Laurel Square Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 1020 Oak Lane Avenue, Philadelphia, Pennsylvania 19126
- CMS Provider Number
- 395535
- Inspections on file
- 23
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Laurel Square Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and bladder incontinence did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. Despite clinical recommendations for skin care and incontinence management, the care plan lacked goals or interventions addressing these needs.
A resident with left eye redness did not receive prescribed tobramycin eye drops due to the medication being lost and subsequent insurance issues, resulting in an eleven-day delay in treatment. The resident's condition worsened, requiring emergency room intervention to obtain the necessary medication. Staff and administration confirmed the failure to provide timely pharmaceutical services.
Surveyors found that spoiled produce, including cabbage, zucchini, celery, and cantaloupe, remained in refrigerated storage well beyond the facility's seven-day retention policy. The Dietary Director and Regional Director confirmed the items were not used in meal preparation but could not explain why they were not discarded in a timely manner.
Surveyors found that food and beverages were not served at safe or appetizing temperatures, with cold foods being served too warm and drinks not properly planned or offered. Multiple residents expressed dissatisfaction with the taste, appearance, and variety of meals, as well as the lack of attention to their dietary preferences and requests. Staff interviews and committee meeting minutes confirmed these ongoing issues.
Surveyors found that the facility did not consistently serve menu items as planned or honor residents' food preferences and prescribed diets. Several residents received meals that did not match their dietary orders or stated dislikes, including repeated serving of pureed foods, disliked items, and missing or substituted menu items. These failures were confirmed through resident and family interviews, observations, and review of facility documentation.
Surveyors observed that food was not properly labeled, dated, or stored on multiple floors, with expired and unidentifiable items found in pantries and refrigerators. Areas were visibly dirty, including sinks, floors, and refrigerators, and soiled trays were left near the ice machine. Staff confirmed these deficiencies, which were not in accordance with facility policy or professional food service standards.
Surveyors observed multiple deficiencies, including stained ceiling tiles in two residents' rooms, trash in hallways, and failure to provide drinks or clothing protectors during meal service. Lunch trays were served with significant delays at one table, and staff informed residents that no juice was available, all contrary to facility policy.
Two residents did not have comprehensive, person-centered care plans reflecting their current needs. One resident, with multiple medical conditions and communication deficits, was not receiving scheduled showers and had no documentation or care plan focus on refusals. Another resident, under NPO orders due to dysphagia and other conditions, was repeatedly non-compliant by consuming ice and water, but this behavior was not addressed in the care plan.
Two nurse aides did not have documented evidence of completing the required annual 12 hours of training and competencies in key care areas, including dementia care and abuse prevention, as confirmed by record review and staff interviews.
A resident who was alert and oriented was moved to another room due to roommate incompatibility without being given written notice or the opportunity to refuse the transfer, as required by facility policy. The resident expressed emotional distress over the move, and interviews with the administrator and DON confirmed that documentation of written notice and the reason for the change was not provided.
A resident with dementia and agitation did not have interventions related to their dementia diagnosis included in their care plan, despite facility policy and regulatory requirements for comprehensive, person-centered care planning.
Trash, including used gloves, paper towels, and food waste, was found scattered in the parking lot and grass areas. At the loading dock, an overfilled dumpster with boxes preventing closure, along with discarded items like a toilet and PVC piping, were observed. The Food Director was unaware of the trash removal schedule.
A resident experienced ongoing issues with a loose and leaking colostomy appliance, leading to frequent changes and a shortage of supplies. Despite the resident's complaints and requests for assistance, facility staff failed to properly assess the stoma site or develop a comprehensive care plan. The resident had to rely on additional supplies from her brother, and a wound care nurse practitioner's recommendations for larger supplies had not yet been implemented.
Laurel Square Healthcare and Rehabilitation Center failed to maintain essential equipment in safe operating condition. A sink in room 213 was missing fixtures, preventing residents from accessing water for handwashing, requiring them to use a distant central bath. Additionally, an ice and water dispenser on the second floor was non-functional, with staff reporting it dispensed cloudy water before being turned off. The facility acknowledged these issues, citing delays in repairs and awaiting a new filter.
The facility did not have a process for residents to file grievances anonymously on two nursing units. During interviews, residents expressed a need for a locked box to submit grievances without revealing their identity. Observations confirmed the absence of such a system, and both the Social Services Director and the Administrator acknowledged this deficiency.
A facility failed to create a comprehensive care plan for a resident with a history of bowel obstruction and constipation. Despite having physician orders for constipation management, the care plan lacked goals, interventions, or timeframes addressing these issues, contrary to the facility's policy requiring care plans to reflect recognized standards of practice.
The facility failed to assist two residents with activities of daily living, including hearing aid management and nail care. One resident with a hearing deficit was found without functioning hearing aids, despite a physician's order for assistance. Another resident, requiring two staff for ADL assistance, had untrimmed nails and unkempt facial hair, with staff citing short-staffing as a reason for neglect.
The facility failed to maintain communication with a dialysis provider for two residents, resulting in incomplete documentation of dialysis services. One resident had missing clinical information from the dialysis center, while another had incomplete pre-dialysis documentation by facility staff. Additionally, there was no contract with the dialysis centers, as confirmed by the Administrator.
The facility did not conduct yearly performance reviews for two nurse aides, as required for quality nursing services. This was confirmed through staff interviews and a review of clinical records, revealing that Employees E13 and E14 lacked completed evaluations and in-service education.
The facility did not post complete and accurate nurse staffing information in a visible and accessible location on all observed floors. Observations revealed missing details such as actual nursing hours, adjusted census, and call outs, which were confirmed during a review with HR staff.
The facility failed to provide palatable food and drink at appropriate temperatures for several residents. Residents reported dissatisfaction with the quality and temperature of the food, often leading them to order from outside. Observations revealed that food items were served below standard temperatures, and the presentation was unappetizing, with soggy and crumbled items. The Food Service Director confirmed the food was not served at acceptable temperatures.
The facility failed to adhere to professional standards for food service safety, as observed during a tour of the Food Service Department. Issues included missing and damp ceiling tiles, rusted shelving, improperly stored food, and unclean equipment. These deficiencies were confirmed by the Food Service Director.
The facility did not ensure proper disposal of trash and recyclables in the receiving and dumpster area. Observations revealed open dumpster lids due to excess unbroken boxes, nine wooden pallets piled near dumpsters, and discarded equipment including wheelchairs and over-bed tables. The FSD confirmed these findings and clarified that the pallets were not from food service or central supply.
A resident's call bell was found nonfunctional, with the cord unplugged and no outlet available on the wall. The call bell for the adjacent bed was improperly installed. A nurse confirmed the issue, and the administrator acknowledged maintenance was aware.
The facility failed to adhere to professional standards of practice, leading to improper handling and storage of personal care items, such as used basins and razors, and a foley catheter on the floor. Staff interviews revealed a lack of awareness and proper labeling, contributing to a failure in maintaining a clean and safe environment for residents.
Failure to Develop Baseline Care Plan for Bladder Incontinence
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident with bladder incontinence. Review of the facility's policy indicated that a baseline care plan should be created to address each resident's immediate health and safety needs within forty-eight hours of admission. However, for a resident with multiple diagnoses including acute kidney failure, personal history of prostate cancer, obstructive and reflux uropathy, and artificial urinary openings, there was no evidence of a baseline care plan addressing bladder incontinence or related preventative measures. Clinical documentation showed that the resident was incontinent and at increased risk for skin breakdown, with recommendations for moisture barrier creams, use of briefs, frequent skin assessments, and pressure relief interventions. Despite these recommendations and a moderate risk score on the Braden scale, the resident's care plan did not include goals or interventions for bladder incontinence or skin breakdown prevention. This deficiency was identified through review of clinical records, facility policy, and staff interviews.
Failure to Provide Timely Pharmaceutical Services for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate receiving, dispensing, and administration of medication for a resident who reported left eye redness. The resident complained of eye redness and was assessed by a physician, who ordered tobramycin ophthalmic solution to be administered four times daily for five days. However, the medication was not received or administered as ordered due to the eye drops being lost by an overnight nurse and subsequent issues with insurance coverage for a reorder. Documentation in the electronic medication administration record (eMAR) and nursing progress notes confirmed that the medication was not given from the time it was ordered through the following eleven days. During this period, the resident's condition worsened, leading her to request emergency room care, where she received the prescribed eye drops. Interviews with nursing staff, the unit manager, and the administrator confirmed the delay in obtaining the medication and the lack of administration as ordered. The administrator expressed dissatisfaction with the pharmacy's handling of the situation, and the resident ultimately required external medical intervention due to the facility's failure to provide timely pharmaceutical services.
Failure to Discard Spoiled Refrigerated Produce in Accordance with Food Safety Standards
Penalty
Summary
Surveyors identified a deficiency related to the facility's failure to ensure timely discarding of refrigerated food items to maintain food safety. During a kitchen inspection, it was observed that the temperature log for the produce refrigerator was not recorded for one night. Further inspection of the refrigerator revealed multiple produce items, including shredded cabbage, zucchini, celery, and cantaloupe, that were visibly spoiled and dated approximately three weeks prior. The facility's own policies, which reference the FDA Food Code, require that time/temperature control for safety (TCS) foods be stored for no more than seven days, yet these items had been retained well beyond that period. Interviews with the Dietary Director and the Regional Director confirmed that the spoiled produce had not been used in meal preparation, but neither could explain why the items remained in storage for such an extended period. The Dietary Director acknowledged the produce was dated and spoiled, and the Regional Director confirmed that new produce had been received and stored, yet the old, spoiled items were not removed. No information was provided regarding any residents being directly affected or any adverse outcomes resulting from the deficiency.
Failure to Provide Palatable, Attractive, and Properly Tempered Food and Drink
Penalty
Summary
Surveyors identified that the food and nutrition department failed to ensure that foods and drinks were palatable, attractive, and served at safe and appetizing temperatures. Observations during the noon meal service revealed that cold foods, such as tuna salad, macaroni salad, fruit, and tomato basil salad, were served at temperatures significantly above the expected range for cold foods, with readings between 60 and 75 degrees Fahrenheit. Additionally, residents were not offered milk, and juice was served despite not being listed on the menu. The posted menu also lacked planned drinks. Interviews with the director of dietary services confirmed that routine temperature checks were required but not effectively implemented, and the food committee meeting minutes documented ongoing resident dissatisfaction with food temperature, taste, and appearance. Multiple residents reported dissatisfaction with the palatability, presentation, and variety of foods and beverages. Complaints included receiving unappetizing meals, foods mixed together on plates, difficulty identifying foods, and not receiving preferred items or condiments. Some residents stated that their dietary preferences and requests, such as for salad platters or avoidance of certain foods, were not honored despite being communicated to staff. These findings were corroborated by both resident interviews and staff confirmations, indicating a systemic failure to meet residents' dietary needs and preferences as outlined in facility policy.
Failure to Follow Menus and Honor Resident Food Preferences
Penalty
Summary
Surveyors identified that the facility failed to prepare and serve menu items as planned and did not consistently provide residents with their requested food preferences. Observations and interviews revealed that several residents received meals that did not match their prescribed diets or stated preferences. For example, one resident with dysphagia and hyperkalemia, who was approved for a regular diet, continued to receive pureed foods and was served disliked items such as mashed potatoes, despite documentation of these preferences. This resident also experienced a significant weight loss over three months. Another resident with multiple diagnoses, including gastroparesis and food intolerances to corn, green peas, beef, and pork, reported repeatedly receiving foods he could not tolerate, such as corn and beef. Observations confirmed that corn was served to this resident despite clear documentation of these intolerances. Additional residents reported discrepancies between their meal tickets and the food actually served, such as missing items (lettuce and tomato) or receiving different desserts than listed on the menu (cookie instead of peach pie). Family members and residents also noted a pattern of receiving the same food items regardless of the menu, such as one resident consistently being served mashed potatoes and butterscotch pudding instead of requested or listed items. The facility's registered dietician confirmed that dislikes should not appear on trays and that the electronic meal tracker system is used to update preferences, but these updates were not consistently reflected in meal service. These findings demonstrate a failure to follow prescribed diets, honor food preferences, and serve menu items as planned, as required by facility policy and state regulations.
Failure to Maintain Safe Food Storage and Sanitation Practices
Penalty
Summary
Surveyors found that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety across all three floors reviewed. During an initial tour of the kitchen, the walk-in refrigerator contained diced chicken and pork pieces that were not properly labeled or marked. Facility policy requires all foods to be wrapped or in covered containers, labeled, dated, and arranged to prevent cross-contamination, but these procedures were not followed. Further observations in the first-floor resident pantry revealed numerous unlabeled, undated, and expired foods, as well as visible dirt on the hand sink, floors, and refrigerator. The refrigerator was dirty with spilled juice, and there were grocery bags of prepared food that were unlabeled. Additional findings included a piece of corn on the cob in a paper towel and a bottle of maple syrup with a watered-down liquid on top of the refrigerator. On the second floor, similar issues were observed, including numerous unlabeled, undated, and expired foods in the refrigerator, visibly soiled pantry floors and walls, and multiple used and soiled trays stacked on the counter next to the ice machine. These findings were confirmed by staff during interviews.
Failure to Maintain Clean, Homelike Environment and Resident-Centered Dining
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment on both the first and second floor nursing units, as evidenced by multiple observations and staff interviews. In one resident's room, two brown water-stained ceiling tiles were observed, while another resident's room had five brown water-stained ceiling tiles. Additionally, paper and plastic trash were found on the floors in the hallways of the first floor unit. These conditions were not in accordance with the facility's policy, which requires a clean, sanitary, and orderly environment with pleasant, neutral scents. During meal service observations, residents in the dining/activities room were not provided with drinks or fluids on their lunch trays, and staff informed residents that no juice was available. Furthermore, clothing protectors were not offered to residents during lunch service, contrary to the facility's policy. The serving of lunch trays at one table was also significantly delayed, with the last resident at the table receiving their meal 20 minutes after the first. These actions and inactions demonstrate a failure to provide a comfortable and resident-centered dining experience as outlined in facility policy.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents as required by policy and federal regulations. For one resident with diabetes, dysphagia, hyperlipidemia, and vocal cord paralysis, there was a communication deficit requiring the use of an electronic device. This resident reported not receiving regular showers as scheduled, stating it had been two weeks or more since the last shower. Although the Assistant Director of Nursing stated the resident had refused a recent shower, a review of nursing notes and documentation showed no record of refusals, and the care plan did not address shower refusals or related issues. For another resident with dysphagia, cognitive communication deficit, and hyperosmolality/hypernatremia, there was a physician order for NPO (nothing by mouth) status. Despite repeated observations and documentation of the resident being non-compliant with NPO status by consuming ice and water, the care plan did not include any focus area or interventions addressing this non-compliance. Nursing notes documented education and monitoring, but the care plan was not updated to reflect the resident's behavior. These findings were confirmed by facility staff.
Failure to Document Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to ensure that nursing assistants completed and retained documentation of the required minimum of 12 hours of annual nursing training for two out of four nurse aides whose personnel records were reviewed. Specifically, for two nursing assistants, there was no documentation available to confirm completion of annual training and competencies in areas such as dementia care, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, and cultural competency. This deficiency was identified through reviews of staff training records, the facility assessment, and staff interviews. The Administrator confirmed that the necessary training and competency documentation for these nursing assistants was not available for review.
Failure to Provide Written Notice and Honor Resident's Right to Refuse Room Change
Penalty
Summary
The facility failed to honor a resident's right to refuse a room change and did not provide written notice prior to the change. According to the facility's own policies, residents have the right to refuse a transfer and must be given written notice with documentation of the reasons for the move and any interventions taken. In this case, a resident who was alert, oriented, and had a history of high blood pressure and bladder cancer was moved to another room due to reported roommate incompatibility. The clinical and social service records indicated that the move was made, but there was no documentation that the resident was given written notice or that her refusal was properly recorded. The resident expressed distress over the move, stating she was told it was easier to move her rather than her roommate, even though the roommate had requested the change. She reported emotional upset from being separated from another resident she was close to. Interviews with the Nursing Home Administrator and DON confirmed the move but failed to provide evidence that the required written notice and explanation were given to the resident prior to the room change.
Failure to Develop Comprehensive Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident, as required by both facility policy and federal regulations. Specifically, a review of the clinical record for a resident admitted with a diagnosis of dementia and agitation showed that the most recent care plan did not include interventions addressing the resident's dementia diagnosis. This deficiency was identified through review of facility policy, clinical records, observations, and staff interviews, and it was noted that the care plan had not been updated to reflect the resident's current needs related to dementia.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Multiple trash items, including used paper towels, latex gloves, empty plastic bottles, plastic disposable utensils, and food particles, were observed scattered in the grass and parking lot area of the facility. During a tour of the Food Service Department, one of two dumpsters at the loading dock was found to be so full that boxes were preventing the lid from closing completely. Additional refuse, such as a toilet and PVC piping, was also present near the dumpster area. The Food Director was unable to specify how long these items had been there, as he was not aware of the trash removal schedule.
Inadequate Colostomy Care Leads to Resident Discomfort and Supply Shortage
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, leading to issues with the resident's colostomy appliance. The resident reported that her colostomy appliance was loose and leaking, requiring frequent changes and additional supplies, which she had to obtain from her brother. Despite the resident's complaints and requests for assistance, the facility staff did not adequately assess the stoma site or the colostomy appliance to ensure a proper fit and seal. The resident experienced leakage and skin irritation due to the improper fit of the appliance and the use of paper tape to secure it. The facility's records showed that the resident had been experiencing these issues for at least four months, and there was no evidence of a comprehensive, resident-centered care plan for colostomy care. The Director of Nursing acknowledged the resident's use of additional supplies and stated that a wound care nurse practitioner specializing in ostomy care visited the facility weekly. However, the resident was only seen by the nurse practitioner on March 10, 2025, who recommended larger supplies, which had not yet been received. The lack of timely intervention and proper assessment contributed to the resident's ongoing issues with colostomy care.
Non-Functional Sink and Dispenser Issues
Penalty
Summary
Laurel Square Healthcare and Rehabilitation Center was found to be non-compliant with the requirement to maintain essential equipment in safe operating condition. During an abbreviated survey, it was observed that the sink in room 213 on the second-floor nursing unit was missing fixtures, preventing residents from accessing water for handwashing. Resident R5 reported that the sink had been non-functional for at least five days, requiring her to walk to the other end of the hall to wash her hands and perform morning hygiene. Resident R8 also confirmed the inconvenience of having to use the central bath for basic hygiene needs. The Maintenance Director acknowledged that the sink had been out of service since November 28, 2024, due to wall patching delays, and the Director of Nursing agreed that the situation was inappropriate for residents and staff. Additionally, the survey revealed that the ice and water dispenser on the second floor was not operational, failing to dispense ice or water. Employee E9, a nurse aide, noted that the dispenser had been out of service for at least a week and had previously dispensed cloudy water. The Administrator confirmed that the dispenser had been non-functional for several days and that a new filter was awaited. These deficiencies indicate a failure to maintain essential equipment in a safe and working condition, impacting the residents' and staff's ability to perform necessary hygiene and hydration tasks.
Plan Of Correction
1. No actual harm occurred. 2. The maintenance director/designee will audit room sinks and ice machines on each floor once per week for 4 weeks to confirm equipment is in proper working condition. 3. Staff will be reeducated on using the facility's maintenance care program to submit findings of any defective equipment promptly and consistently. 4. Any/all negative findings during the audits will be presented and discussed during QAPI. 5. Corrective actions will be completed by 12/18/24. UPDATE: 12/23/24 - Ice machine was repaired and is currently in proper working condition. In addition, the room sink audits will be completed for all rooms for 4 weeks.
Failure to Provide Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to provide a process for residents to file grievances anonymously on both the first and second nursing units. During a group interview with seven alert and oriented residents, it was revealed that none of them were aware of how to file an anonymous grievance. They expressed a desire for a locked box to submit grievances anonymously. Observations conducted during the survey confirmed the absence of any means to file an anonymous grievance on the nursing units or bulletin boards throughout the facility. The Social Services Director and the Administrator both acknowledged the lack of a system for anonymous grievance filing.
Failure to Develop Comprehensive Care Plan for Constipation and Bowel Obstruction
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for a resident with a medical history of intestinal obstruction, retention of urine, ulcerative colitis, acute abdomen, nausea and vomiting, and hemiplegia and hemiparesis following a cerebral infarction. The resident was hospitalized for hematochezia and a small bowel obstruction, and upon discharge, had active physician orders for multiple medications to manage constipation. Despite these medical conditions and treatment orders, the resident's care plan lacked goals, measurable interventions, or timeframes related to constipation and bowel obstruction. The facility's policy on comprehensive, person-centered care plans, revised in March 2022, requires that care plans reflect currently recognized standards of practice for problem areas and conditions. However, the review of the resident's care plan revealed no evidence of adherence to this policy, as it did not address the resident's specific needs related to bowel obstruction and constipation. This oversight was identified during a review of facility documentation and clinical records, highlighting a deficiency in the facility's resident care policies.
Deficiency in Assistance with ADLs for Residents
Penalty
Summary
The facility failed to assist dependent residents with activities of daily living, specifically related to hearing aids and nail care. Resident R9, who has a communication problem due to a hearing deficit, was observed without functioning hearing aids on multiple occasions. Despite having an active physician order to assist with hearing aids at 6:00 AM, Resident R9 was found watching television with the hearing aids on the bedside table and later without them entirely, indicating a lack of assistance from the staff. Resident R2, who requires two staff members for assistance with activities of daily living, was observed with untrimmed and dirty nails, and unkempt facial hair. The resident expressed a desire for nail care, stating that it interferes with daily activities and that staff become frustrated when requests are made. A nurse aide assigned to Resident R2 admitted to being short-staffed, which contributed to the neglect in providing necessary nail care and hygiene.
Failure in Communication and Documentation for Dialysis Services
Penalty
Summary
The facility failed to maintain ongoing communication with a dialysis provider for two residents receiving dialysis services. Resident R54 had a physician's order for hemodialysis three times a week, but the dialysis log records were incomplete, with two out of five pages lacking documentation from the dialysis center. This was confirmed by the Nursing Supervisor, who acknowledged the missing clinical documentation. Similarly, Resident R7, who also had a physician's order for hemodialysis three times a week, had one log page not completed by the facility staff before the resident went to dialysis. The Nursing Supervisor confirmed that the pre-dialysis documentation of Resident R7's clinical status was not completed. Additionally, there was no contract available for review between the facility and the dialysis centers serving Residents R54 and R7. This was confirmed by the Administrator, who acknowledged the absence of a contract related to dialysis services for these residents. The Director of Nursing also confirmed that the log sheets should be completed each time the resident goes to dialysis by both the facility nurse and the dialysis center staff. The lack of proper documentation and communication between the facility and the dialysis provider led to the deficiency.
Lack of Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to provide evidence of yearly performance reviews for nurse aides, which is a requirement for maintaining quality nursing services. During a clinical record review and staff interviews, it was discovered that two out of five nurse aides, identified as Employees E13 and E14, did not have completed performance evaluations or in-service education based on these reviews. This deficiency was confirmed through interviews with the facility's human resources representative and the Director of Nursing.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent and accessible location for residents on all three observed floors: Ground, First, and Second. During observations conducted on September 10 and 11, 2024, it was noted that the facility did not post the nurse staffing data at the beginning of each shift. The posted information was incomplete and inaccurate, lacking required details such as actual nursing hours, adjusted census, and call outs. These deficiencies were confirmed during a review with a Human Resources employee on September 12, 2024.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at appropriate temperatures for seven residents. During a group meeting, these residents expressed dissatisfaction with the quality and temperature of the food, stating it was often not cooked properly and served cold, leading them to order food from outside. Observations during a test tray conducted with the Assistant Food Service Director revealed that the ham was at 128 degrees, sweet potatoes at 133 degrees, and orange juice at 69 degrees, all of which were below the standard temperatures of 135 degrees for hot foods and 41 degrees for cold foods. Additionally, the presentation of the food was unappetizing, with a soggy roll and a crumbled cake in a plastic bag. An interview with the Food Service Director confirmed the food was not served at acceptable temperatures, making it unpalatable.
Deficiencies in Food Storage and Safety Standards
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, several deficiencies were observed. In the dry storeroom, a missing ceiling tile exposed pipes, and another tile had a damp spot. Metal wire shelving was found to be pitted with rust-colored and dark stains, and a dark black substance was growing from the floor to two to three feet high on the outer aluminum wall of the walk-in refrigerated units. Additionally, cardboard boxes of pretzels and plastic lids were stored less than the required 18 inches from the ceiling. In the walk-in freezer, three cases of food were not properly sealed, leaving the contents exposed to air. The convection ovens had a significant build-up of black burned-on food spillage on all interior surfaces. The wall between the dish machine and the reach-in refrigerator was spattered with food, and the paint on the wall behind the tilt skillet was peeling. These observations were confirmed by the Food Service Director during the tour, indicating a failure to adhere to the facility's policy on food storage and safety.
Improper Disposal of Trash and Recyclables
Penalty
Summary
The facility failed to ensure proper disposal of trash and recyclables in the receiving and dumpster area. During an initial tour of the Food Service Department, it was observed that the side sliding door to the garbage dumpster was open, and the top lids of the recycling dumpster were open due to an excess of boxes, many of which were not broken down, preventing the lids from closing. Additionally, nine wooden pallets were haphazardly piled near the dumpsters, and there were three wheelchairs and five over-bed tables in the area. An interview with the Food Service Director (FSD) confirmed that the equipment was to be discarded and that the pallets were not from food service or central supply.
Nonfunctioning Call Bell in Resident's Room
Penalty
Summary
The facility failed to ensure that call bells were available and operable for resident use, as evidenced by the situation involving Resident R33. During an interview with Resident R33, it was revealed that the call bell in his room was not functioning. The call bell cord was found unplugged, with the plug lying on the floor, and there was no visible outlet on the wall behind the bed, only a hole where an outlet might have been. Additionally, the call bell for the adjacent bed in the same room was improperly installed, being plugged into a box resting on top of the overbed light rather than attached to the wall. Employee E11, a Licensed Nurse, confirmed the nonfunctioning status of the call bell for Resident R33's bed and admitted to being unaware of the issue until prompted to contact maintenance. The Nursing Home Administrator later confirmed that the maintenance department was aware of the problem with the call bell in Resident R33's room.
Inadequate Infection Control and Personal Care Management
Penalty
Summary
The facility failed to implement resident-directed care and treatment consistent with professional standards of practice, which placed residents at risk for infections or accidents. Observations on the first floor unit revealed improper handling and storage of personal care items. Used basins with gloves and wet washcloths were found improperly stored, and multiple used urinals were stacked on toilet handrails. Additionally, a used razor without a guard was left unattended next to a sink faucet, and a foley catheter was observed on the floor. These findings indicate a lack of adherence to the facility's policies on infection control and personal care item management. Interviews with staff revealed a lack of awareness and proper labeling of personal care items, as only one basin had a fading room number, and four residents shared the restroom space. A grievance report indicated that a nurse aide left a resident's room in disarray, with feces found on a bedside table, which was later cleaned by a charge nurse. The director of nursing confirmed that the unattended razor belonged to a resident, highlighting a lapse in ensuring safe and hygienic care practices. These deficiencies demonstrate a failure to maintain a clean and safe environment for residents, as required by professional standards and facility policies.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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