residents. One resident with hemiplegia and depression reported that there were no chairs in her room for visitors, and observation confirmed the absence of chairs. Another resident with an overactive bladder, cataract, and depression was observed in bed and stated she could not watch television because the remote control was out of reach; this was confirmed during two separate observations. A third resident, who had a history of stroke, muscle weakness, and depression, stated he could not watch television because it was mounted behind his headboard and out of his field of vision, a situation that persisted over multiple observations since his readmission. Additionally, during a group interview, all seven residents present reported that they often did not know what meals they would be receiving. Observation revealed that the posted menus on the nursing unit were not updated to reflect the current date or meal, and a review of the facility menus confirmed discrepancies between the posted and actual menus. These findings demonstrate a failure to honor residents' rights to dignity, self-determination, and communication.
Failure to Provide Reasonable Access to Mail Services
Penalty
Summary
The facility failed to provide reasonable access to mail services for all residents. During a resident council group interview, all seven residents present reported that mail was not delivered or made available on Saturdays. Further interviews with the Nursing Home Administrator and DON confirmed that, although mail was delivered to the facility Mondays through Saturdays, the business office only distributed mail during their scheduled work hours, resulting in residents not receiving mail services on Saturdays.
Failure to Provide Written Bed-Hold and Transfer Notices Upon Hospitalization
Penalty
Summary
The facility failed to provide required written notifications to residents and their representatives regarding bed-hold policies, transfer information, and Ombudsman contact details when residents were transferred to the hospital. Specifically, for five out of six sampled residents who experienced a change in condition and were subsequently transferred and admitted to the hospital, there was no documentation that written information about the bed-hold policy or the reasons for transfer was given to the residents or their representatives. Clinical record reviews for these residents showed multiple instances of hospital transfers following changes in condition, yet in each case, the necessary written notifications were not documented. An interview with the Administrator confirmed that there was no evidence to support that these notices were sent to the appropriate parties at the time of transfer.
Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement appropriate interventions to prevent accident hazards for two residents with a history of falls. For one resident with a history of stroke, difficulty walking, and muscle weakness, the care plan required non-skid footwear at all times. However, after an unwitnessed fall that resulted in a femoral neck fracture and subsequent hospitalization, the resident was observed on two occasions without non-skid footwear, instead wearing regular socks. The DON confirmed that non-skid footwear should have been in place as per the care plan. Another resident with dementia, glaucoma, muscle weakness, lack of coordination, muscle wasting, and a history of falls experienced multiple falls over several months. Despite repeated incidents, there was no evidence that new interventions were implemented to prevent further falls until after several events had occurred. Additionally, staff did not complete incident reports or notify the resident's physician or responsible party following the falls, as confirmed by both the DON and the Infection Preventionist.
Failure to Document Daily Weights for Dialysis Resident
Penalty
Summary
Facility staff failed to provide dialysis care and services consistent with professional standards for a resident diagnosed with end stage renal disease who required dialysis. According to the facility's Hemodialysis Policy and Procedure, staff were required to weigh the resident daily. Review of the resident's care plan also indicated a need to monitor weight due to the risk of fluid volume changes associated with dialysis. However, clinical record review showed there was no documented evidence that daily weights were obtained for this resident. This lack of documentation was confirmed by the Infection Preventionist during an interview.
Failure to Address Pharmacy Recommendations in Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that pharmacy recommendations made during monthly drug regimen reviews were reviewed and addressed by the physician in a timely manner for five sampled residents. According to the facility's policy, a licensed pharmacist is required to review each resident's drug regimen monthly and report any irregularities to the attending physician, DON, and Medical Director, with the expectation that these reports are acted upon and documented in the physician's progress notes. However, clinical record reviews revealed that for five residents, pharmacy recommendations made over several months were not addressed by the physician, and there was no evidence of follow-up or documentation in the residents' medical records. Specifically, recommendations for medication changes or concerns were made by the pharmacist for each of the five residents on multiple occasions, but there was no documentation that these recommendations were reviewed or acted upon by the physician. The DON confirmed during an interview that there was no documentation to show that the pharmacy recommendations were addressed in a timely manner. This deficiency was cited under federal and state regulations governing drug regimen review and nursing services.
Failure to Notify Responsible Party of Medication Change
Penalty
Summary
The facility failed to inform a resident's responsible party about an increase in the resident's antidepressant medication dosage and did not discuss alternative treatment options. Clinical record review showed that a resident with dementia had a physician's order to increase sertraline from 50 mg to 75 mg daily. There was no documentation or evidence that the responsible party was notified of this medication change or provided with information about other possible treatments. A confidential interview confirmed that the responsible party was not made aware of the increased dose and would have declined the change if notified. The Director of Nursing also confirmed that the responsible party was not informed of the new physician's order.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address grievances raised by residents during resident council meetings and group interviews. Seven residents reported during a group interview that call bells were not answered in a timely manner and that there had been no access to a hairdresser for several months. Review of resident council meeting minutes from March and June 2025 showed repeated concerns from multiple residents about delayed call bell responses and the lack of a hairdresser. There was no evidence that the facility took action to address these ongoing concerns as documented in the meeting minutes and interviews.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
Staff failed to follow a physician's order for a resident with dementia and hypertension, which required administration of carvedilol twice daily with the instruction to hold the medication if the resident's heart rate was less than 60 beats per minute. Clinical record review showed that the medication was administered on three separate occasions in June 2025 when the resident's heart rate was below the specified threshold. The Director of Nursing confirmed that the medication was given outside of the ordered parameters on those dates.
Failure to Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate treatment and services to promote healing and prevent pressure ulcers for one resident. According to the facility's Skin and Wound Management Policy, staff were required to provide ongoing monitoring and evaluation for residents with wounds or at risk for skin compromise. Clinical records showed that the resident, who had a diagnosis including muscle weakness, developed new open areas on the sacrum. However, weekly skin assessments did not contain evidence that staff adequately assessed or measured these areas. Interviews with the Director of Nursing confirmed that staff did not perform or document complete weekly assessments and measurements of the resident's open areas as required.
Failure to Maintain Proper Positioning of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to provide adequate catheter care for one resident who required an indwelling urinary catheter due to diagnoses including sepsis, hematuria, kidney failure, and urinary retention. According to the facility's urinary catheter care policy, the urinary drainage bag must always be positioned lower than the bladder and kept off the floor. However, observations revealed multiple instances where the resident's urinary drainage bag was either placed on the resident's lap or hooked to the arm of the wheelchair, both above the level of the bladder, and on other occasions, the drainage bag was observed on the floor while the resident was at the dining room table. These actions were not in accordance with the facility's policy and proper catheter care procedures.
Failure to Provide Enteral Nutrition According to Physician and Dietitian Orders
Penalty
Summary
A resident with a diagnosis of gastrostomy was readmitted to the facility and required enteral nutrition via a feeding tube. The care plan indicated the need for a feeding tube, and a physician's order initially directed staff to administer Nutren 2.0 at 55 ml per hour for 18 hours. Subsequent physician's orders changed the formula to Jevity 1.5 for 20 hours but did not specify the administration rate. The dietitian recommended a rate of 66 ml per hour of Jevity 1.5 to meet the resident's nutritional needs. Observation revealed that the tube feed pump was set to deliver Jevity 1.5 at 50 ml per hour, and staff were unable to identify a rate in the physician's order. Interviews with the LPN and DON confirmed that the order for Jevity 1.5 lacked a specified rate, and the 50 ml per hour rate was initiated in error. There was no evidence that the recommended rate of 66 ml per hour was ever administered, and the DON confirmed that the order was transcribed incorrectly, omitting the required rate.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to ensure timely physician supervision of care for one resident with multiple diagnoses, including polyneuropathy, congestive heart failure, and cirrhosis of the liver. The resident's care plan required staff to report weight changes to the physician due to altered cardiovascular status. Clinical records showed significant weight increases over two consecutive months, with a 28.7 lb. gain followed by a 20.5 lb. gain. There was no documented evidence that these significant weight changes were reported to or reviewed by the physician. Staff interviews confirmed that the physician was unaware of the resident's weight changes.
Failure to Provide Food in Appropriate Texture for Residents with Dysphagia
Penalty
Summary
The facility failed to provide food in a form that met the individual dietary needs of two residents with dysphagia and other medical conditions. For one resident with dysphagia and dementia, a physician's order required a mechanically altered, ground diet. However, observation revealed that the resident was served large pieces of cut meat that were not ground or mechanically soft, as required. Staff interviews confirmed that the meat was only cut with a rocker knife and not processed to the appropriate texture, despite the resident's tray ticket specifying a mechanically soft, ground diet. Another resident, also with dysphagia, dementia, and esophageal stricture, had a physician's order for a pureed diet and was identified as being at nutritional risk and requiring supervision during meals. Despite these orders, the resident was served a regular texture meal and vomited after eating a few bites. The care plan and staff notes confirmed the resident's need for a mechanically altered diet and supervision, which were not provided at the time of the incident.
Failure to Provide Required Adaptive Eating Equipment
Penalty
Summary
A resident with diagnoses including tremor and muscle weakness was identified as being at nutritional risk and required the use of red foam handles on silverware, as documented in the care plan and supported by a physician's order. Despite these documented needs, the resident was observed during a meal without the adaptive equipment, and reported that the red foam handles were also not provided at a previous meal. The Director of Nursing confirmed that the adaptive equipment should have been provided with the resident's meals.
Incomplete Clinical Records for Wound Consultant Visits
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three of eleven sampled residents. For one resident with iron deficiency anemia, muscle wasting, and osteomyelitis, there was no evidence in the clinical record that the resident was seen by the wound consultant on two specified dates, despite the Administrator stating these assessments should have been scanned into the record. Another resident with Parkinson's disease also lacked documentation of wound consultant visits on the same dates, as confirmed by the Administrator. A third resident with hypertension was similarly missing documentation of a wound consultant assessment on a specified date. These omissions were identified through clinical record review and staff interviews.
Failure to Readmit Resident After Hospital Transfer
Penalty
Summary
The facility failed to readmit a resident following a transfer to the hospital. The resident, who had a history of heart failure, kidney disease, diabetes, depression, and prior suicidal behavior, was transferred to the hospital after expressing suicidal intent and attempting self-harm. After a psychiatric evaluation, the hospital determined the resident was safe to return to the facility. However, hospital records indicated that the facility refused to accept the resident back, a fact confirmed by the Regional Director of Operations.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
Kadima Rehabilitation and Nursing at Palmyra was found to have a deficiency related to the posting of nurse staffing information. During an abbreviated survey conducted in response to two complaints, it was observed that the facility failed to post the current nurse staffing information as required by federal and state regulations. Specifically, on April 4, 2025, at 9:57 a.m., the nurse staffing information displayed was dated April 3, 2025, indicating that the facility did not update the information daily as mandated. The deficiency pertains to the requirements outlined in 42 CFR Part 483, Subpart B, and the 28 PA Code, which necessitate that facilities post accurate and current nurse staffing data daily. This includes details such as the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides per shift, along with the resident census. The failure to update this information daily could potentially lead to minimal harm to residents, as it does not comply with the transparency and accessibility standards set for nurse staffing data.
Plan Of Correction
1) The form was behind the dated 4/1/2025; it was removed, and the correct one was placed immediately in the front of the folder. 2) The scheduler updates the form, and the night shift supervisor will be responsible for ensuring the correct one is in place. The Supervisors will be educated on the importance of ensuring the nursing staff staffing is accurate and has the correct date. 3) The NHA and/or designee will monitor to ensure compliance. The sheets for the weekends and holidays are in the folder, and the supervisor will be responsible to ensure the correct one is posted. 4) Random audits will continue to ensure compliance. Results of the audits will be reviewed at the QAPI meeting for suggestions and input to maintain compliance.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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