Laureldale Skilled Nursing And Rehabilitation Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Laureldale, Pennsylvania.
- Location
- 2125 Elizabeth Avenue, Laureldale, Pennsylvania 19605
- CMS Provider Number
- 395477
- Inspections on file
- 26
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Laureldale Skilled Nursing And Rehabilitation Cent during CMS and state inspections, most recent first.
A deficiency was identified when an exit sign near a resident room in one smoke compartment was found to be unilluminated, as confirmed by the Director of Maintenance.
A corridor door leading to the Patio Lounge failed to positively latch within the door frame, as observed and confirmed by the Director of Maintenance. This deficiency affected one of twelve smoke compartments and did not meet NFPA 101 and CMS requirements for corridor door latching.
An unprotected penetration was found in a smoke barrier wall above double doors near the ADON/Medical Records Office, where blue and red wires passed through without proper protection. This issue, confirmed by the Director of Maintenance, affected two of twelve smoke compartments.
An electrical junction box above the Zone 8 suspended ceiling, near the smoke barrier doors by the Unit Scheduler's Office, was found without a cover plate, leaving electrical wiring exposed. The Director of Maintenance confirmed the issue during the inspection.
A surge suppressor was used to supply power to a toaster, coffee machine, and microwave in a medical records room, contrary to NFPA requirements. The Director of Maintenance confirmed the improper use of the surge suppressor for these high-draw appliances.
A survey found that the facility is a three-story, Type II (000) unprotected noncombustible building with a basement, which exceeds the maximum allowable story height for this construction type. The Director of Maintenance confirmed that the building's construction type and height are not permitted under current regulations.
The facility did not provide documentation confirming that quarterly inspections of the automatic sprinkler system were completed over the past year. This was confirmed by the Director of Maintenance, and the deficiency impacted the entire sprinkler system component.
Surveyors observed multiple environmental deficiencies across two nursing units, including missing roof shingles, peeling ceiling tiles and wallpaper, damaged walls, stained ceiling tiles, and a crushed dryer vent hose. These issues reflect a failure to maintain a safe, clean, and comfortable environment for residents.
Four residents with significant medical conditions requiring ADL assistance were repeatedly observed with long, dirty fingernails and, in some cases, unshaven, despite care plans specifying the need for grooming and bathing support. Staff did not provide necessary grooming services, and the administrator confirmed these tasks should have been completed during bathing and as needed.
Staff did not follow physician orders for two residents regarding medication administration. One resident received a blood pressure medication despite a low heart rate, and another did not receive an as-needed antihypertensive when their blood pressure was elevated. These failures were confirmed by the Administrator.
A resident with dementia and ventricular tachycardia, who was dependent on staff for care, was found with multiple unexplained bruises by a nurse aide and an LPN. Despite facility policy requiring immediate reporting of such incidents, the Administrator was not notified until nearly two days later, and an investigation was delayed accordingly.
A cognitively impaired female resident, dependent on staff for mobility, was not protected from sexual abuse by another resident with a known history of sexually inappropriate behavior. Despite repeated incidents, including wandering into female residents' rooms, exposing himself, and ultimately groping a peer, the facility did not update the care plan or increase supervision to prevent further abuse.
A resident with a history of falls and requiring maximum assistance for toileting fell and sustained a head injury due to neglect. Despite the care plan's requirement for two staff members to assist, only one nurse aide was present, leading to the resident's fall and subsequent death. The facility's investigation confirmed the aide's awareness of the need for two-person assistance.
A resident with a history of falls and requiring maximum assistance for toileting fell and suffered a head injury when only one nurse aide assisted during a transfer. Despite the care plan requiring two staff members for assistance, this protocol was not followed, resulting in the resident's fall and subsequent death.
A resident with multiple health conditions fell after using the toilet, and the facility failed to notify the responsible party immediately, delaying notification until the next day. This was against the facility's protocol, as confirmed by the DON.
The facility failed to maintain sanitary conditions in the kitchen. Observations revealed three dusty pipes on the floor near the ice machine, two dirty bowls behind it, and water draining onto the floor, creating standing water. Additionally, a vent in the dish room had peeling paint.
The facility failed to follow physician's orders for two residents, leading to improper medication administration. A resident with a history of stroke and high blood pressure received metoprolol without checking required blood pressure and heart rate parameters. Another resident with sepsis and heart failure was given furosemide without confirming blood pressure was above the prescribed threshold. The DON confirmed the oversight.
The facility failed to provide restorative nursing services for three residents, leading to a lack of documented evidence for required passive range of motion exercises. A resident with dementia and hemiplegia, another with dementia and knee pain, and a third with COPD and anxiety were all at risk for loss of range of motion. Despite care plans indicating the need for exercises, there was no documentation to confirm their completion, as confirmed by the DON.
The facility failed to provide adequate supervision and prevent accident hazards on two nursing units. A resident with cognitive impairment was fed by another resident without staff intervention, and a treatment cart with medications was left unlocked near unsupervised, cognitively impaired residents. Additionally, the facility did not properly investigate a fall involving a resident with dementia, implementing an inappropriate intervention and failing to document bed positioning as required.
The facility did not accommodate the meal preferences of two residents, leading to deficiencies. A resident with diabetes and GERD was served a meal with gravy, contrary to her preference. Another resident with dementia and malnutrition received broccoli instead of the specified carrots. These actions did not align with their care plans.
The facility failed to provide written notification to the representatives of nine residents who were transferred to the hospital due to changes in their conditions. The Director of Nursing confirmed that the required documentation was not provided.
The facility failed to develop a comprehensive care plan for a resident with diabetes and an altered mental state. The resident was identified as being at risk for impaired nutrition, but no interventions were included in the care plan. This was confirmed by the Nursing Home Administrator.
The facility failed to timely assess the nutritional status of two residents, leading to significant weight loss without appropriate intervention. One resident lost 12.5% of their weight, and another lost 10.13%, with no evidence of assessment or notification to the physician and responsible party.
Failure to Maintain Illuminated Exit Signage
Penalty
Summary
The facility failed to maintain the required illumination of exit signage in accordance with NFPA 101 standards. During an observation, it was found that the exit sign located in Zone 11, near Resident Room 319, was not illuminated. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the exit sign was not functioning as required. The issue affected one of twelve smoke compartments within the component.
Plan Of Correction
The light bulb for the Exit Signage in Zone 11 by Resident room 319 has been replaced. Maintenance staff will be educated on ensuring all exit signage is illuminated moving forward. Maintenance Director/Designee to perform random quarterly audits on exit signage to ensure all exit signage is illuminated. Results of audits will be forwarded to the QAPI Committee.
Failure to Maintain Positive Latching of Corridor Door
Penalty
Summary
The facility failed to maintain the positive latching of a corridor door, specifically the Zone 8 door to the Patio Lounge. During an observation, it was found that this door did not positively latch within the door frame as required by NFPA 101 and CMS regulations. The deficiency was identified during a survey, and the issue was confirmed through an interview with the Director of Maintenance, who acknowledged that the corridor door failed to latch properly. This deficiency affected one of twelve smoke compartments within the facility. The report does not mention any specific residents or patients involved, nor does it provide details about their medical history or condition at the time of the deficiency. The focus of the finding is solely on the failure of the door to meet the required positive latching standard, as observed and confirmed by facility staff.
Plan Of Correction
The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee. The Zone 8 patio lounge door has been adjusted to latch positively. Maintenance staff will be educated on ensuring all doors latch positively moving forward. Maintenance Director/Designee to perform an audit on doors latching positively weekly for 4 weeks and monthly for 2 months to ensure doors in the facility are latching properly. Results of audits will be forwarded to the QAPI Committee.
Unprotected Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls as required by NFPA 101. During an observation, an unprotected penetration was found in the Zone 11 smoke barrier wall, located above the double doors near the ADON/Medical Records Office, where blue and red wires passed through the wall without proper protection. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged the unprotected penetration. The issue affected two of twelve smoke compartments within the component. No information about residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The smoke barrier wall was repaired using an approved through-penetration fire stop system. The facility will maintain the rating of the smoke barrier walls moving forward. Maintenance staff will be educated on ensuring penetrations are protected and maintaining the rating within smoke barrier walls. Maintenance Director/Designee to perform random quarterly audits for 1 year on smoke barrier walls. Results of audits will be forwarded to the QAPI Committee.
Exposed Electrical Wiring Due to Missing Junction Box Cover
Penalty
Summary
During an inspection, it was observed that an electrical junction box located above the Zone 8 suspended ceiling, near the smoke barrier doors by the Unit Scheduler's Office, was missing a cover plate. This resulted in exposed electrical wiring. The Director of Maintenance confirmed the presence of the exposed wiring at the time of the observation. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The electrical junction box cover plate was replaced above the suspended ceiling in Zone 8. Maintenance staff will be educated on ensuring cover plates are in place for junction boxes moving forward. The Maintenance Director/Designee will perform an audit on junction box cover plates when work is completed above the ceiling to ensure the junction boxes have a cover plate in place. Results of audits will be forwarded to the QAPI Committee.
Improper Use of Surge Suppressor for High-Draw Appliances
Penalty
Summary
A deficiency was identified when, during an observation, a surge suppressor was found supplying electrical power to a toaster, coffee machine, and microwave in the Zone 11 Medical Records Room. The use of a surge suppressor for these high-draw appliances does not comply with NFPA 101 and related standards, which restrict the use of power strips and surge suppressors for such equipment. The Director of Maintenance confirmed during an interview that these appliances were indeed plugged into the surge suppressor, indicating a failure to monitor and ensure proper use of electrical equipment within the facility. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
The surge suppressor containing the toaster, coffee machine, and microwave has been removed from the Medical Records Office. Staff will be educated on the forbidden use of surge suppressors/mini appliances moving forward. Maintenance Director/Designee to perform a quarterly random audit for 1 year to determine if surge protectors are in use within the facility. Results of audits will be forwarded to the QAPI Committee.
Noncompliance with Building Construction Type and Height Requirements
Penalty
Summary
The facility failed to maintain compliance with building construction requirements as specified by NFPA 101. During an observation, it was found that the building is a three-story, Type II (000) unprotected noncombustible structure with a basement, which exceeds the maximum allowable story height for this construction type. The deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the construction type and height do not meet the permitted standards. No information about specific residents or their conditions was provided in the report. The deficiency centers on the facility's noncompliance with the required building construction type and height limitations, as the structure's number of stories surpasses what is allowed for its construction classification.
Failure to Maintain Documentation of Quarterly Sprinkler System Inspections
Penalty
Summary
The facility failed to provide documentation verifying that quarterly inspections of the automatic sprinkler system were conducted over the previous twelve months. During a document review, it was found that there was no documentation available to confirm that the sprinkler system was inspected between January 23, 2025, and July 3, 2025. This was confirmed in an interview with the Director of Maintenance, who acknowledged the absence of inspection records for the specified period. The deficiency affected the entire sprinkler system component, as required records of inspection and maintenance were not available for review.
Plan Of Correction
Quarterly sprinkler inspections were conducted at Laureldale Skilled Nursing and Rehabilitation Center throughout the previous 12 months. Maintenance staff will be educated on ensuring all sprinkler inspection documentation is maintained moving forward. Maintenance Director/Designee to perform quarterly audits on sprinkler inspection documentation for 1 year to ensure compliance. Results of audits will be forwarded to the QAPI Committee.
Environmental Deficiencies Compromise Resident Comfort and Safety
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment on two of its three nursing units, specifically the second and third floors. Observations conducted over a seven-hour period revealed multiple environmental deficiencies, including missing roof shingles over the Heritage Wing, peeling ceiling tiles and wallpaper in several resident rooms and bathrooms, damaged walls in both resident rooms and common areas, and stained ceiling tiles. Additional issues included a badly crushed vent hose for a resident dryer and discolored areas below molding trim. These findings were directly observed and documented by surveyors, indicating a lack of adequate facility maintenance and oversight in ensuring a homelike and safe environment for residents.
Failure to Provide Adequate Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for four residents who required assistance with activities of daily living (ADLs), specifically grooming and bathing. Clinical record reviews indicated that these residents had significant medical conditions such as paraplegia, congestive heart failure, dementia, polyneuropathy, muscle wasting, diabetes with neuropathy, and hemiplegia due to stroke, all of which necessitated staff support for personal care. Despite care plans outlining the need for assistance, observations on multiple dates revealed that these residents consistently had long and dirty fingernails, and in some cases, were unshaven. Residents who were able to communicate confirmed their need for nail trimming and shaving, while non-verbal residents indicated agreement through gestures. Staff interviews and documentation confirmed that grooming tasks, such as nail trimming and shaving, were not performed as required. The administrator acknowledged that these services should have been provided during bathing and as needed. The repeated observations over several days demonstrated a pattern of inaction in maintaining residents' grooming and hygiene, directly contradicting the care plans and residents' expressed or indicated needs.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Facility staff failed to follow physician orders for two residents. One resident with Alzheimer's disease and hypertension had a physician's order for Bisoprolol Fumarate to be administered three times daily, with instructions to hold the medication if the systolic blood pressure was below 90 mm/Hg or if the heart rate was less than 60 beats per minute. Despite these parameters, the medication was administered multiple times over several months when the resident's heart rate was below 60. Another resident with epilepsy, dementia, and hypertension had a physician's order for Hydralazine to be given every 8 hours as needed if the systolic blood pressure exceeded 140 mm/Hg. Staff failed to administer the medication on several occasions when the resident's blood pressure was above this threshold. These findings were confirmed by the Administrator during an interview.
Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator or Abuse Prevention Coordinator as required by facility policy. According to the policy, all incidents and allegations of abuse, including injuries of unknown origin, must be reported immediately to the administrator or designee. In this case, a nurse aide observed multiple bruises on a resident's left arm, breast, and axilla during the evening shift, and an LPN documented the injuries as being of unknown cause or onset. Facility documentation indicated that the injury was identified by the LPN, but there was no evidence that the Administrator was notified within two hours as required. The resident involved had diagnoses including dementia and ventricular tachycardia, was cognitively impaired, and required staff assistance for personal hygiene and transfers. Despite the identification and documentation of the injuries, the Administrator was not notified until nearly two days later, and an investigation was not initiated until that time. Interviews with the Administrator confirmed that staff did not follow the facility's policy for immediate notification regarding the injury of unknown origin.
Failure to Protect Resident from Sexual Abuse by Peer
Penalty
Summary
The facility failed to protect a cognitively impaired female resident, who had dementia and depression and was dependent on staff for mobility, from sexual abuse by another resident with a history of sexually inappropriate behavior. The male resident, who also had dementia and was able to move about the facility independently, had previously exhibited sexually inappropriate behaviors, including being moved to a different room due to such incidents and being monitored by a psychiatrist for these concerns. Despite multiple documented instances of the resident wandering into female residents' rooms without consent, becoming aggressive when discovered, and exposing himself to others, there was no evidence that the facility took action to address or prevent further incidents. The male resident's sexually inappropriate behavior was not included in his care plan, and supervision was not increased, even after repeated incidents. The situation culminated in an incident where the male resident was found groping the female resident while unsupervised in her room. Facility documentation and staff interviews confirmed that no interventions were implemented to protect residents from further abuse, despite a clear pattern of behavior and ongoing risk.
Neglect Leads to Resident's Fall and Head Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. The resident, who had a history of falls and required maximum assistance for toileting, was diagnosed with muscle wasting, hypertension, transient ischemic attacks, atherosclerotic cardiovascular disease, and chronic respiratory failure. The care plan specified that two staff members were needed to assist the resident with transfers. Despite this, on the day of the incident, only one nurse aide assisted the resident, leading to a fall in the bathroom where the resident struck his head. The incident occurred when the resident's knees buckled while being assisted off the toilet, causing him to fall and sustain a head injury, including a hematoma and bleeding. The resident was dazed and had difficulty breathing following the fall. Although the resident refused hospital transport, he stopped breathing shortly after, and staff were unable to revive him. The facility's investigation confirmed that the nurse aide was aware of the requirement for two staff members but failed to comply, contributing to the resident's fall and subsequent injury.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents related to falls for a resident, resulting in actual harm. The resident had a history of falls and required maximum assistance for toileting, as indicated in the care plan. The care plan specified that two staff members were needed to assist the resident with walking and transferring. However, on the day of the incident, only one nurse aide was assisting the resident during a transfer from the toilet, leading to the resident's fall. The resident, who had multiple diagnoses including muscle wasting, hypertension, and chronic respiratory failure, fell and struck his head, resulting in a hematoma and bleeding. Despite being monitored by staff, the resident refused hospital transport and later stopped breathing, with staff unable to revive him. The Director of Nursing confirmed that two staff members should have been assisting the resident at the time of the fall.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility failed to notify the responsible party of a change in condition and a fall for one of the sampled residents. The resident, who had diagnoses including muscle wasting, hypertension, history of transient ischemic attacks, atherosclerotic cardiovascular disease, and chronic respiratory failure, experienced a fall on August 6, 2024, at 3:15 p.m. after using the toilet. Despite the facility's protocol to notify the responsible party immediately after a fall, the notification was delayed until the following day at 3:30 p.m. This deficiency was confirmed during an interview with the Director of Nursing on August 16, 2024.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an environmental tour. Three pipes covered in dust were found lying on the floor near the ice machine. Additionally, two dirty bowls were located behind the ice machine, and water was observed draining from the ice machine onto the floor, creating areas of standing water. In the dish room, a vent was noted to have various areas of peeling paint.
Failure to Implement Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to a deficiency in care. Resident 135, with a history of stroke and high blood pressure, was prescribed metoprolol tartrate to be administered twice daily, with specific parameters to hold the medication if the systolic blood pressure was below 110 mmHg or the heart rate was less than 50 beats per minute. However, the medication was administered over 43 times in June 2024 without checking these parameters. Similarly, Resident 151, diagnosed with sepsis, kidney failure, and heart failure, was ordered to receive furosemide on specific days, with instructions to hold the medication if blood pressure was below 90/60 mmHg. The medication was given ten times in June 2024 without confirming the blood pressure was above the set parameter. The Director of Nursing confirmed that the parameters were not checked prior to administering the medications for both residents.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility for three residents. Resident 4, diagnosed with dementia, congestive heart failure, and hemiplegia, was identified as being at risk for loss of range of motion. Her care plan required staff to perform passive range of motion exercises on her legs during morning and evening care. However, there was no documented evidence that these exercises were being completed. Similarly, Resident 31, who had dementia and knee pain, required passive range of motion exercises for his legs, but again, there was no documentation to confirm these were performed. Resident 83, with chronic obstructive pulmonary disease and anxiety, was supposed to receive passive range of motion exercises for her right arm, but she reported that staff did not complete these exercises. The Director of Nursing confirmed the lack of documentation for the completion of these restorative nursing programs.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards on two of its nursing units. On the Second Floor Unit, Resident 9, who had cognitive impairment and required a mechanically altered texture diet, was observed being fed by another resident without staff intervention. This lack of supervision posed a risk to Resident 9, who had a self-care deficit and required meal support as per her care plan. On the Third Floor Unit, a treatment cart containing various medications was found unlocked and accessible to cognitively impaired residents, including Residents 56 and 88, who were observed moving around the unit unsupervised. Additionally, the facility failed to thoroughly investigate a fall involving Resident 56, who had dementia and was at risk for falls. After a fall, the intervention added was inappropriate, as it involved a toileting program despite the resident having an indwelling urinary catheter. Furthermore, there was no documentation confirming that the resident's bed was in a low position during a subsequent fall, as required by the care plan.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to accommodate the meal preferences of two residents, leading to deficiencies in their care. Resident 21, who has diabetes, gastro-esophageal reflux disease (GERD), and intestinal issues, was observed with a meal that included gravy, despite her meal ticket specifying no gravy due to her dislike for it. This occurred while she was alert and oriented, as noted in her care plan. Additionally, Resident 130, who suffers from dementia, underweight, and malnutrition, was served broccoli instead of the carrots specified on her meal ticket. Her care plan highlighted a potential nutritional problem due to poor appetite, yet the meal provided did not align with her documented preferences.
Failure to Notify Residents' Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the residents' representatives regarding the transfer of nine residents to the hospital. These residents were transferred due to changes in their conditions, but there was no evidence that their responsible parties were informed in writing about the transfers and the reasons for these moves. This deficiency was identified through clinical record reviews and confirmed by the Director of Nursing during an interview. The residents involved in this deficiency were transferred to the hospital on various dates between March and June 2024. Despite the requirement to notify the residents' representatives in writing, the facility did not provide such documentation for any of the nine residents. This lack of communication was acknowledged by the Director of Nursing, who confirmed that the necessary written information was not provided to the residents' representatives.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan to meet the needs of a resident identified in the comprehensive assessment. Clinical record review revealed that the resident was admitted with diagnoses including diabetes and an altered mental state. The Minimum Data Set Care Area Assessment summary noted that the resident was at risk for impaired nutrition and that this should be addressed in the care plan. However, there was no evidence that interventions to address the resident's nutritional needs were included in the current care plan. This deficiency was confirmed by the Nursing Home Administrator during an interview.
Failure to Timely Assess Nutritional Status
Penalty
Summary
The facility failed to timely assess the nutritional status of two residents, leading to significant weight loss without appropriate intervention. Resident 1, who had diagnoses including diabetes and altered mental state, was admitted to the facility and weighed 147 pounds on January 12, 2024. However, no further weights were recorded until March 5, 2024, when the resident weighed 128.65 pounds, indicating a significant 12.5 percent weight loss. During this period, the resident was documented to be eating only about 25 percent of his meals from February 27 to March 8, 2024. There was no evidence that the facility assessed or addressed this significant weight loss or notified the physician and responsible party of the resident's change in condition. Similarly, Resident 6, who had diagnoses including spastic paraplegia and anemia, weighed 122.4 pounds on January 5, 2024. The next recorded weight was on March 8, 2024, showing a weight of 110 pounds, a significant 10.13 percent weight loss. Again, there was no evidence that the facility assessed or addressed this significant weight loss or notified the physician and responsible party. The Nursing Home Administrator confirmed that there was no documented evidence that staff obtained weights according to the facility policy or that they immediately notified the physician and responsible party of the significant weight losses.
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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