Liberty Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 7310 Stenton Avenue, Philadelphia, Pennsylvania 19150
- CMS Provider Number
- 395764
- Inspections on file
- 24
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Liberty Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors identified multiple failures in food storage and preparation, including a walk-in freezer with a broken seal and temperatures above required levels, partially defrosted food, lack of temperature monitoring, unsanitary kitchen equipment, and improper ice machine drainage. These deficiencies were confirmed by the Food Service Director and Maintenance staff.
Multiple units were observed with unsanitary and disorderly conditions, including rooms with gnats, food debris, dirty linens, and foul odors. Dining areas had used trays left out, linens and equipment stored improperly, and limited seating. Additional issues included a sink hanging off the wall and stained window shades. These conditions were confirmed by staff and did not meet requirements for a clean, safe, and homelike environment.
Breakfast was not served at the scheduled time, with several residents left waiting and expressing hunger. Dietary staff began plating meals late due to staffing shortages, and multiple residents reported that inconsistent meal times interfered with their routines.
Surveyors observed unsanitary conditions, including excess trash, food debris, dirty linens, and used utensils on two units, leading to the presence of gnats and flies. A resident reported gnats in their room, and staff acknowledged that cleanliness was only improved due to surveyor presence. Facility records showed repeated pest complaints without adequate follow-up, and a pest control inspection confirmed excessive gnat activity and poor sanitation.
A resident who was NPO but permitted pudding or applesauce at lunch was seated with other residents during a meal but was not offered the allowed food items, despite being dependent on staff for eating. Staff confirmed the resident was not provided with pudding or applesauce while others ate.
A resident with severe cognitive impairment, wandering behaviors, and multiple care needs did not receive required supervision and care over two shifts when a CNA assigned to the resident's room was unaware of the assignment and failed to provide necessary services, resulting in neglect.
A resident with psychomotor and cognitive communication deficits was not provided with a care plan addressing hearing loss, despite repeated documentation and self-report of difficulty hearing and lack of hearing aids. The same resident experienced significant weight loss over several months, but the care plan did not include interventions or communication regarding this decline, even though supplemental nutrition was recommended and facility policy required multidisciplinary care planning.
Two residents requiring substantial assistance with personal hygiene and grooming were found in unsanitary conditions, including soiled briefs and unwashed lower extremities, with gnats present in their rooms. Care plans specifying regular hygiene and bathing were not followed, as confirmed by direct observation and record review.
A resident with a history of hearing impairment was documented as hard of hearing over several months and reported difficulty communicating with staff. Despite the resident's request for help and the absence of hearing aids, staff did not assist in obtaining or replacing the necessary assistive devices.
Two residents, one with significant cognitive decline and another with hoarding behaviors, shared a room that contained multiple accident hazards, including exposed wires, extension cords, and unidentified substances. Staff confirmed the hazardous conditions and noted that the hoarding behavior of one resident directly placed the other at risk.
Two residents with PTSD did not receive trauma-informed or culturally competent care, as their care plans failed to identify or address their specific trauma-related needs, preferences, or triggers. Instead, care plans focused on general behavioral and medication interventions, without individualized strategies to prevent re-traumatization, despite facility policy requiring such approaches.
A resident was served a plain pork chop instead of the posted menu item of pork chop with apple marinade. Staff confirmed the apple marinade was not prepared because the apples were used to make applesauce for medication administration, and no gravy was available when requested.
The facility did not effectively allocate or manage housekeeping staff, resulting in unsanitary conditions such as excess trash, dirty linens, food debris, and persistent gnats and flies in resident rooms and common areas. Staff interviews revealed that cleaning was only improved during surveyor presence, and the facility scheduled fewer housekeeping staff than required by its own assessment. Service logs confirmed ongoing pest and sanitation issues.
A resident was unable to wash hands before meals due to a persistently clogged sink, with no hand disinfectant provided as an alternative. During meal service, a kitchen cook failed to follow proper infection control by handling a food thermometer and touching their apron before returning the thermometer to food. The facility also lacked a water management program, including Legionella risk assessment and water quality monitoring, as confirmed by staff interviews and policy review.
Surveyors found that essential kitchen equipment, including the walk-in freezer, dish machine, and produce refrigerator, was not maintained in safe, operating condition. The walk-in freezer had ice build-up and food items that were not fully frozen, with no temperature logs maintained. The dish machine leaked water onto the floor during use, and the produce refrigerator had stagnant water and condensation. Staff interviews confirmed inadequate dish cleaning and lack of equipment monitoring, resulting in unsafe kitchen conditions.
The facility failed to conduct Level II PASARR evaluations for four residents with serious mental illnesses, despite policy requirements and documented needs. Diagnoses included schizophrenia, anxiety disorder, psychotic disorder, depression, PTSD, bipolar disorder, and dementia. Interviews confirmed the evaluations were not completed, indicating a lapse in compliance with PASARR requirements.
The facility failed to provide education on the benefits and potential side effects of the influenza vaccine to three residents, as required by their policy. The clinical records of these residents lacked documentation of such education, which was confirmed by the DON. The facility's policy mandates that this information be provided prior to vaccination, but it was not followed in these instances.
The facility was found to have significant environmental and safety deficiencies across all nursing units. Observations revealed unsanitary conditions, such as missing baseboards, strong odors, and cluttered pathways. Additionally, numerous call bells were either missing, broken, or not accessible to residents, compromising their safety and communication. These issues were confirmed by staff and had been ongoing without resolution.
A resident with severe intellectual disability and other mental health conditions was involved in an incident where a nursing assistant swung a mop stick to maintain distance after the resident reportedly pushed her. Witnesses did not see the resident being hit, and no injuries were found. The nursing assistant's actions were deemed inappropriate, leading to her termination.
The facility failed to thoroughly investigate an alleged abuse incident involving a resident with schizophrenia and other mental health conditions. Despite reports of inappropriate behavior by another resident, the facility did not follow its abuse prevention policy, resulting in a deficiency in handling the situation.
The facility failed to ensure a safe environment and adequate supervision for residents. A resident was found with hazardous cleaning supplies in their room, and multiple instances of unsupervised residents were observed in dining and activity areas, as well as outside. These lapses were confirmed by staff, indicating a pattern of insufficient supervision.
A resident was prescribed Ativan on a PRN basis without a documented diagnosis of anxiety, and the medication order lacked a required stop date within 14 days. Despite pharmacy recommendations, the physician did not specify a duration for the Ativan use. The resident, on hospice and prone to agitation, had no documented anxiety diagnosis to justify the medication. Interviews confirmed these deficiencies.
A resident was found with a tube of Medihoney on their overhead table, which was left by a nurse for use on an ulcer. The DON confirmed that the Medihoney should have been stored in a locked treatment cart, as per facility policy requiring all drugs and biologicals to be stored securely.
A resident with severe cognitive impairment and multiple physical diagnoses did not receive necessary specialized rehabilitative services due to the facility's failure to implement a restorative nursing program. The program was not carried out after the only trained restorative aide became unavailable, and no other staff were trained to continue the program, leaving the resident without needed care.
The facility did not ensure a designated infection preventionist (IP) was working part-time solely on infection control. The Director of Nursing (DON) was performing IP duties in addition to their full-time role, without evidence of additional hours dedicated to infection control. The IP's responsibilities include data analysis and staff training on healthcare-associated infections, but no documentation was provided to confirm the DON's additional work hours.
The facility failed to maintain essential kitchen equipment, including a gas stove and exhaust fan, in safe working condition. A gas oven lacked control knobs, requiring a makeshift solution that was initially unsuccessful. The kitchen served a cold menu due to the non-functioning exhaust fan, affecting working conditions. The facility's policy and industry standards require equipment to be operational, but these were not met, leading to a deficiency.
The facility failed to provide palatable and safe food on the second-floor nursing unit. Multiple residents reported that the meat was too chewy and tough to swallow. Observations revealed that burger patty melts were pink and undercooked. The Food Service Director and chef confirmed that the patties did not reach the safe minimum internal cooking temperature.
The facility failed to adequately treat, assess, and monitor a resident's PICC line, as required by physician orders and facility policy. Documentation for the assessment and measurement of the catheter was missing for February and March 2024, and this deficiency was confirmed by the DON.
The facility failed to develop and implement a comprehensive care plan for a resident with multiple skin disorders, including fungal dermatitis and lymphedema. Despite having physician's orders for treatment, the interdisciplinary care team did not create care plans addressing these conditions, as confirmed by interviews with the DON and a licensed nurse.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in accordance with professional standards for food service safety. During a tour of the main kitchen and outbuilding containing the walk-in freezer, surveyors observed that the steel entry door to the freezer was not properly closed, with the bottom rusted through and unable to seal. Significant dirt and debris were present in the outbuilding. Inside the walk-in freezer, there was a substantial build-up of ice on the fan and ceiling, and food items such as hot dogs and bread were not frozen solid, indicating partial defrosting. The freezer's external thermometer read 32°F and the internal thermometer read 28°F, both above the required 0°F or below. The Food Service Director confirmed that the freezer had temporarily turned off, and there was no documentation or log of ongoing temperature monitoring as required by facility policy. Additional observations in the main kitchen included a sticky juice machine, a large bag of cabbage sitting in stagnant water inside the reach-in produce refrigerator, and a dish machine that leaked water from the food trap onto the floor during use. The ice machine was found in a hallway without the required 1-inch air gap between its drain and the floor drain, with the drain sitting in stagnant water. These findings were confirmed by the Food Service Director and Maintenance staff during the survey.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Facility staff did not maintain a clean, safe, and homelike environment on multiple nursing units, as evidenced by numerous observations of unsanitary and disorderly conditions. On wing C, room C-12 was found to have gnats, used cups, excess food crumbs on the floor, dirty bedside tables, used utensils, and used applesauce cups left on bedside tables, along with a foul urine odor. On wing D, near room D-19, a large bin with used breakfast cups and plates and gnats was observed. Room D-21 had used portable urinals hanging on a trash bin, used napkins and plastic wraps on the floor, and dirty bed linen. Room D-26 contained excess trash on the floor, food crumbs, and gnats. Additional observations on the second floor units revealed a collection of used breakfast items in a large bin near the day room and the presence of gnats. During lunch meal service, used linen and foot rests were stored under tables in the dining room. Further issues were noted in the 1st floor dining room, where only two tables were available, the back half was used to store bed frames, and three resident meal trays from breakfast were left on a table. The Registered Dietitian confirmed that few residents use the dining room for meals and verified the observed conditions. Additional deficiencies included a sink hanging off the wall in room A-9 and stained window shades in room A-11. These findings demonstrate a failure to provide a clean, safe, and homelike environment as required by facility policy and state regulations.
Delayed Meal Service Due to Staffing Shortage
Penalty
Summary
The facility failed to serve breakfast at the scheduled time of 8:00 a.m. on June 3, 2025, as evidenced by observations at 9:26 a.m. showing seven residents still waiting for their meal, with two residents expressing hunger. At 9:30 a.m., dietary staff had only just begun plating meal trays in the first-floor dining room. The Registered Dietitian confirmed that the delay was due to dietary employees not showing up for work. During a group meeting later that morning, several alert and oriented residents reported that meals are not served according to posted times, which disrupts their ability to maintain a consistent routine.
Failure to Maintain Effective Pest Control and Sanitation
Penalty
Summary
The facility failed to maintain an effective pest control program on two out of four units observed, as required by its own policy. Observations on multiple units revealed excess trash, food crumbs, dirty bedside tables, used utensils, and soiled linens, which contributed to the presence of gnats and flies. Specific rooms were noted to have accumulated trash, used food containers, and unsanitary conditions, such as urine-filled portable urinals left on the floor. A large bin with used breakfast items and gnats was also observed near one room. During medication administration, an excess number of flies was noted by surveyors. A resident complained about gnats in their room, and staff interviews indicated that the unit was only cleaner than usual due to the presence of surveyors. Review of facility documentation showed that pest issues, including gnats and flying insects, had been reported on multiple occasions earlier in the year, but the pest log lacked details on follow-up actions or specific locations. A pest control service inspection confirmed excessive gnat activity and poor sanitation, including the presence of urine odors, in at least one room. The facility's failure to remove trash daily and maintain cleanliness contributed to ongoing pest problems, in violation of state regulations regarding the responsibility of the licensee and management.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
A deficiency was identified when a resident with a physician order for NPO (nothing by mouth) status, but with a care plan allowing pudding or applesauce at lunch with specific feeding instructions, was observed seated in a dining area with other residents who were consuming lunch. The resident was not provided with pudding or applesauce during the meal, despite being permitted these items according to the care plan. Staff confirmed that the resident was placed in the dining room during lunch and was not offered the allowed food items while others ate. The resident was noted to be dependent on staff for eating, dressing, and mobility.
Failure to Provide Supervision and Care Resulting in Resident Neglect
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral vascular accident, seizure disorder, schizophrenia, severe cognitive impairment, wandering behaviors, and incontinence was not provided with appropriate supervision and care over two scheduled shifts. The resident required partial to moderate assistance with activities of daily living, supervision for mobility, and was at risk for elopement and seizures, as documented in the care plan. The care plan also specified interventions such as encouraging fluids, assisting with toileting, monitoring behaviors, and ensuring staff awareness of elopement risk. On the days in question, a certified nursing assistant (CNA) was assigned to the resident's room but was unaware that the resident occupied the assigned bed. The CNA stated that she believed the bed was unoccupied and had not provided care to the resident, despite facility documentation and the midnight census confirming the resident's assignment to that room and bed. The CNA was new to the floor but had previously been assigned to the same room. Observations revealed the resident's bed was in poor condition, with no sheets, a torn mattress, and evidence of bug infestation. Interviews with other staff confirmed that all shifts receive staff reports detailing resident assignments and needs, and that it is standard practice to check on all assigned residents at the beginning of each shift. Despite these procedures, the CNA failed to recognize her responsibility for the resident, resulting in a lack of supervision and care. This failure was determined to be neglect, as it did not meet the resident's physical, mental, and psychosocial needs as required by facility policy and regulatory standards.
Failure to Develop and Implement Comprehensive Care Plan for Hearing and Nutrition
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the hearing and nutritional needs of a resident with a history of psychomotor and cognitive communication deficits. Despite multiple clinical records and progress notes documenting that the resident was hard of hearing and the resident's own report of difficulty hearing and lack of hearing aids, there were no care plan goals or interventions in place to maintain or support the resident's hearing. Staff interviews confirmed the absence of hearing aids and the lack of related care planning, even though the facility's policy requires care plans to reflect recognized standards of practice for identified problem areas. Additionally, the facility did not address significant weight loss in the same resident, who experienced an 8.63% decrease in body weight over a three-month period. Although the resident was identified as being at nutritional risk and received a mechanically altered diet, the care plan did not include interventions or communication regarding the resident's ongoing weight loss. Dietary notes and staff interviews confirmed that the resident's weight had been trending downward and that supplemental nutrition was recommended, but there was no evidence of interdisciplinary team meetings or updated care planning to address the weight loss, contrary to facility policy.
Failure to Provide Adequate Personal Hygiene and Grooming Assistance
Penalty
Summary
Two residents were found to have not received adequate assistance with activities of daily living, specifically in the areas of personal hygiene and grooming. One resident, a male with diagnoses including schizophrenia, anxiety, mobility and vision impairments, and a documented need for substantial to maximal assistance with toileting and hygiene, was observed in bed with an exposed soiled brief and gnats present. His care plan required regular incontinence checks and hygiene care, but these were not provided as needed at the time of observation. Another male resident, with cognitive and behavioral diagnoses such as dementia, major depressive disorder, and psychotic disorder, also required substantial to maximal assistance for bathing. He was observed in bed wearing only briefs, with heavily soiled lower extremities and a used meal tray on the bed, also attracting gnats. His care plan specified twice-weekly bathing, but the observed condition indicated this was not being followed. These findings were based on direct observation and review of clinical records, in violation of the facility's own policies and state regulations.
Failure to Assist Resident in Obtaining Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident with documented hearing impairment received proper treatment and assistive devices to maintain hearing abilities. Clinical records indicated that upon admission, the resident had hearing aids in both ears, and multiple progress notes over several months consistently documented that the resident was hard of hearing. Despite this, there was no evidence that the facility assisted the resident in obtaining or replacing hearing aids after they were no longer in the resident's possession. During interviews, the resident reported ongoing difficulty hearing and expressed that staff sometimes became frustrated with communication challenges. The resident also requested assistance regarding hearing aids. A licensed nurse confirmed that the resident currently did not have any hearing aids. The facility did not fulfill its responsibility to assist the resident in accessing necessary hearing services and devices, as required by regulation.
Failure to Prevent Accident Hazards Due to Clutter and Unsafe Materials
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents. One resident with a history of cerebrovascular accident (stroke), dementia, significant cognitive decline, and a history of falls and suicide ideation required substantial assistance with daily activities and was care planned for a clutter-free environment. Another resident with depression and intact cognition exhibited hoarding behaviors, frequently ordering and accumulating items, and refused to allow staff to remove clutter from the shared room. During an observation, the shared room was found to contain multiple accident hazards, including eight wires hanging from a shelf, three electrical extension cords, a bottle of liquid dish detergent poured into a cup on a bed, and a pharmacy medication bag filled with an unidentified white powder, later identified as baking soda. Staff interviews confirmed the hazardous conditions and the ongoing issue with hoarding, which directly placed the cognitively impaired resident at risk for harm. The hazardous environment was acknowledged by both housekeeping and nursing staff.
Failure to Provide Trauma-Informed, Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents diagnosed with post-traumatic stress disorder (PTSD), as required by professional standards and facility policy. Both residents had care plans that referenced PTSD as a diagnosis but did not identify or address their specific trauma-related needs, preferences, or triggers. For one resident with schizophrenia and severe cognitive impairment, the care plan listed general problems such as risk for falls, chronic pain, and behavior issues related to PTSD, but interventions were limited to medication administration, anticipating needs, and general encouragement, without individualized strategies to prevent re-traumatization. For the other resident, who had intact cognition and diagnoses of dementia, bipolar disorder, and PTSD, the care plan similarly focused on medication management and general behavioral interventions, without specifying trauma-informed approaches or identifying personal triggers. Interviews with the Director of Nursing confirmed that while PTSD was acknowledged in the care plans, there was no specific focus on the unique needs associated with the diagnosis. The facility's policy outlined the importance of individualized assessment, care planning, and interventions to prevent re-traumatization and support healing, but these were not implemented for the residents in question. The deficiency was cited under regulations related to nursing services, resident care planning, and social services.
Failure to Serve Posted Menu Item as Planned
Penalty
Summary
On June 2, 2025, during a lunch meal observation, the posted menu indicated that pork chops topped with apple marinade were to be served. However, a resident was served a plain pork chop without any gravy or marinade and subsequently requested gravy, which was not available. Staff interviews confirmed that the apple marinade was not provided as listed on the menu because the apples intended for the marinade were used to make applesauce for medication administration, leaving none available for the meal. The kitchen also did not have any gravy to offer the resident upon request. These actions resulted in the facility failing to serve the posted menu as required.
Failure to Allocate and Manage Housekeeping Resources Resulting in Unsanitary Conditions
Penalty
Summary
The facility failed to use its housekeeping resources effectively and efficiently, resulting in substandard sanitation and cleanliness throughout multiple units. Observations revealed excess trash, food crumbs, dirty bedside tables, used utensils, and gnats in several resident rooms and common areas. A large bin with used breakfast items and gnats was found near one room, and two urine-filled portable urinals along with dirty bed linens were observed on the floor in another room. The C-unit dining room had a pillowcase, food crumbs, and wheelchair footrests stored under a table. Multiple observations during the survey week noted an excess of flies during medication administration. A resident complained of gnats in their room, and the facility's pest log documented reports of gnats and flying insects on several occasions, with limited documentation of pest control measures taken. Interviews with staff indicated that the unit was only cleaner than usual due to the presence of surveyors, and the housekeeping director reported that staff often did not complete their assigned tasks unless supervised. The facility's assessment required six housekeeping staff for the census, but only four were scheduled, and the housekeeping director was not on the schedule for the week reviewed. Service inspection reports confirmed excessive gnat activity and poor sanitation, including urine odors. These findings demonstrate that the facility did not allocate or manage housekeeping resources in accordance with its own assessment and professional standards, leading to unsanitary conditions.
Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program as evidenced by multiple deficiencies in water management, meal service, and hygiene care. A resident reported a clogged sink in his restroom that had been left unaddressed for an extended period, as confirmed by maintenance logs and staff interviews. This issue prevented the resident from washing his hands prior to meals, and no alternative hand disinfectant was provided. During meal service, it was observed that a kitchen cook repeatedly handled a food thermometer and touched their apron before placing the thermometer back into food, indicating a lapse in proper infection control practices. Further investigation revealed that the facility lacked a comprehensive water management program, including policies and procedures for Legionella risk assessment, water system flow charts, testing of shower heads, and professional water testing for contaminants. The facility was unable to provide documentation of control measures, water quality parameter measurements, or plans for corrective action when control limits were not met. These findings were confirmed through interviews with the nursing home administrator and review of relevant policies and regulatory guidelines.
Failure to Maintain Safe and Functional Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe, operating condition. During a tour of the main kitchen, surveyors observed a significant build-up of ice on the outside of the fan and ceiling in the walk-in freezer, and noted that hot dogs and bread were not frozen solid, indicating partial defrosting. The freezer's external thermometer read 32°F and the internal thermometer read 28°F, both above the required 0°F or below. There was no documentation or log of ongoing temperature monitoring for the freezer. Additionally, the dish machine was observed to leak water from the food trap onto the floor during use, rendering it unusable due to flooding. The reach-in produce refrigerator contained a large bag of cabbage sitting in stagnant water and condensation was present on other items inside the fridge. Interviews with the Food Service Director and Registered Dietitian revealed that the morning cook had reported the freezer temporarily turning off, and that dietary staff were not adequately cleaning dishes before placing them in the dish machine, contributing to a clogged grease trap. The lack of proper maintenance and monitoring of essential kitchen equipment, including the freezer, dish machine, and produce refrigerator, led to unsafe conditions and failure to comply with facility policy regarding food storage and equipment safety.
Failure to Conduct Required Level II PASARR Evaluations
Penalty
Summary
The facility failed to ensure that a Level II PASARR evaluation was conducted for residents with mental disorders as required. This deficiency was identified for four residents, each of whom had a documented need for a Level II PASARR evaluation due to serious mental illnesses. The facility's policy mandates that a Level II evaluation be completed if a Level I screening indicates a potential mental illness, and admission to the facility is contingent upon the completion of the PASARR process. However, the clinical records for Residents R1, R3, R20, and R36 showed no indication that the required Level II evaluations had been completed, despite their diagnoses of serious mental illnesses such as schizophrenia, anxiety disorder, psychotic disorder, depression, PTSD, bipolar disorder, and dementia. Interviews with Employee E23, a social worker, confirmed that the Level II PASARR evaluations had not been completed for these residents as required. The facility's policy also states that regular audits should be conducted to ensure compliance with PASARR requirements, but the lack of completed evaluations suggests a failure in this process. The deficiency was noted under the regulation 28 Pa. Code 201.14(a), which outlines the responsibility of the licensee to ensure compliance with such requirements.
Failure to Provide Influenza Vaccine Education
Penalty
Summary
The facility failed to ensure that residents were provided with education regarding the benefits and potential side effects of influenza immunization. This deficiency was identified for three residents, specifically Residents R85, R8, and R17. Upon review of their clinical records, there was no documented evidence that these residents or their legal representatives received the necessary education about the influenza vaccine. The facility's policy mandates that such information be provided prior to vaccination, yet this was not adhered to in these cases. The Director of Nursing (DON), identified as Employee E2, confirmed during an interview that the facility lacked documented evidence of providing the required education to the residents or their representatives. The facility's policy clearly states that between October 1st and March 31st, the influenza vaccine should be offered to residents and employees, and pertinent information about the vaccine's risks and benefits should be provided. However, this policy was not implemented effectively, leading to the deficiency noted in the report.
Widespread Environmental and Call Bell Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment across all four nursing units, as observed during a survey. On the D unit, several rooms were found with missing baseboards, strong odors of urine and stool, sticky floors, and cluttered pathways due to random items on the floor. Additionally, some rooms had missing or broken furniture, such as shelves and doorknobs. The dining area on the D unit also had missing and broken tiles, contributing to the unsanitary conditions. These observations were confirmed by the assistant director of nursing and the administrator. Furthermore, the facility had numerous issues with call bells across multiple units, which are critical for resident safety and communication. Several rooms in units A, B, C, and D had call bells that were either missing, broken, or not within reach of residents. Some call bells were found cut off, with hanging wires, or disconnected from the wall. Interviews with staff and residents revealed that these issues had been ongoing, with some residents reporting non-functional call bells for extended periods without resolution. The maintenance director confirmed the widespread nature of these deficiencies and acknowledged the lack of awareness and communication regarding the broken call bells.
Inappropriate Handling of Resident by Nursing Assistant
Penalty
Summary
The facility failed to protect a resident, identified as Resident R137, from potential abuse. Resident R137, who has severe intellectual disability, restlessness, agitation, psychotic disorder with delusion, autism, and mood disorder, was involved in an incident with a nursing assistant, Employee E18. The incident occurred when Employee E18 was seen swinging a mop stick in front of Resident R137, following a series of interactions where the resident reportedly pushed the nursing assistant, causing her head to hit the wall. The nursing assistant claimed she used the mop stick to maintain distance from the resident, who she perceived as coming towards her aggressively. The situation escalated when Resident R137, after reportedly pushing Employee E18, was followed by the nursing assistant who then picked up a broom to keep the resident at bay. Witnesses, including a cook and a licensed nurse, observed the commotion but did not see the nursing assistant hit the resident with the broom. The licensed nurse conducted a skin assessment on Resident R137 and found no injuries. Despite the lack of physical harm, the act of swinging the mop stick was deemed inappropriate and placed the resident in a potentially harmful situation. The Director of Nursing confirmed that the actions of Employee E18 were inappropriate, leading to her termination. The facility's failure to ensure the resident's safety and freedom from abuse was identified as a deficiency, as the nursing assistant's response to the resident's behavior was not handled according to appropriate protocols. The incident highlights a lapse in the facility's management of resident interactions and staff conduct, particularly in handling residents with complex behavioral and mental health needs.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of potential sexual abuse involving Resident R11. The facility's policy on abuse prevention requires separating residents involved, notifying representatives, consulting with medical professionals, and documenting all interventions and their effectiveness. However, the investigation into the incident involving Resident R11 and Resident R42 was not completed as required by the policy. Resident R11, who has a history of schizophrenia, anxiety disorder, psychotic disorder, and bipolar disorder, was reported to have entered Resident R42's room and engaged in inappropriate behavior. Resident R42, who also has schizophrenia, anxiety disorder, psychotic disorder, dementia, and depression, reported feeling uncomfortable with Resident R11's actions. Despite these reports, the facility did not conduct a comprehensive investigation to determine the facts of the incident or to rule out abuse. Interviews with staff and residents revealed inconsistencies in the handling of the incident. The licensed nurse unit manager, Employee E8, acknowledged that the incident was not investigated as an abuse case, and only a statement was taken from Resident R42. The social worker, Employee E24, was asked to counsel Resident R11 on boundaries but did not conduct a full assessment of the situation. This lack of a thorough investigation and documentation of the incident represents a deficiency in the facility's response to potential abuse allegations.
Inadequate Supervision and Hazardous Environment in LTC Facility
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision for its residents. One resident, identified as R30, was found with three large bottles of an unknown blue cleaning substance in their room. Despite the resident's cognitive intactness, as indicated by a BIMS score of 15, the presence of these substances posed a potential hazard. The Director of Nursing confirmed the presence of these cleaning supplies and agreed to secure them, but the initial oversight indicates a lapse in ensuring a safe environment. Additionally, several instances of inadequate supervision were observed. On multiple occasions, residents were left unsupervised in various areas of the facility, including dining and activity rooms, and even outside the building. One resident was found sleeping outside without staff supervision, and another resident barricaded themselves in a shower without staff presence. These observations were confirmed by facility staff, highlighting a pattern of insufficient supervision that could lead to potential accidents or harm.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications. Specifically, a resident was prescribed Ativan, an anti-anxiety medication, on a PRN basis without a documented diagnosis of anxiety. The medication order was initiated with an indefinite stop date, which did not comply with the requirement for a stop date within 14 days. Despite a recommendation from the pharmacy to document the rationale and duration of therapy if the PRN order was to continue, the physician did not specify a duration for the Ativan use. The resident, who was on hospice and prone to agitation, was admitted with diagnoses including cerebral infarction, schizophrenia, and altered mental status. However, there was no documented diagnosis of anxiety to justify the use of Ativan. Interviews with the Director of Nursing and the Medical Director confirmed the lack of a required stop date and a proper diagnosis documented in the clinical record, leading to the deficiency.
Improper Storage of Medihoney with Resident
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with professional standards, as evidenced by an incident involving a resident. During a tour of the first floor A unit, it was observed that a tube of Medihoney was left on a resident's overhead table. The resident, who was awake in bed, confirmed that the Medihoney was left by a nurse for her use on an ulcer on her bottom. The Director of Nursing (DON) confirmed that the Medihoney was improperly left with the resident and should have been stored in the locked treatment cart. The facility's policy mandates that all drugs and biologicals be stored in locked compartments and that only authorized personnel have access to them. The incident highlights a lapse in adherence to these policies, as the Medihoney was accessible to the resident, contrary to the facility's storage and labeling protocols.
Failure to Provide Specialized Rehabilitative Services
Penalty
Summary
The facility failed to assess the need for specialized occupational therapy services for a resident, identified as Resident R18, according to professional standards of practice. Resident R18 was admitted with multiple diagnoses, including age-related osteoporosis, gait and mobility abnormalities, muscle weakness, and dementia. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and a family member reported that the resident required assistance with walking. Despite these needs, the facility did not provide the necessary specialized rehabilitative services. The facility's restorative nursing program was not implemented for Resident R18 after the discharge from physical therapy. Although a restorative program was initiated, it was not carried out due to the absence of trained staff. The only restorative aide, Employee E14, was unable to work after June 11, 2024, due to a life-threatening event, and no other staff were trained to continue the program. Interviews with the Director of Nursing and the Administrator confirmed that no restorative program was provided to any residents since Employee E14's absence, highlighting a significant gap in resident care.
Failure to Designate a Dedicated Infection Preventionist
Penalty
Summary
The facility failed to ensure that a designated infection preventionist (IP) was working at the facility focusing solely on infection control at least part-time, as required. The Director of Nursing (DON) was fulfilling the role of the IP in addition to their full-time duties as DON. The facility could not provide valid proof that the DON completed additional part-time hours specifically for infection control. The job description for the IP includes responsibilities such as collecting and analyzing health data, implementing and evaluating public health practices, and conducting education and training on healthcare-associated infections. During an interview, the DON stated that they were able to divide their time between roles, with their assistant covering the floor when needed. However, there was no documentation, such as time-stamped computer notes or punch reports, to evidence that the DON worked additional hours for infection control duties.
Deficiency in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential food service equipment in a safe operating condition, specifically regarding a gas stove and kitchen exhaust fan. During an initial tour of the main kitchen, it was observed that one of the five refrigerators was out of order, and the gas oven/grill lacked control knobs necessary for igniting the flame and adjusting the temperature. An employee demonstrated the use of a makeshift plastic knob to operate the stove, which was initially unsuccessful in igniting the gas. The employee revealed that the oven had not been functional for the past six years. Additionally, the kitchen was serving a cold menu due to the non-functioning kitchen exhaust fan, which made working conditions intolerable for the staff. The facility's policy requires equipment to be ready for use at all times, and the National Fire Protection Association mandates that all components of the commercial kitchen exhaust system be kept in working condition. Despite these requirements, the facility's kitchen equipment was not maintained properly, leading to a deficiency in food service operations. The dietary director confirmed that the current menu, which meets dietary requirements, was a temporary measure due to the exhaust fan issue. The nursing home administrator provided evidence of an order and deposit for a new exhaust fan, with installation scheduled for a future date.
Undercooked and Unpalatable Food Served to Residents
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature on the second-floor nursing unit. Multiple residents reported that the meat served was too chewy and tough to swallow. Observations in the dining room revealed that the burger patty melts were pink in color and appeared undercooked. The Director of Nursing and a server confirmed these observations, noting that the beef patties should appear brown when thoroughly cooked. The Food Service Director and the chef confirmed that there was no evidence that the beef patties reached the safe minimum internal cooking temperature of 155 degrees Fahrenheit for 17 seconds. Further interviews with the Food Service Director, chef, and Director of Nursing confirmed that the beef burger patties covered with melted cheese were pink, unattractive, and not palatable. This deficiency was observed and confirmed on April 30, 2024, and it was determined that the facility did not meet the requirements set forth by 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(3).
Failure to Monitor and Document PICC Line Care
Penalty
Summary
The facility failed to provide adequate treatment, assessment, and monitoring for the care and maintenance of an intravenous catheter for Resident CL1. The resident was admitted with a PICC line in the left arm, and physician orders required weekly dressing changes and measurements of the external catheter length. However, a review of the treatment administration record for February and March 2024 revealed no documentation related to the assessment of the PICC line, measurement of the external length of the catheter, or the resident's arm circumference. This lack of documentation and monitoring was confirmed by the Director of Nursing on April 30, 2024. The facility's policy mandates immediate notification of the medical doctor if changes in the length of the catheter exiting from the insertion site occur, but this protocol was not followed. This deficiency was identified based on observations, clinical record reviews, and facility policy reviews, indicating a failure to adhere to professional standards of practice for intravenous catheter care.
Failure to Develop Comprehensive Care Plan for Skin Disorders
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with skin alterations and skin disorders. The resident, identified as Resident Cl1, was admitted with multiple diagnoses including seizure disorder, obesity, hypertension, diabetes mellitus, lymphedema of the lower extremities, and fungal dermatitis. Despite having a physician's order for the application of a topical cream to treat the fungal dermatitis, the interdisciplinary care team did not create a care plan addressing this condition. Additionally, there was no care plan developed for the resident's lymphedema, which should have included measurable goals for the care of this skin disorder. Interviews with the Director of Nursing and a licensed nurse confirmed that the interdisciplinary care team had not developed or implemented a comprehensive care plan for the resident's skin disorders. The facility's policy required the care plan to describe the services needed to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, but this was not done for Resident Cl1. The failure to create these care plans was a violation of the facility's policies and state regulations.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
