Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Pottstown during CMS and state inspections, most recent first.
Improper Food Labeling, Dating, and Expired Item in Kitchen Storage: Food items in the kitchen and storage areas were found without labels or dates, including dried pasta, brown powder, toasted oats, frozen English muffins, and frozen fish. An expired container of sweet tea was also observed in the refrigerator, and the Dietary Manager confirmed the facility failed to ensure food items were properly labeled, dated, and used within their designated timeframes.
Expired hand sanitizer units were observed in multiple locations, including near the nurses' station, dining room, activity room, and NHA office. Two med carts also had pudding used for med administration with an outdated date on the container.
A resident was discharged home without a physician discharge summary being completed before discharge. Review of the closed record found no evidence of the required summary, and the DON confirmed it was not completed.
A resident had an active PRN order for oxycodone-acetaminophen for moderate to severe pain, with the facility’s pain scale defining moderate pain as 4-7 and severe pain as 8-10. Review of the MAR showed the medication was given outside the ordered parameters on six occasions, and the Regional Clinical Director confirmed staff administered the pain med outside the physician-ordered parameters.
An unlocked, unattended medication cart was observed with medications left in a cup on top of the cart while multiple residents were in the hallway and room doorways, and no nursing staff were nearby. The DON confirmed that staff should not have left medications unattended on the cart.
A resident had an active PRN order for oxycodone-acetaminophen for moderate to severe pain, but the clinical record did not document any non-pharmacological interventions before the medication was given. The facility’s pain assessment documentation required recording any non-pharmacological measures used prior to PRN pain meds, and the Regional Clinical Director confirmed staff were not implementing those interventions.
The facility did not maintain petty cash for residents to access their funds, as required. Interviews with residents showed they were unaware of their account balances and did not request funds. The NHA confirmed that checks are written and cashed at the bank for residents, but no petty cash is available on-site, violating resident rights.
The facility did not meet the required nurse aide staffing ratios over a ten-day period, failing to provide one nurse aide per 10 residents during the day shift for nine days, one nurse aide per 11 residents during the evening shift for one day, and one nurse aide per 15 residents during the night shift for five days.
The facility used a transportation vehicle without a valid safety inspection to transport residents to medical appointments, and staff operating the vehicle lacked training in safety procedures. A resident with hemiplegia slid from their wheelchair during transport, highlighting the absence of proper safety measures. Interviews confirmed that multiple staff members had not received necessary safety training, and the vehicle was used despite a tire pressure warning light being on.
The NHA and DON failed to ensure resident safety during transportation to appointments, as they did not manage the facility effectively to follow proper procedures for staffing and protection. This led to potentially unsafe conditions, violating federal and state guidelines.
A facility failed to maintain accurate medical records for a resident who slid from a wheelchair during transport. The incident was not documented in the clinical record, despite a progress note indicating the resident was post-fall. The Nursing Home Administrator confirmed the lack of documentation.
The facility failed to ensure the required minimum of one LPN per 30 residents during the evening shift on two occasions. This deficiency was identified through a review of staffing data and confirmed with the Nursing Home Administrator.
The facility did not meet the required nurse aide staffing ratios from January 26 to February 4, 2025. The day shift lacked the minimum one nurse aide per 10 residents for ten days, the evening shift fell short of one nurse aide per 11 residents for eight days, and the night shift did not meet the one nurse aide per 15 residents requirement for two days. This was confirmed by the Nursing Home Administrator.
A resident with chronic respiratory failure and hemiplegia had a bed rail that was not properly secured, making it unusable for repositioning. Despite the facility's policy requiring frequent safety checks, the Nursing Home Administrator confirmed the oversight, leading to a deficiency in compliance with federal regulations.
The facility failed to meet the required LPN staffing levels, with insufficient LPNs per resident during both day and evening shifts on multiple occasions. This was confirmed through a review of staffing data and discussions with the Nursing Home Administrator.
Kadima Rehabilitation & Nursing at Pottstown was found non-compliant with Life Safety Code requirements due to a lack of maintenance and documentation for carbon monoxide alarms and the absence of an evacuation and alarm protocol. Additionally, the Main Mechanical Room was unsecured, leaving utilities vulnerable. These deficiencies were confirmed by the Director of Maintenance.
The facility did not maintain stairtower doors within the required gap margins, as observed on two floors. The gaps exceeded one eighth of an inch, which was confirmed by the Director of Maintenance. A follow-up observation showed the issue remained uncorrected.
The facility failed to address identified deficiencies in its sprinkler system, including gauge recalibration, valve and pipe inspections, and a pipe replacement. Additionally, a required fire department connection sign was missing. These issues were confirmed through interviews with the Director of Maintenance.
The facility failed to conduct and document essential inspections and tests of the emergency generator, including weekly visual inspections, battery voltage recordings, monthly load tests, annual fuel quality tests, and the 3-year load bank test. The Director of Maintenance confirmed the lack of verification for these inspections and tests.
The facility did not conduct the required annual electrical receptacle inspection in resident care areas within one of two smoke zones. Documentation review revealed no verification of testing within the last 12 months, confirmed by the Director of Maintenance. Subsequent observation showed the issue remained uncorrected.
The facility failed to maintain hazardous area doors to self-close and positively latch, as observed in the basement Central Supply and Laundry areas. The Central Supply door lacked latching hardware, and the Laundry door was wedged open, preventing self-closing. These deficiencies were confirmed by the Director of Maintenance.
The facility failed to maintain corridor doors to be smoke tight and to positively latch. A door to a resident room had a gap greater than 1/2 inch, and corridor doors at another resident room and the Activity Room failed to positively latch, with the latter having the latch removed. These issues were not corrected upon follow-up observation.
The facility failed to secure electrical panels located behind the 1st floor Nurses' Station, as observed during a survey. The panels were found unlocked and accessible to unauthorized persons, a situation confirmed by the Director of Maintenance. A follow-up observation determined the issue remained uncorrected.
The facility failed to document monthly exit sign inspections as required by NFPA 101. A review revealed no records of inspections for the past year, confirmed by the Director of Maintenance. A follow-up observation showed the issue was not corrected.
The facility failed to document the semi-annual inspections of the kitchen suppression system as required by NFPA 101. This deficiency was confirmed during a document review and interview with the Director of Maintenance, and a follow-up observation showed the issue remained uncorrected.
The facility failed to document the semi-annual visual fire alarm system inspection as required by NFPA codes. This deficiency was identified during a document review and confirmed by the Director of Maintenance. A follow-up observation showed the issue remained uncorrected.
The facility failed to conduct required fire drills as per NFPA 101 standards. Document review revealed missing drills during specific shifts across multiple quarters, confirmed by the Director of Maintenance. A follow-up observation confirmed the issue remained uncorrected.
The facility did not conduct the required annual inspection of rated doors as per NFPA 80 standards. On two separate occasions, it was confirmed through document review, observation, and interviews with the Director of Maintenance that the inspections had not been completed in the last 12 months.
The facility failed to conduct required functional tests of the battery-powered emergency lighting source at the generator. Observations revealed that the tests were not performed, and the light was not mounted, as confirmed by the Director of Maintenance.
A long-term care facility failed to provide sufficient nursing staff for 39 residents, resulting in neglect during two shifts. Observations showed residents in unkempt conditions, and staff interviews revealed awareness of the staffing issue by the Nursing Home Administrator, who was not present. The facility lacked a Director of Nursing and had no contracts with staffing agencies due to unpaid bills. Residents did not receive timely medication, meal assistance, or adequate care, leading to an Immediate Jeopardy situation.
The facility experienced a critical staffing shortage, leaving only one NA, one LPN, and one RN to care for residents during two shifts. This resulted in residents not receiving timely medications, assistance with meals, or adequate ADL care. The Nursing Home Administrator was aware of the issue but failed to secure additional staff, and the facility had no contracts with staffing agencies due to unpaid bills. Residents expressed concerns about the lack of care, and the facility's staffing schedule showed open slots for RNs and LPNs.
The facility did not have a full-time DON from November 20 to November 25, 2024. Staff interviews confirmed the absence of a DON after the previous one resigned. A new DON started on November 25, 2024, and was undergoing orientation.
The NHA and DON failed to manage staffing effectively, resulting in inadequate resident care due to insufficient nursing staff during emergency shortages. Their job descriptions require them to ensure compliance with regulations and maintain quality care, but they did not utilize alternative resources to address staffing issues, leading to deficiencies cited under F600 and F725.
The facility failed to maintain appropriate dishwashing temperatures, as the dish machine did not reach the required minimum wash temperature of 120 degrees Fahrenheit on multiple occasions. Staff did not perform a test cycle before using the machine, and the facility was waiting for a booster to rectify the issue. The Nursing Home Administrator confirmed the deficiency.
The facility did not implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices, as recommended by their policy. Observations showed a lack of signs and PPE for EBP, and during tracheostomy care, a nurse did not wear a gown. The nurse was unaware of EBP requirements and had not received training, which was confirmed by the DON.
The facility failed to complete clinical assessments accurately for several residents, as their Quarterly MDS assessments were missing Sections C and D, which cover cognitive and mood evaluations. This issue was confirmed by an LPN and had been previously cited, indicating a recurring problem with resident assessments.
The facility failed to monitor and address significant weight changes for two residents, leading to deficiencies in nutritional care. One resident experienced a significant weight loss and gain without timely nutritional assessments or re-weights. Another resident had a substantial weight loss over several months without dietary recommendations. The DON confirmed that proper procedures were not followed.
The facility lacked a proper grievance handling process, as required by its policy. There was no tracking system for grievances, and no evidence of grievances being investigated or resolved. The designated grievance official position was vacant, with no one acting in the role.
A resident at risk for pressure ulcers developed an unstageable ulcer on the left heel due to inadequate preventive measures. The care plan only included lotion application, which was insufficient. This deficiency was confirmed by the DON and Nursing Home Administrator.
A facility failed to document care for a resident's Foley catheter, as revealed by a clinical record review and staff interview. Despite a physician's order for the catheter, there was no evidence in the resident's records that care was being provided. The DON confirmed the lack of documentation, leading to a deficiency under specific nursing service regulations.
The facility did not conduct or document a comprehensive facility-wide assessment to determine necessary resources for resident care during routine operations and emergencies. During an entrance conference, the facility was unable to provide the requested assessment, and an interview with the Nursing Home Administrator confirmed the absence of a current assessment, violating 28 Pa. Code 201.18(b)(1)(3) Management.
Two residents experienced missed and incomplete medical appointments due to unreliable transportation services. One resident missed an orthopedic follow-up, while another faced multiple rescheduled or incomplete appointments, including nephrology and eye doctor visits, due to transport conflicts and personal issues of the driver.
Improper Food Labeling, Dating, and Expired Item in Kitchen Storage
Penalty
Summary
The facility failed to properly label, date, and monitor food products in the Main Kitchen. During an observation in the dry storage room, six plastic bags of dried pasta, one bag of brown powder, and one bag of toasted oats were found without labels or dates. In the freezer located in dry storage, one bag of frozen English muffins was observed without a label or date, and in the freezer in the Main Kitchen, one bag of frozen fish was also found without a label or date. In the refrigerator in the Main Kitchen, one container of sweet tea was observed to be expired with a use-by date of November 17, 2025. The Dietary Manager confirmed that the facility failed to ensure food items were properly labeled, dated, and used within their designated timeframes.
Expired Hand Sanitizer and Improperly Dated Medication Administration Supply
Penalty
Summary
Infection control practices were not monitored on two nursing units and two medication carts. Observation of hand sanitizer units on November 19, 2025, at 9:15 a.m. found multiple dispensers with expired dates, including units near the nurses' station, in the short hallway near the nurses' station, outside the dining room, in the dining room, inside the front door, in the activity room, and outside the Nursing Home Administrator's office, with expiration dates ranging from December 2023 to February 2023 and January 2024. Observation of two medication carts on November 19, 2025, also found pudding used for medication administration with a date of November 14, 2025, located on the top of the container. This information was conveyed to administration on November 20, 2025, at 11:00 a.m.
Missing Physician Discharge Summary
Penalty
Summary
The facility failed to obtain a physician's discharge summary for Resident 41 before the resident was discharged home. Review of the closed record showed that Resident 41 was discharged to home, but further clinical record review did not reveal evidence that a Physician's Discharge Summary had been completed prior to discharge. The Director of Nursing confirmed that no Physician's Discharge Summary was completed before the resident left the facility.
Pain Medication Given Outside Ordered Parameters
Penalty
Summary
Resident R24 had an active physician order for oxycodone-acetaminophen 5-325 mg, one tablet by mouth every eight hours as needed for moderate to severe pain, with the facility’s pain scale defining moderate pain as 4-7 and severe pain as 8-10. Review of the resident’s MARs for August, September, October, and November 2025 showed the medication was administered outside the prescribed parameters on six occasions. The Regional Clinical Director confirmed in interview that staff administered the resident’s pain medication outside the physician-ordered parameters.
Unattended Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure residents were free from accidents and hazards when Medication Cart 1 was observed unlocked and unattended. Medications were left in a medication cup on top of the cart while multiple residents were present in the hallway and room doorways, and no nursing staff member was observed in the vicinity of the cart at the time of the observation. The Director of Nursing later confirmed that nursing staff should not have left medications on the top of the cart unattended.
Failure to Document Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to implement non-pharmacological interventions before administering PRN pain medication for Resident R24. Review of the resident’s clinical record showed an active order for oxycodone-acetaminophen 5-325 mg, one tablet by mouth every eight hours as needed for moderate to severe pain, with a start date of August 28, 2025. The facility’s Pain Assessment documentation required staff to record the pain location, pain level, type of pain relief used, and any non-pharmacological interventions applied before giving PRN pain medication. However, the clinical record did not show documentation of any non-pharmacological interventions attempted before the PRN pain medication was administered. In an interview on November 20, 2025, the Regional Clinical Director confirmed that staff were not implementing non-pharmacological interventions prior to administering PRN pain medication.
Lack of Petty Cash for Resident Financial Access
Penalty
Summary
The facility failed to provide petty cash for residents to access funds from their accounts, as required by regulations. Interviews with several residents revealed that they never requested funds and were unaware of the amounts available in their accounts. The Nursing Home Administrator confirmed that when residents request funds, a check is written from their account, which the administrator then cashes at the bank on behalf of the resident. However, there was no petty cash available on-site for immediate resident use, which is a violation of resident rights as per the cited regulations.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during a ten-day period from March 3 through March 12, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents on the day shift for nine days, one nurse aide per 11 residents on the evening shift for one day, and one nurse aide per 15 residents on the night shift for five days. These deficiencies were identified through a review of facility staffing data and were communicated to the Nursing Home Administrator during a telephone interview on March 18, 2025.
Plan Of Correction
1. A comprehensive facility audit will be undertaken to ensure that the minimum staffing ratios for Certified Nursing Assistants (CNAs) are consistently met on a daily basis. The Recruitment Team is proactively enhancing recruitment efforts to attract additional CNAs while also assessing and adjusting wages to remain competitive with those offered by nearby healthcare facilities. 2. To support the staffing requirements, agency staff is currently being utilized to fill gaps and maintain compliance with the established minimum staffing ratios. We are actively engaging with local nursing schools to build relationships and identify potential candidates from their graduating CNA classes. This networking initiative aims to create a robust pipeline of qualified applicants. 3. In addition, the Nursing Scheduler/Designee will undergo a thorough re-education process to reinforce the importance of adhering to the minimum staffing ratios for CNAs. This training will focus on strategies and protocols to maximize staffing efficiency and ensure adequate coverage at all times. 4. To monitor compliance, the Administrator or an appointed designee will conduct regular audits aimed at confirming adherence to staffing ratios. These audits will take place daily, weekly, and then monthly for a period of three months. The findings from these audits will be meticulously compiled and submitted to the Quality Assurance and Performance Improvement (QAPI) Committee for thorough review and analysis. This ongoing evaluation will help determine the necessity for continued monitoring and any potential adjustments to our staffing strategies moving forward.
Failure to Ensure Vehicle Safety and Staff Training for Resident Transport
Penalty
Summary
The facility failed to ensure that their transportation vehicle underwent a timely safety inspection, resulting in the vehicle being used to transport residents without a valid safety inspection for several months. The vehicle's safety inspection sticker expired, and the next inspection was not completed until February 4, 2025. During this period, the vehicle was used on 11 occasions to transport seven residents to medical appointments, posing a potential risk to their safety. Additionally, the staff responsible for operating the transport van had not received any training in safety procedures. This lack of training was evident when a resident, who was cognitively intact but had functional limitations due to hemiplegia, slid from their wheelchair onto the floor of the van during transport. The incident occurred as the driver slowed down to allow another vehicle to pass, and the resident reported wearing a seatbelt but still slid out of the wheelchair. The van did not have a seatbelt specifically for the resident, and the wheelchair locks and brakes were reportedly engaged before departure. Interviews with staff members confirmed that multiple employees who drove the transportation vehicle had not received any training in safety procedures. One employee reported driving the vehicle with a tire pressure warning light on, further indicating a lack of attention to vehicle safety. The Nursing Home Administrator confirmed that the facility did not use an outside contractor for transportation during the period in question, meaning all transports were conducted using the facility's vehicle without proper safety measures in place.
Removal Plan
- Facility vehicle will be inspected by a mechanic. Regular maintenance will be maintained by the facility. Calendar for checks was established to verify if preventative maintenance items are needed.
- Corporate representative is now monitoring expiration dates of facility owned vehicles and will put vehicles out of service if they do not have a current vehicle inspection by a mechanic. A corporate contract with IMT was established for transportation services.
- Facility designated drivers and back-up drivers will receive re-education and competency training on properly securing residents in wheelchairs to the vehicle. The facility will have at least three individuals designated as competent vehicle operators.
- NHA or designee will complete an audit of staff competencies before appointments. The audit will then transition to once weekly then monthly. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Deficiency in Resident Transportation Safety
Penalty
Summary
The facility was found deficient in ensuring the safety of residents being transported to appointments using a facility transportation vehicle. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure proper procedures were followed for staffing and resident protection. This failure was identified through a review of their job descriptions, which highlighted their responsibilities to manage the facility and nursing services in accordance with federal, state, and local standards, guidelines, and regulations. The report specifically notes that the NHA and DON did not fulfill their essential job duties to ensure compliance with these guidelines and regulations, leading to potentially unsafe conditions for residents during transportation. The deficiency was linked to a failure in management and oversight, as outlined in the job descriptions, which emphasize the need for maintaining the highest degree of quality care and safety for residents at all times.
Failure to Document Resident Fall During Transport
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was involved in an incident during transportation. On January 30, 2025, the resident was being transported to a pain management facility when they slid from their wheelchair to the floor of the van. The driver, a certified occupational therapist, repositioned the resident back into the wheelchair, fastened the seat belts, and continued to the appointment after determining that no injury was sustained. However, the clinical record lacked documentation of this fall. The following day, a progress note indicated the resident was two of nine shifts post-fall, yet there was no documentation of the fall in the clinical record. An interview with the Nursing Home Administrator confirmed the absence of documentation regarding the fall in the resident's clinical record.
LPN Staffing Deficiency on Evening Shifts
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one licensed practical nurse (LPN) per 30 residents during the evening shift. This deficiency was identified during a review of staffing data for the period from January 26, 2025, through February 4, 2025. Specifically, the facility did not meet the required staffing levels on the evening shifts of January 26, 2025, and February 1, 2025. This finding was confirmed with the Nursing Home Administrator during a telephone interview on February 6, 2025.
Plan Of Correction
1. The facility is unable to retroactively provide minimum LPN coverages to meet minimum required staffing ratios for 1/26/25 & 2/1/25. 2. A facility audit was completed to ensure LPN minimum staffing ratios were being met daily. The Recruitment Team is continuing efforts to recruit more LPNs and ensuring wages are competitive with surrounding area facilities. Agency staff are being utilized to assist with meeting minimum LPN staffing ratios while recruitment continues. 3. The Nursing Scheduler/Designee was re-educated on ensuring nursing care LPN minimum staffing ratios are met, and that the facility is actively recruiting LPNs. 4. The Administrator or designee will conduct an audit of the nursing care LPN ratios to ensure compliance weekly for 4 weeks, then monthly for 2 months. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the period from January 26 through February 4, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift for ten days, one nurse aide per 11 residents during the evening shift for eight days, and one nurse aide per 15 residents during the night shift for two days. This deficiency was identified through a review of the facility's staffing data and was confirmed by the Nursing Home Administrator during a telephone interview on February 6, 2025.
Plan Of Correction
1. A comprehensive facility audit will be undertaken to ensure that the minimum staffing ratios for Certified Nursing Assistants (CNAs) are consistently met on a daily basis. The Recruitment Team is proactively enhancing recruitment efforts to attract additional CNAs while also assessing and adjusting wages to remain competitive with those offered by nearby healthcare facilities. 2. To support the staffing requirements, agency staff is currently being utilized to fill gaps and maintain compliance with the established minimum staffing ratios. We are actively engaging with local nursing schools to build relationships and identify potential candidates from their graduating CNA classes. This networking initiative aims to create a robust pipeline of qualified applicants. 3. In addition, the Nursing Scheduler/Designee will undergo a thorough re-education process to reinforce the importance of adhering to the minimum staffing ratios for CNAs. This training will focus on strategies and protocols to maximize staffing efficiency and ensure adequate coverage at all times. 4. To monitor compliance, the Administrator or an appointed designee will conduct regular audits aimed at confirming adherence to staffing ratios. These audits will take place daily, weekly, and then monthly for a period of three months. The findings from these audits will be meticulously compiled and submitted to the Quality Assurance and Performance Improvement (QAPI) Committee for thorough review and analysis. This ongoing evaluation will help determine the necessity for continued monitoring and any potential adjustments to our staffing strategies moving forward.
Improper Installation and Maintenance of Bed Rails
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for a resident, as required by Title 42 Code of Federal Regulations (CFR) S483.25(n). The regulation mandates that if a bed or side rail is used, the facility must follow the manufacturer's recommendations and specifications for installing and maintaining bed rails. The facility's policy, dated August 28, 2018, also indicated that residents should be frequently checked for safety. However, during an interview conducted on December 30, 2024, the resident reported that the side rail next to their left hand was not properly secured to the bed, rendering it unusable for turning and repositioning. The resident, who was admitted with chronic respiratory failure with hypoxia, hemiplegia affecting the left nondominant side, and tracheostomy status, had a side rail/restrain enabler evaluation assessment indicating that side rails were necessary for safety. Despite this, the Nursing Home Administrator confirmed during an inspection that the bedrail was not properly secured and acknowledged that nursing staff should have regularly inspected the bedrails. This oversight led to a deficiency in ensuring the resident's safety as per the facility's policy and federal regulations.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to comply with the staffing regulations for Licensed Practical Nurses (LPNs) as mandated effective July 1, 2023. Specifically, the facility did not maintain the required minimum of one LPN per 25 residents during the day shift on December 19 and 22, 2024. Additionally, the facility did not meet the requirement of one LPN per 30 residents during the evening shift on December 25 and 28, 2024. These deficiencies were identified through a review of the facility's staffing data and were confirmed with the Nursing Home Administrator on December 30, 2024, at 2:15 p.m.
Plan Of Correction
1. The facility is unable to retroactively provide minimum LPN coverage to meet minimum required staffing ratios from December 18th through December 29th, 2024. 2. A facility audit was completed to ensure LPN minimum staffing ratios were met. The Recruitment Team is recruiting more LPNs and ensuring wages are competitive with surrounding area facilities. Agency staff are being utilized to assist with meeting minimum LPN staffing ratios while recruitment continues. 3. The Nursing Scheduler/Designee was re-educated on ensuring nursing care LPN minimum staffing ratios are met, and that the facility is actively recruiting LPNs. 4. The Administrator or designee will conduct an audit of the nursing care LPN ratios to ensure compliance weekly for 4 weeks, then monthly for 2 months. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.
Non-Compliance with Life Safety Code at Kadima Rehabilitation & Nursing
Penalty
Summary
Kadima Rehabilitation & Nursing at Pottstown was found to be non-compliant with the Life Safety Code requirements during a revisit to a Medicare/Medicaid Recertification Survey. The facility failed to maintain a documented program for testing, cleaning, and replacing batteries in the carbon monoxide alarms. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the carbon monoxide detection system was not being maintained as required. Additionally, the facility lacked an evacuation and alarm protocol policy for the carbon monoxide detection system. This was also confirmed by the Director of Maintenance, who admitted that the facility could not provide an alarm protocol and evacuation plan for carbon monoxide. Furthermore, the exterior doors to the Main Mechanical Room, which houses critical utilities such as the domestic water main, main electrical panel, and generator, were not secured from unauthorized access, leaving these utilities vulnerable. These issues were observed and confirmed during the survey, and subsequent observations determined that the deficiencies related to the carbon monoxide alarms and protocols were not corrected.
Plan Of Correction
1. The facility is unable to retroactively document testing, cleaning, and battery replacement program of the carbon monoxide alarms. 2. Facility-wide audit of carbon monoxide detectors conducted. Carbon monoxide detectors will be installed in places where fossil fuel appliances are in use. 3. Audits will be conducted monthly for twelve months and annually thereafter. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring. 4. An evacuation and alarm protocol policy will be written and enacted. Education will be provided to staff regarding policy. 5. Exterior doors to the Main Mechanical Room have been secured and will remain secured at all times. 6. Audits will be conducted monthly for 12 months. 7. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring.
Failure to Maintain Stairtower Door Gap Margins
Penalty
Summary
The facility failed to maintain stairtower doors within the allowed gap margins, as required by NFPA 101 standards for stairways and smokeproof enclosures. During an observation on October 8, 2024, it was noted that the stairtower doors on both the basement and the 1st floor had gaps greater than one eighth of an inch. This deficiency was confirmed through an interview with the Director of Maintenance. A follow-up observation on December 9, 2024, revealed that the issue had not been corrected, which was again confirmed by the Director of Maintenance.
Plan Of Correction
1. The facility is unable to retroactively ensure stair tower door gaps are within the allowed margin. 2. Facility-wide audit of all stair tower doors conducted. The basement and first floor stair tower doors will be adjusted to ensure gaps are less than one eighth of an inch. 3. Audits will be conducted monthly for 3 months then quarterly for 3 quarters. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring.
Sprinkler System Deficiencies Unaddressed
Penalty
Summary
The facility failed to address deficiencies in its sprinkler system as identified by Johnson Control on February 29, 2024. These deficiencies included the need for replacement or recalibration of gauges, internal valve and pipe inspections, obstruction inspection, and replacement of a pipe with a pinhole over the kitchen. Additionally, the facility lacked a required fire department connection sign. These issues were confirmed through interviews with the Director of Maintenance on October 8, 2024, and again on December 9, 2024, when it was observed that the deficiencies had not been corrected.
Plan Of Correction
1. Johnson Control will be contacted to come out before 01/06/25: a. Replace or recalibrate gauges as needed b. Internal valve inspection c. Internal pipe inspection d. Obstruction inspection 2. Maintenance Director and Maintenance Staff will be educated on inspection and documentation requirements. Deficiencies identified by Johnson Control will be repaired. 3. An audit of the life safety book will be conducted quarterly for 12 months and bi-annually thereafter. 4. A fire department sign will be installed at the site of the connection. 5. Maintenance Director or Designee will conduct audits quarterly for 12 months, then biannually thereafter and filed in the LifeSafety. 6. Results of audits will be reported to the QAPI Committee for recommendations for review and analysis for ongoing monitoring.
Failure to Conduct and Document Emergency Generator Inspections
Penalty
Summary
The facility failed to conduct and document the necessary inspections and tests of the emergency generator, which is crucial for the entire component's operation. During a review of documentation and an observation conducted on October 8, 2024, it was found that the facility did not perform the required weekly visual inspections, nor did they record the battery voltage weekly. Additionally, the monthly load test and operation of the transfer switch were not conducted, and the annual fuel quality test was not performed. Furthermore, the facility did not complete the required 3-year, 4-hour load bank test. An interview with the Director of Maintenance confirmed that the facility could not provide verification that these essential generator inspections and tests had been performed. This lack of documentation and testing indicates a failure to comply with the standards set forth by NFPA 101 and related guidelines, which are critical for ensuring the reliability of the emergency power system in the event of a power failure.
Plan Of Correction
1. Facility is unable to retroactively conduct inspections and tests of the emergency generator. 2. GenServ-DynaTech will be contacted to complete the following required inspections before 01/06/25. Tests of the emergency generator will be completed with corresponding documentation kept on file: a. Weekly visual inspection b. Weekly recording of the battery voltage c. Monthly load test and operation of the transfer switch d. Annual fuel quality test e. 3-year, 4-hour load bank 3. Maintenance Director will complete audits. Maintenance Director and Maintenance staff will be educated on and complete the required weekly, monthly, annual, and tri-annual inspection, as required by regulation. 4. NHA or Designee will complete monthly audits of the Life Safety Book to ensure that inspections and tests are being completed weekly, monthly, annually, and tri-annually per regulation. Audits will be done quarterly once substantial compliance is achieved.
Failure to Conduct Annual Electrical Receptacle Inspection
Penalty
Summary
The facility failed to conduct the required annual electrical receptacle inspection in resident care areas within one of two smoke zones. During a document review on October 8, 2024, it was found that there was no documentation verifying that electrical receptacles had been tested within the last 12 months. This was confirmed in an interview with the Director of Maintenance, who acknowledged that the receptacles in patient care areas had not been tested in the past year. Further observation on December 9, 2024, revealed that the issue had not been corrected, as confirmed again by the Director of Maintenance. The lack of testing and documentation indicates a failure to comply with the NFPA 101 Electrical Systems - Maintenance and Testing requirements, specifically regarding the testing of hospital-grade receptacles in patient care areas.
Plan Of Correction
1. Facility is unable to retroactively conduct annual electrical receptacle inspection in resident care areas. 2. A facility-wide audit of electrical receptacles will be completed. Maintenance Staff will be educated on the requirement to perform annual receptacle inspections. 3. Maintenance Director will complete annual electrical receptacle inspections by 01/27/2025. 4. NHA or designee will audit Life Safety Book semi-annually to confirm completion of annual inspections and that the documentation has been completed. The results of monitoring will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.
Failure to Maintain Hazardous Area Door Safety
Penalty
Summary
The facility failed to maintain the required safety standards for hazardous area doors, as evidenced by several observations. On October 8, 2024, it was observed that the basement Central Supply door lacked the necessary latching hardware and failed to positively latch. This deficiency was confirmed during an interview with the Director of Maintenance. Additionally, on October 28, 2024, the basement Laundry door was found unable to self-close due to a wedge placed in the door, which was also confirmed by the Director of Maintenance. Further observations on the same day revealed that the rated door to the basement Laundry Chute Room was impeded from closing by a wedge. This was again confirmed by the Director of Maintenance. Despite these findings, a follow-up observation on December 9, 2024, determined that the issue with the Central Supply door had not been corrected, as confirmed by the Director of Maintenance. These deficiencies indicate a failure to maintain the necessary fire safety measures in hazardous areas of the facility.
Plan Of Correction
1. Facility-wide audit of doors completed. Any doors found unable to positively latch were referred to the maintenance director and will be repaired or replaced as necessary. 2. Audits of door latches will be conducted monthly for 12 months. Random audit of no less than 3 doors will be conducted monthly thereafter. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring. 3. Education will be provided to staff regarding not impeding doors from closing by Maint. Director. 4. Audits to ensure doors are not being impeded from closing will be conducted monthly for 12 months. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring.
Failure to Maintain Smoke Tight and Positively Latching Corridor Doors
Penalty
Summary
The facility failed to maintain corridor doors to be smoke tight and to positively latch, as observed on October 8, 2024. Specifically, the door to resident room 113 had a gap greater than 1/2 inch between the door and the frame, which was confirmed by the Director of Maintenance. Additionally, corridor doors at resident room 124 and the Activity Room had issues with positive latching, with the Activity Room double doors having the latch removed. A follow-up observation on December 9, 2024, determined that the issues identified in items 1 and 2 were not corrected. The Director of Maintenance confirmed during an interview that the deficiencies related to the corridor doors' smoke tightness and positive latching remained unresolved.
Plan Of Correction
1. The facility is unable to retroactively ensure corridor door gaps are within the allowed margin. 2. Maintenance Director completed facility-wide audit of all corridor doors. Doors will be adjusted as needed to ensure gaps conform to regulation. Fire/Smoke door seal will be installed on doors where adjustments won't close the gap to regulation. 3. Door to Room 124, and activity room will be corrected to positively latch. Fire/smoke door seal will be installed to close the gap on the door to room 113. 4. All staff will be educated on the need to report doors that do not positively latch. Maintenance staff will be educated on door gap regulatory requirements. Maintenance Director or Designee will complete audits monthly for 12 months. Results of the audits will be presented to the QAPI Committee for review and analysis of need for ongoing monitoring.
Unsecured Electrical Panels in Facility
Penalty
Summary
The facility failed to ensure that electrical panels were secured, as observed during a survey on October 8, 2024. Three wall-mounted recessed electrical panels located off the corridor behind the 1st floor Nurses' Station were found to be unlocked and accessible to unauthorized persons. This observation was confirmed through an interview with the Director of Maintenance at the time of the survey. A follow-up observation on December 9, 2024, at 10:30 AM and 11:30 AM, determined that the issue had not been corrected, as the electrical panels remained unlocked. The Director of Maintenance confirmed during interviews at both times that the panels were still unsecured, indicating a continued failure to address the deficiency identified in the initial survey.
Plan Of Correction
1. A facility-wide audit of electrical panels has been completed. Any electrical panel found to be unlocked was locked. 2. Education will be provided to staff that electrical panels should remain locked at all times. 3. NHA or designee will audit electrical panels weekly for 4 weeks, then monthly for 2 months, and monthly thereafter to ensure they are locked. 4. Results of the audits will be presented to the QAPI committee for review and analysis of need for ongoing monitoring.
Failure to Document Monthly Exit Sign Inspections
Penalty
Summary
The facility failed to provide documentation of monthly exit sign inspections, which is a requirement under NFPA 101 for exit signage. During a document review on October 8, 2024, it was found that the facility did not have records verifying that exit signs were visually inspected over the past twelve months. This deficiency was confirmed in an interview with the Director of Maintenance, who acknowledged the absence of the required documentation. A follow-up observation on December 9, 2024, revealed that the issue had not been corrected, as the facility still lacked the necessary documentation. The Director of Maintenance confirmed during an interview on the same day that the deficiency remained unaddressed.
Plan Of Correction
1. The facility is unable to retroactively document visual inspection of exit signs. 2. Facility-wide audit of all exit signs completed. 3. Audits of exit signs will be conducted monthly. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring.
Lack of Documentation for Kitchen Suppression System Inspections
Penalty
Summary
The facility failed to provide documentation of the semi-annual inspections of the kitchen suppression system, which is a requirement under NFPA 101 for cooking facilities. During a document review and interview conducted on October 8, 2024, it was revealed that the facility did not have records verifying that the kitchen suppression system had undergone the required semi-annual inspection in the past year. This deficiency was confirmed by the Director of Maintenance during an interview on the same day. A follow-up observation on December 9, 2024, confirmed that the issue had not been corrected, as the facility still lacked the necessary documentation, which was again confirmed by the Director of Maintenance.
Plan Of Correction
1. Vendor will be contacted to provide documentation of the semi-annual inspection of the kitchen suppression system. 2. Audit will be conducted semi-annually to ensure inspections occur as required. 3. Results of audits will be reported to the governing body through QAPI.
Failure to Document Semi-Annual Fire Alarm Inspection
Penalty
Summary
The facility failed to provide documentation of the semi-annual visual fire alarm system inspection, which is a requirement under NFPA 101, NFPA 70, and NFPA 72. During a document review on October 8, 2024, it was discovered that the facility did not have records of the required inspection. This was confirmed in an interview with the Director of Maintenance, who acknowledged the absence of documentation verifying that the inspection had been conducted. A follow-up observation on December 9, 2024, revealed that the issue had not been corrected, as confirmed again by the Director of Maintenance.
Plan Of Correction
1. Johnson Control was contacted to provide documentation of semi-annual visual fire alarm inspection. Per Johnson Control documentation, the fire alarm inspection was last completed on 5/15/24 and will be completed again prior to 01/06/25 in order to maintain compliance. 2. NHA and Maintenance Director will conduct semi-annual audits to ensure inspections occur as required. Maintenance Director or designee will ensure that all fire alarm reports are received and filed in the life safety book. 3. Maintenance Director will report audit results to the governing body through the QAPI Committee for review and recommendation for continued monitoring.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct and perform fire drills as required by NFPA 101 standards. During a document review on October 8, 2024, it was revealed that the facility did not perform fire drills during the 2nd quarter on the 1st and 2nd shifts, the 3rd quarter on the 3rd shift, and the 4th quarter on the 2nd shift. This deficiency was confirmed through an interview with the Director of Maintenance on the same day. A subsequent observation on December 9, 2024, confirmed that the issue had not been corrected, as verified by another interview with the Director of Maintenance.
Plan Of Correction
1. The facility is unable to retroactively ensure fire drills are completed in compliance with regulations. 2. Fire drills will be completed monthly in varying locations and varying shifts as per regulation. Quarterly audits will be completed to confirm drills are being conducted on the shifts for which they are scheduled. 3. Maintenance Director or Designee will conduct documentation audits to ensure compliance with regulation. Audit results will be presented to the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Inspect Rated Doors Annually
Penalty
Summary
The facility failed to conduct the required annual inspection of all rated/labeled doors as mandated by NFPA 80, Standard for Fire Doors and Other Opening Protectives. During a document review and observation on October 8, 2024, it was revealed that the rated doors in all areas had not been inspected in the last 12 months. This deficiency was confirmed through an interview with the Director of Maintenance on the same day. Further observation on December 9, 2024, confirmed that the issue had not been corrected, as the rated doors still had not been inspected. The Director of Maintenance confirmed during interviews at 10:30 AM and 11:30 AM on December 9, 2024, that the deficiency remained unaddressed.
Plan Of Correction
1. The facility is unable to retroactively document inspection of rated/labeled doors. 2. Maintenance staff will be educated on the annual fire door inspection procedures. Rated doors will be inspected annually per regulations. 3. NHA and Maintenance Director will conduct annual audits to ensure inspections and corresponding documentation is completed per annual regulatory requirement. Audit results will be documented in the Life Safety Book. 4. Audit results and corresponding documentation will be presented to QAPI committee for review and analysis of need for ongoing monitoring.
Failure to Perform Emergency Lighting Tests at Generator
Penalty
Summary
The facility failed to perform the required functional tests of the battery-powered emergency lighting source at the generator, which serves the entire component. During an observation on October 8, 2024, it was noted that the facility did not conduct the battery back-up emergency lighting test at the generator for 30 seconds monthly and 90 minutes annually. Additionally, the emergency light was found not mounted and was instead laying on an electrical duct. This deficiency was confirmed through an interview with the Director of Maintenance on the same day. A follow-up observation on December 9, 2024, revealed that the issue had not been corrected. The emergency lighting test had still not been performed, and the light fixture remained unmounted. The Director of Maintenance confirmed during interviews on December 9, 2024, that the deficiency identified in the initial observation had not been addressed.
Plan Of Correction
1. The facility is unable to retroactively conduct a 30-second monthly test or 90-minute annual test of the battery backup emergency lighting in the generator room before the survey. 2. The facility had a new Maintenance Director that started on 12/09/24. Maintenance or Designee will conduct a 30-second monthly test and a 90-minute annual test of the battery backup emergency lighting. The 90-minute test will be completed by 01/27/2025. Battery will be replaced as necessary. 3. Education will be provided to Maintenance staff regarding testing of the battery backup emergency lighting. Documentation of testing will be maintained in the Life Safety Book per regulation. 4. Maintenance Director or Designee will complete audits of routine testing monthly until substantial compliance has been achieved and quarterly thereafter. 5. Results of the audits will be presented to the QAPI committee for review and analysis for continued monitoring.
Staffing Shortages Lead to Neglect in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from neglect by not providing sufficient nursing staff to meet the needs of 39 residents during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts on November 22, 2024. Observations revealed that all residents were in bed with unwashed hair and soiled clothing, and there was a strong odor of urine throughout the facility. The facility was understaffed with only one Nursing Assistant, one Licensed Practical Nurse, and one Registered Nurse available to care for all residents, leading to an Immediate Jeopardy situation. Interviews with staff members indicated that the Nursing Home Administrator was aware of the staffing shortages but was not present at the facility and only communicated via text. The facility lacked a Director of Nursing, and staff were instructed not to contact the corporate representative. The facility also had no current contracts with staffing agencies due to outstanding bills, and recent staff resignations were attributed to untimely payment of wages. As a result, residents did not receive timely medication administration, assistance with meals, or adequate activities of daily living care. Residents expressed concerns about the lack of staff, which resulted in missed showers, delayed incontinence care, and unresponsive call bells. The facility's staffing schedule confirmed the absence of scheduled RNs and LPNs for the shifts in question, and the Nursing Home Administrator acknowledged the open availability for staffing. The Immediate Jeopardy situation was identified and presented to the Nursing Home Administrator due to the neglect in ensuring sufficient nursing staff to provide necessary care.
Staffing Shortages Lead to Immediate Jeopardy
Penalty
Summary
The facility failed to maintain sufficient nursing staff to provide necessary care and services to residents, resulting in an Immediate Jeopardy situation. On November 22, 2024, during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, the facility was understaffed, with only one Nursing Assistant, one Licensed Practical Nurse, and one Registered Nurse present. This staffing shortage led to residents not receiving timely medications, assistance with meals, or adequate activities of daily living (ADL) care, such as showers and incontinence care. The facility's emergency staffing plan was not effectively implemented, as there were no additional staff from other departments or contracted agency staff available. Interviews with staff revealed that the Nursing Home Administrator was aware of the staffing issues but was working from home and had not arranged for replacement staff. The facility had no current contracts with staffing agencies due to outstanding bills, and the sudden resignation of the Director of Nursing further exacerbated the situation. Staff reported that the facility's failure to pay employees had led to multiple resignations, contributing to the staffing crisis. Observations confirmed that residents were left in an unkempt state, with unwashed hair and soiled clothing, and a strong odor of urine was noted throughout the facility. Residents expressed concerns about the lack of staff, indicating that they had not received showers or bed baths in several days and that call bells were not being answered promptly. The facility's staffing schedule showed open slots for RNs and LPNs, with no staff scheduled for the night shift. The Nursing Home Administrator confirmed the accuracy of the schedules and the open availability for staffing. The Immediate Jeopardy situation was identified and communicated to the Nursing Home Administrator, highlighting the facility's failure to ensure adequate staffing levels and the inability to utilize alternative resources during a staffing emergency.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure a full-time Director of Nursing (DON) was employed from November 20, 2024, to November 25, 2024. This deficiency was identified through interviews with staff members. A Licensed Nursing Employee confirmed on November 22, 2024, that there had been no DON since the previous one resigned on November 20, 2024. The Nursing Home Administrator also confirmed the absence of a DON during this period. A new DON began their role on November 25, 2024, and was in the process of completing their orientation on that day.
Inadequate Staffing Management Leads to Deficiency
Penalty
Summary
The facility was found to have deficiencies in the management and staffing of its nursing services, as the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure proper staffing levels. The job descriptions for both the NHA and DON emphasize their responsibility to manage the facility and nursing services in accordance with federal, state, and local regulations, ensuring the highest degree of quality care for residents. However, the review revealed that they failed to implement procedures to maintain adequate staffing levels, particularly during emergency staffing shortages. This failure resulted in inadequate resident care, as there were insufficient nursing staff available to provide necessary care and services. The report specifically notes that alternative resources were not utilized to address staffing shortages, which is a critical component of the NHA and DON's responsibilities. The deficiencies were cited under F600 and F725, and the facility was found to be in violation of several Pennsylvania codes related to the responsibility of the licensee and management.
Failure to Maintain Appropriate Dishwashing Temperatures
Penalty
Summary
The facility failed to maintain appropriate temperatures during dishwashing, as observed on October 22, 2024. The facility's policy requires a minimum wash temperature of 120 degrees Fahrenheit and a minimum rinse temperature of 140 degrees Fahrenheit. However, during an observation with the Facility Cook, the dish machine was used with a gauge reading only 100 to 110 degrees Fahrenheit. The staff did not perform a test cycle before running the dishes, contrary to the facility's policy. The Facility Cook mentioned that the gauge had been changed and the facility was waiting for a booster for the dish machine. A review of the Dish Machine Temperature Log for October 2024 showed that the wash temperature did not reach the required 120 degrees Fahrenheit on 17 out of 21 occasions. The Nursing Home Administrator confirmed that the minimum wash temperatures had not been reached and stated that the facility was waiting on the repair company to address the issue. This deficiency was noted under the regulations 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(1).
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices during high-contact resident care activities. Despite the facility's policy recommending the use of gowns and gloves when there is potential exposure to affected areas, observations during the survey revealed that none of the residents with chronic wounds or indwelling medical devices had signs indicating the implementation of EBP or personal protective equipment (PPE) available for use. During an observation of tracheostomy care, a Licensed Nursing Employee did not wear a gown, and upon interview, the employee stated they were unaware of the need for EBP and had not received any training. The Director of Nursing confirmed that the facility does not implement Enhanced Barrier Precautions.
Incomplete Clinical Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete clinical assessments accurately and completely for 8 out of 16 residents reviewed. Specifically, the Quarterly Minimum Data Set (MDS) assessments for these residents were missing critical sections, namely Section C for cognitive assessment and Section D for mood. This deficiency was identified through a clinical record review and confirmed by an interview with licensed staff, Employee E3. The residents affected by this oversight were Residents 4, 6, 13, 17, 21, 29, 34, and 38. The failure to complete these sections was previously cited on November 6, 2023, indicating a recurring issue with resident assessments and clinical records.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to obtain and monitor weights for two residents, leading to deficiencies in nutritional care. For one resident, an admission weight was recorded, but no nutritional assessment was completed at that time. The resident experienced a significant weight loss of 5.7% without a re-weight being obtained, and later a weight gain of 5.3% also without a re-weight. A nutritional assessment was not completed until several months after admission. The Director of Nursing confirmed that nutrition assessments should be completed on admission and quarterly, and re-weights should have been obtained. Another resident experienced a weight loss of 8.59% over several months, with no dietary recommendations made to address the weight loss. A re-weight confirmed the resident's weight loss. The Director of Nursing acknowledged that further dietary interventions should have been implemented to address the resident's weight loss. These findings indicate a failure to adhere to the facility's policy on monitoring and addressing significant weight changes in residents.
Deficiency in Grievance Handling Process
Penalty
Summary
The facility was found to have a deficiency in its grievance handling process. The facility's policy, revised on February 28, 2018, requires a system to ensure the prompt resolution of grievances, overseen by a designated grievance official. However, during an entrance conference with the Nursing Home Administrator and the Director of Nursing, it was revealed that the facility lacked a tracking system for grievances and had no evidence of grievances being investigated or resolved. The Social Worker, who was designated as the grievance official, was not in the position, and no one else was acting in that role at the time of the survey.
Inadequate Pressure Ulcer Prevention
Penalty
Summary
The facility failed to develop adequate interventions to prevent pressure ulcers for a resident identified as being at risk. The resident's Braden assessment indicated a risk for pressure ulcer development, yet the care plan only included the application of lotion as an intervention. This was deemed inadequate, as evidenced by the development of an unstageable pressure ulcer with dry eschar on the resident's left heel. The deficiency was confirmed through an interview with the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of preventive measures beyond lotion application prior to the ulcer's development.
Failure to Document Foley Catheter Care
Penalty
Summary
The facility failed to provide proper care for a Foley catheter for a resident, as determined through clinical record review and staff interview. The resident had a physician's order dated September 14, 2024, for a Foley catheter, which is a flexible tube used to drain urine from the bladder into a collection bag. However, a review of the resident's entire clinical record showed no documented evidence that the facility was providing the necessary care for the catheter. An interview with the Director of Nursing on October 25, 2024, confirmed the absence of documentation indicating that the facility was attending to the resident's Foley catheter care. This deficiency was noted under the regulations 28 Pa. Code 211.5 (f) Clinical record and 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services.
Failure to Conduct Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. During an entrance conference with the Nursing Home Administrator and the Director of Nursing, the facility was unable to provide the requested facility assessment. An interview with the Nursing Home Administrator confirmed that the facility did not have a current facility assessment, which is a requirement under 28 Pa. Code 201.18(b)(1)(3) Management.
Transportation Issues Lead to Missed Medical Appointments
Penalty
Summary
The facility failed to ensure reliable transportation for residents to attend their medical appointments, affecting two residents. Resident R1 missed an orthopedic follow-up appointment due to transportation issues, with no documented reason for the missed transport in the clinical record. Resident R3 experienced multiple missed and incomplete medical appointments due to transportation conflicts. These included a nephrology appointment canceled due to a transport conflict and a gastrointestinal appointment rescheduled because no transport was available. Additionally, Resident R3's eye doctor appointment was cut short because the transportation personnel had to leave for another resident's appointment. Resident R3, who has multiple diagnoses including peripheral vascular disease, diabetes, and pulmonary hypertension, expressed frustration over missed medical appointments, including those with the VA. The resident reported that a transportation driver had a personal conflict, leading to a rescheduled appointment. Nursing progress notes further documented instances where Resident R3's appointments were either incomplete or rescheduled due to transportation issues, such as a cataract surgery consultation and an ophthalmology appointment where no follow-up paperwork was provided. These deficiencies were discussed with the Nursing Home Administrator.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 561 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pottstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manatawny Center For Rehabilitation And Nursing | 4.7 mi | ★★★★★ | 7 | 0 |
| Pottstown Skilled Nursing And Rehabilitation Cente | 6.4 mi | ★★★★★ | 5 | 0 |
| Southeastern Pennsylvania Veteran's Center | 6.6 mi | ★★★★★ | 1 | 0 |
| Sanatoga Center | 7 mi | ★★★★★ | 0 | 0 |
| Parkhouse Rehabilitation And Nursing Center | 10.2 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.