Liberty Pointe Rehabilitation And Healthcare Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Doylestown, Pennsylvania.
- Location
- 252 Belmont Avenue, Doylestown, Pennsylvania 18901
- CMS Provider Number
- 395409
- Inspections on file
- 21
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Liberty Pointe Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
The facility failed to maintain the fire resistance rating of fire doors on the first floor due to the absence of a bottom latching device. This issue was initially observed and confirmed during an inspection in December and remained unresolved during a follow-up revisit in February.
The facility's building exceeds the maximum allowable story height for its Type V(III) protected wood frame construction, which is fully sprinklered. The building is three stories high, while the construction type permits only one story when sprinklered. This deficiency was confirmed during a document review and interview, and remains unresolved as of a follow-up visit.
The facility's dietary department was found to have several sanitation and food storage deficiencies. Observations included a large hole in the recycling area paneling, soiled convection ovens with grease and burnt debris, improper storage of a metal scoop in a flour bin, debris on the floor near the steamer and dry goods bins, a brown substance inside the ice machine, and cracked floor tiles near the utility hallway entrance.
The facility failed to maintain clear means of egress as required by NFPA 101 standards. The headroom clearance of Exit Stairway Five was below the required minimum, and obstructions were found in exit pathways on two floors, including storage and trash on landings. These deficiencies were confirmed during an exit interview with the facility's administration.
The facility did not maintain and inspect portable fire extinguishers as required, specifically missing monthly inspections for the extinguisher on the first floor next to a resident room. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to ensure that corridor doors were properly latched, affecting fire safety and smoke containment. Observations revealed that doors on the first and second floors, including the Housekeeping Closet, Employee Storage Room, Nourishment Room, and Storage Room near resident room 106, failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the smoke resistance of smoke barriers, as observed by an open penetration by a data wire in the smoke barrier on the third floor near a resident room. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the smoke resistance of smoke barrier doors on the third floor, as holes were found in the door frame. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain fire resistance in soiled linen and trash chutes, with doors on the third and second floors failing to close and latch. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the fire resistance rating of fire doors, as observed when a fire door on the first floor lacked bottom latching. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Two residents experienced issues with the call bell system, as one resident's call bell did not activate the light outside her door, and another's produced no sound or light, requiring him to yell for help. Observations confirmed these deficiencies in the call bell system.
A resident with dementia and other health conditions did not have physician-ordered compression stockings applied as required. Observations over two days showed the resident without the Tubigrips, despite orders for daily application during morning care. Both an LPN and the DON confirmed the oversight.
The facility was found to have a building classified as a three-story, Type V(III), protected wood frame construction, which is fully sprinklered. This classification exceeds the maximum allowable story height for this type of construction by one story, affecting the entire component of the facility.
A resident with dementia, difficulty walking, and osteoporosis experienced a fall, resulting in increased pain levels. Despite the facility's policy requiring notification of changes in clinical condition, the resident's physician was not informed of the increased pain following the fall.
A resident with dementia and osteoporosis was not properly assessed for pain medication effectiveness after a fall. Despite worsening pain, the resident was given acetaminophen without notifying the physician for additional pain management. The DON confirmed the lack of documentation on medication effectiveness.
The facility failed to monitor weight changes for two residents as per policy and physician orders. One resident with dementia and diabetes was not weighed weekly as required, and another with dementia and dysphagia lacked a documented weight schedule and weekly monitoring. The DON confirmed the absence of required documentation.
The facility failed to provide food that was palatable and at appetizing temperatures on three of five nursing units. Residents reported that the food was often cold and not palatable. A test tray audit confirmed that food temperatures were significantly below the required 130 degrees Fahrenheit, and further interviews indicated that this issue was consistent across both room service and dining room meals.
Fire Door Deficiency Due to Lack of Bottom Latching
Penalty
Summary
The facility failed to maintain the fire resistance rating of fire doors, specifically on the first floor, where the fire door did not have a bottom latching device. This deficiency was initially observed on December 12, 2024, during an inspection at 10:00 a.m. The absence of the bottom latching was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day. During a follow-up onsite revisit conducted on February 4, 2025, between 08:15 a.m. and 11:00 a.m., it was determined that the issue had not been resolved. The component separation fire door on the first floor still lacked a bottom latching device, as confirmed in an exit interview with the Administrator at 11:00 a.m.
Plan Of Correction
The first-floor fire door bottom latching has been repaired. Maintenance staff to be educated on the importance of maintaining fire resistance rating of fire doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Building Construction Type and Height Deficiency
Penalty
Summary
The facility was found to be non-compliant with building construction requirements as per NFPA 101 standards. During a document review and interview on December 12, 2024, it was revealed that the building is classified as a three-story, Type V(III), protected wood frame construction, which is fully sprinklered. However, this construction type is only permitted to have a maximum of one story when sprinklered, indicating that the facility exceeds the allowable story height by two stories. An onsite revisit conducted on February 4, 2025, confirmed that the issue of exceeding the maximum story height allowance had not been resolved. The Administrator acknowledged the deficiency and is in the process of obtaining a Fire Safety Evaluation System (FSES) to address the non-compliance. The deficiency affects the entire component of the building, as the construction type and story height do not meet the required standards.
Plan Of Correction
I am requesting the Department of Health do the FSES in this case. Facility is consulting Lenhardt Rodgers Architecture to assist with this citation. Facility will also be requesting a TLW.
Sanitation and Food Storage Deficiencies in Dietary Department
Penalty
Summary
The facility failed to maintain sanitary conditions and proper food storage in the dietary department. During an environmental tour, a large hole was observed in the paneling on the back wall of the recycling area. The convection ovens were found to be soiled, with the insides of the oven doors coated with grease and the bottom of the top oven covered with burnt debris and food crumbs. A large metal scoop was improperly stored inside a bin containing flour. Debris was present on the floor near the steamer and dry goods bins. Additionally, a brown substance was noted on parts of the lid and the left inside wall of the ice machine. There were also five cracked floor tiles near the entrance of the utility hallway within the dietary department.
Plan Of Correction
1) The hole in the back wall of the recycling area has been repaired. Convection ovens were cleaned & grease to top & bottom ovens removed & area cleaned. Metal scoop was removed from the flour bin. Debris was removed from wall near the steamer. Ice machine was cleaned. Cracked floor tiles near the entrance of the kitchen was repaired. 2) All residents have the potential to be affected by the failure to maintain sanitary conditions & storing food properly in the dietary department. 3) Dietary staff to be educated on importance of maintaining sanitary conditions & proper food storing in the dietary department. 4) Audits will be completed weekly x4 & then monthly x2 or until compliance is met to ensure that sanitary conditions & proper food storing in the dietary department is maintained. Findings will be brought to the QAPI committee.
Failure to Maintain Clear Means of Egress
Penalty
Summary
The facility failed to maintain the means of egress in compliance with NFPA 101 standards, as evidenced by two specific deficiencies. Firstly, during a document review, it was found that the headroom clearance of Exit Stairway Five leading to the attic was approximately 6'3", which is below the required minimum of 6'8". This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Secondly, observations revealed obstructions in the exit pathways on two different floors. On the second floor, storage was found on the lower landing of the exit stairwell by the RNAC Office. Additionally, trash was observed on the landing of the exit stairwell next to resident room 216, and storage was found on the lower landing of the exit stairwell near resident room 108 on the first floor. These obstructions were also confirmed during the exit interview with the facility's administration.
Plan Of Correction
I am requesting the Department of Health do the FSES in this case. Facility is consulting Lenhardt Rodgers Architecture to assist with this citation. The second-floor exit stairwell by the RNAC Office was cleaned from storage on the lower landing. Maintenance staff to be educated on the importance of maintaining means of egress. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee. Trash was cleaned from landing on the second-floor exit stairwell next to room 216. Storage was removed from the exit stairwell lower landing near room 108. Maintenance staff to be educated on the importance of maintaining means of egress. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers as required by NFPA 10, affecting one of three levels in the component. During an observation on December 12, 2024, at 9:52 a.m., it was noted that the portable fire extinguisher located on the first floor next to resident room 161 was missing its monthly inspections. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
Facility completed a monthly inspection for portable fire extinguisher next to resident room 161. Maintenance staff to be educated on how to maintain and inspect portable fire extinguishers. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Ensure Proper Latching of Corridor Doors
Penalty
Summary
The facility failed to ensure that corridor doors were properly latched, which is a requirement for maintaining fire safety and smoke containment. During an observation on December 12, 2024, it was noted that the Housekeeping Closet door on the second floor was binding on the floor and failed to latch. Similarly, the Employee Storage Room door on the first floor also failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, further observations on the same day revealed that the Nourishment Room door on the second floor and the Storage Room door near resident room 106 on the first floor also failed to latch. These findings indicate a pattern of non-compliance with the requirement for corridor doors to have positive latching hardware, as mandated by the NFPA 101 and CMS regulations. The failure to ensure proper latching of these doors affects the facility's ability to resist the passage of smoke, which is critical for the safety of residents and staff.
Plan Of Correction
The latch & door were repaired for the second floor Housekeeping Closet across from resident room 252. The latch was repaired for the employee storage room door on the first floor. Maintenance staff to be educated on ensuring corridor doors are latched. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee. The second-floor nourishment door latch was repaired. The first-floor storage room door near resident room 106 latch was repaired. Maintenance staff to be educated on ensuring corridor doors are latched. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Smoke Barrier Deficiency Due to Open Penetration
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barriers, which is a requirement for ensuring safety in the event of a fire. During an observation on December 12, 2024, at 9:08 a.m., it was noted that there was an open penetration by a data wire in the smoke barrier located on the third floor near resident room 304. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director later that morning at 10:30 a.m.
Plan Of Correction
Open penetration by data wire in the smoke barrier by resident room 304 was repaired using an UL approved stop gap penetration system. Maintenance staff to be educated on maintaining the smoke resistance of smoke barriers. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Smoke Barrier Door Deficiency on Third Floor
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier doors on the third floor, as observed during a survey. Specifically, there were holes found in the door frame, which compromised the smoke resistance of the doors. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Holes in the door frame on the third floor were repaired. Maintenance to be educated on maintaining the smoke resistance of smoke barrier doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Fire Resistance Deficiency in Linen and Trash Chutes
Penalty
Summary
The facility failed to maintain the fire resistance of soiled linen and trash chutes, affecting two of four levels in the component. During an observation on December 12, 2024, it was noted that the door to the soiled linen chute on the third floor would not close and latch. Additionally, the trash chute door on the second floor also failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
Latch was repaired for the third-floor door to the Soiled Linen chute. Latch was repaired for the trash chute door. Maintenance to be educated on maintaining the fire resistance of Soiled Linen and trash chutes. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Fire Door Deficiency Due to Lack of Bottom Latching
Penalty
Summary
The facility failed to maintain the fire resistance rating of fire doors, which is a requirement for ensuring safety in multiple occupancies. During an observation on December 12, 2024, at 10:00 a.m., it was noted that a fire door on the first floor lacked bottom latching. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day.
Plan Of Correction
The first-floor fire door bottom latching was repaired. Maintenance staff to be educated on the importance of maintaining fire resistance rating of fire doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Deficiency in Call Bell System for Two Residents
Penalty
Summary
The facility failed to provide a working call bell system for two residents, leading to a deficiency in resident safety and communication. During a resident group meeting, one resident reported that activating the call bell from her bed did not trigger the light outside her door. Another resident stated that his call bell did not produce any sound or light, forcing him to yell for assistance. Observations confirmed these issues, as the call bell for the first resident did not activate the light, and the second resident's call bell produced neither sound nor light when tested.
Plan Of Correction
1) The call bell system was immediately repaired for residents 4 & 142. 2) Audit was completed to assure residents have a working call bell available. 3) Staff will be educated on the importance of ensuring residents have access to a working call bell. 4) Audits will be completed weekly x4 & then monthly x2 or until compliance is met by randomly auditing 10 resident rooms, to ensure residents have access to working call bells. Findings will be brought to the QAPI committee.
Failure to Implement Physician's Orders for Compression Stockings
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with dementia, hypertension, and chronic obstructive pulmonary disease. The resident, who was dependent on staff for dressing, was ordered by a physician on November 10, 2024, to have compression stockings (Tubigrips) applied to both legs for swelling. However, observations on December 10 and 11, 2024, revealed that the resident was seated in her wheelchair without the Tubigrips in place. A licensed practical nurse confirmed that the Tubigrips were supposed to be applied during morning care. The Director of Nursing also stated that the staff was to apply the Tubigrips daily as per the physician's order.
Plan Of Correction
1. Tubigrips were immediately placed on resident 2. 2. Current residents with Compression stockings were reviewed to assure residents had application per the physician orders. 3. Education will be completed for licensed nursing staff by staff educator/designee on Importance of ensuring residents have physician prescribed measures in place. 4. Audits will be completed by DON/designee to assure residents with Compression stockings have it in place per physician orders. Audits will be done weekly x4 & then monthly x2 or until compliance is met. Findings will be brought to the QAPI committee.
Building Construction Type Exceeds Allowable Height
Penalty
Summary
The facility failed to maintain the building construction requirements as per NFPA 101 standards. During a document review and interview conducted on December 12, 2024, it was found that the building is classified as a three-story, Type V(III), protected wood frame construction, which is fully sprinklered. However, this classification exceeds the maximum allowable story height for this type of construction by one story. This deficiency affects the entire component of the facility, as confirmed during the exit interview with the Administrator and Maintenance Director.
Plan Of Correction
I am requesting the Department of Health do the FSES in this case. Facility is consulting Lenhardt Rodgers Architecture to assist with this citation. Facility will also be requesting a TLW.
Failure to Notify Physician of Resident's Increased Pain Post-Fall
Penalty
Summary
The facility failed to notify a resident's physician of a change in clinical condition, specifically an increase in pain following a fall. The facility's policy, last reviewed on November 1, 2023, requires staff to notify the physician and resident representative of any change in clinical condition. A review of the clinical records for a resident with dementia, difficulty walking, and osteoporosis revealed that the resident experienced a fall on May 13, 2024, and was found on her left side. Initially, the resident's pain was rated as a 3, but by the following morning, it had increased to a 6, with specific pain noted in the left hip. Despite this significant change in the resident's condition, there was no documentation indicating that the resident's physician was notified of the increased pain level.
Failure to Evaluate Pain Medication Effectiveness
Penalty
Summary
The facility failed to evaluate the effectiveness of pain medication for a resident, which is inconsistent with professional standards. The resident, who had diagnoses including dementia, difficulty walking, and osteoporosis, had a physician's order for acetaminophen to be administered as needed for mild pain. After a fall, the resident was given acetaminophen for pain rated at a 3, but there was no documentation of an assessment to determine if the medication was effective. The following morning, the resident's pain worsened to a 6, and the nurse administered the same medication without notifying the physician for additional pain management orders. The Director of Nursing confirmed that the nursing staff should have documented the effectiveness of the pain medication.
Failure to Monitor Resident Weight Changes
Penalty
Summary
The facility failed to accurately monitor weight changes for two residents, CL1 and 3, as per the facility's weight monitoring policy and physician orders. Resident CL1, who was admitted with diagnoses including dementia, diabetes, and adult failure to thrive, had a care plan that required weekly weight monitoring for four weeks. However, there was no documented evidence that weights were obtained on March 19 or 26, 2024, as ordered by the physician. Similarly, Resident 3, admitted with dementia and dysphagia, had a care plan that included monitoring weights per facility policy. A nutrition assessment recommended weekly weights for four weeks, followed by monthly monitoring. Despite this, there was no documented evidence of a weight schedule being developed upon admission or that weekly weights were obtained as recommended. The Director of Nursing confirmed the lack of documentation for weights as per physician orders, dietitian recommendations, or facility policy.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide food that was palatable and at appetizing temperatures on three of five nursing units. A review of the facility policy revealed that food should be palatable, attractive, and served at a safe and appetizing temperature. However, interviews with residents indicated that the food was often cold and not palatable. A test tray audit showed that the temperatures of the chicken, stuffing, and Brussels sprouts were significantly below the required 130 degrees Fahrenheit. Further interviews with residents confirmed that the issue of cold food was consistent, affecting both room service and dining room meals.
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.
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.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
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.
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.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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