Maplewood Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 125 W Schoolhouse Lane, Philadelphia, Pennsylvania 19144
- CMS Provider Number
- 395865
- Inspections on file
- 29
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Maplewood Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident reported that an LPN, with whom the resident had an ongoing conflict, did not personally administer prescribed medications and instead directed a nurse aide to hand the medications to the resident. Facility policy requires that only state-licensed or permitted personnel prepare and administer medications. The LPN confirmed instructing an aide to give the medications while the LPN remained nearby, and neither the LPN nor the resident could identify the aide involved. This resulted in medications being administered by unlicensed staff, contrary to facility policy and regulatory requirements.
A resident was moved to a different room without receiving prior written notice, despite being alert and oriented. Staff asked the resident to move without allowing him to pack his belongings himself, and documentation showed no evidence that written notice was provided before the room change. The administrator confirmed that written notice was not given.
A resident was not given a written summary of the baseline care plan or a medication list within 48 hours of admission, as required. Review of records and staff interviews confirmed that the facility lacked a process to ensure these documents were provided to residents or their representatives.
A resident with end stage renal disease was receiving hemodialysis four days a week, but the physician's order only specified three days. Staff and documentation confirmed the resident's increased dialysis frequency, yet the order was not updated to reflect this change.
A resident with PTSD, major depressive disorder, and a traumatic subdural hemorrhage was admitted and had a care plan that did not address possible triggers for re-traumatization. The care plan lacked trauma-informed interventions, and the Social Service Director confirmed that potential triggers were not identified or managed, resulting in a deficiency in culturally competent care.
Three residents were not offered or provided with required influenza or pneumococcal vaccines, as evidenced by missing documentation in their clinical records and staff interviews.
A resident, dependent on staff for transfers, was unsafely transferred by a single nurse aide using a mechanical lift, contrary to the facility's policy requiring two staff members. The aide acknowledged the requirement but stated the assisting staff left to attend to another resident.
A facility failed to submit necessary medical information for a resident's imaging study, resulting in the denial of a CT scan approval. The resident, with a complex medical history, required a stealth CT scan for prosthetic manufacturing. Despite attempts by a nurse aide to contact the insurance company, the required information was not provided, leading to the deficiency.
The facility failed to meet food service safety standards, with issues such as improperly stored and packaged food items, dirty equipment, and water drainage problems in the kitchen. Additionally, a resident was found to keep perishable food items at room temperature in their room, despite requiring refrigeration, and staff were aware of this unsafe practice.
The facility failed to develop comprehensive care plans for residents, leading to unaddressed needs such as contractures, hoarding behaviors, diet non-compliance, and safety risks. A resident with hemiplegia had no care plan for a hand contracture, while another with cognitive impairment hoarded perishable food. A third resident was non-compliant with a diet, and a fourth was found with foil in the mouth, yet care plans lacked necessary interventions.
The facility failed to maintain effective infection control practices, particularly in the use of PPE for residents requiring enhanced barrier precautions. A resident with a PEG tube received medication from a nurse wearing only gloves, while another resident's wound care involved improper PPE disposal. Additionally, a resident with a colostomy bag and tracheostomy received care from aides wearing only gloves, and there was a lack of accessible PPE stations and disposal bins.
A deficiency was identified in the handling of the PASRR process for a resident with multiple mental health diagnoses. The facility failed to update the PASRR assessment to reflect the resident's current conditions, as required by policy. The most recent PASRR was from 2017, despite the resident having diagnoses of dementia, depression, bipolar disorder, and psychotic disorder.
A resident admitted with cerebral infarction, aphasia, and cerebral atherosclerosis did not have a baseline care plan developed within 48 hours, as required. Observations showed the resident's left hand in a fist and unkempt facial hair. The MDS assessment indicated a need for extensive assistance with ADLs, but a care plan was only initiated five days post-admission.
A resident with hemiplegia and muscle weakness was found to have a left-hand contracture without a splint, and no documented treatment or services to maintain or improve range of motion. Staff interviews confirmed the absence of a restorative nursing program, and new therapy staff were unaware of previous treatments, highlighting a deficiency in nursing services.
A facility failed to ensure proper communication with a dialysis provider for a resident with end-stage renal disease. The facility's policy requires ongoing communication and documentation, but multiple instances of incomplete documentation were found, including missing dialysis assessments, weights, and nurse signatures. This deficiency was confirmed by a unit manager who acknowledged the incomplete documentation.
A LTC facility was found to have a medication error rate of 20.69%, exceeding the acceptable limit of 5%. Errors included a nurse improperly crushing and combining medications for a resident with a PEG tube, and another nurse administering polyethylene glycol without a physician's order. These actions violated facility policies and physician orders.
The facility failed to properly label and date medications on two medication carts, with open and undated insulin vials and pens found. Additionally, a medication cart was left unlocked and unattended for ten minutes during administration on a nursing unit, contrary to facility policy.
The facility failed to employ a qualified Registered Dietitian and Director of Food and Nutrition Services. The Registered Dietitian worked part-time and lacked state licensure, while the Food Service Director did not meet statutory qualifications, lacking necessary certifications and educational credentials.
The facility failed to provide sufficient dietary staff for breakfast service, resulting in significant delays. The scheduled cook was absent, leaving the Assistant Food Service Director to prepare breakfast, which delayed the tray line start to 9:35 a.m. and residents began receiving breakfast around 9:50 a.m. The fourth-floor nursing unit received their last breakfast trays at 11:05 a.m., despite the usual requirement of four dietary aides, only three were present.
The facility did not adhere to planned menus on multiple occasions, serving different meals than scheduled due to time constraints and resident preferences. Additionally, some residents did not receive items listed on their meal tickets, such as orange juice and nutritional supplements, due to supply issues.
The facility failed to serve food at appetizing temperatures, as evidenced by resident complaints and observations. Breakfast foods were served cold due to broken equipment, including a steam table and plate warmer. A test tray confirmed the inadequate temperatures, and the Food Service Director acknowledged the issue.
The facility failed to prepare foods in a form that met the needs of residents on a pureed diet, affecting eight residents. Observations revealed that scrambled eggs and oatmeal were not prepared according to the IDDSI framework, as they were not smooth, homogenous, or cohesive. The Assistant Food Service Director incorrectly believed regular scrambled eggs were suitable for residents on a pureed diet.
The facility failed to provide appropriate beverages for two residents. A resident with lactose intolerance received whole milk instead of non-dairy options, and another resident received thickened beverages despite a physician's order for thin liquids. These discrepancies were confirmed through observations and staff interviews.
The facility failed to serve meals on time and provide scheduled snacks, affecting multiple nursing units and residents. Breakfast was served late due to a staffing issue, with the last unit receiving trays significantly past the scheduled time. Additionally, residents with documented nutritional needs did not receive their scheduled snacks, as confirmed by staff.
The facility was unable to provide rehabilitation records for three residents due to a change in rehab company and ownership, resulting in a lack of access to previous therapy notes. Interviews with staff confirmed the deficiency.
A resident with severe cognitive impairment, indicated by a BIMS score of 3, was allowed to sign a binding arbitration agreement upon admission. The facility lacked a consistent Admission Director, leading to a failure in ensuring the resident's capacity to understand the agreement, as confirmed by the Nursing Home Administrator.
The facility failed to maintain essential equipment, affecting resident care and food service. A resident's wheelchair headrest was broken, and another's air mattress was malfunctioning, causing discomfort. In the kitchen, broken equipment, including a steam table and dish machine, hindered meal service. These issues were confirmed through interviews and observations.
The facility did not maintain the required emergency water supply, having only 294 gallons instead of the necessary 468 gallons for 156 residents. This deficiency was confirmed by the Food Service Director during an observation and interview.
The facility failed to maintain an effective pest control program, with live roach activity and fruit flies observed in the kitchen, and flies present in the rooms of two residents with open wounds. The pest control company recommended improved sanitation and plumbing repairs, but these issues persisted, affecting the residents' environment and potentially increasing infection risks.
The facility did not ensure menus were posted and followed on the third floor. Residents reported cold food, blank food tickets, and lack of food choices per preferences. Menus were only posted at the nursing station, leaving bedbound residents uninformed. Staff confirmed these issues, citing a transition to a new meal tracking system as a cause for blank food tickets.
A resident with cognitive impairments sustained second-degree burns after spilling a hot water beverage that was not temperature-checked by staff. Despite offers of assistance, the resident carried the tray themselves, leading to the accident. The facility failed to adhere to its policy on serving hot liquids at safe temperatures.
The facility failed to provide assistance with showers for a resident who had not received a shower for three weeks, despite having a care plan and physician orders for twice-weekly showers. The resident only received bed baths, and there was no documentation of shower refusals or reasons for not providing the showers.
Unlicensed Staff Directed to Administer Medications During Nurse–Resident Conflict
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were administered by a licensed nurse in accordance with the resident’s plan of care and facility policy. The facility’s medication administration policy states that only persons licensed or permitted by the state may prepare, administer, and document the administration of medications. A grievance filed by Resident R1 indicated that a licensed nurse (Employee E4) did not personally give the resident their medications. The grievance documentation showed that Employee E4 reported the resident would not accept medications from them, and the Medication Administration Audit Report reflected that Employee E4 was removed from Resident R1’s nursing unit on February 21, 2026. Resident R1 reported an ongoing conflict with Employee E4 and stated that the nurse gave the resident’s medications to a nurse aide to hand to the resident because they were not getting along. In a telephone interview, Employee E4 confirmed instructing a nurse aide to administer medications to Resident R1, stating that the nurse remained nearby while the aide handed the medications to the resident. Employee E4 also stated they did not know the name of the nurse aide involved. Resident R1 similarly did not recall the aide’s name and expressed not wanting the aide to get in trouble. These findings show that an unlicensed nurse aide was directed to administer medications, contrary to the facility’s policy and state requirements that only licensed or permitted personnel may perform this task.
Failure to Provide Written Notice Before Resident Room Change
Penalty
Summary
A deficiency occurred when a resident was moved to a different room without receiving prior written notice from the facility. The resident, who was alert and oriented, reported that staff entered his room and asked him to move without giving him the opportunity to pack his belongings himself, which was important to him. Review of the clinical records and room change notification confirmed that the room change and the notification were both dated the same day, and the section for providing a written copy to the resident was marked as not applicable. There was no evidence in the records that written notice was provided to the resident before the room change, and the administrator confirmed that written notice was not given.
Failure to Provide Baseline Care Plan and Medication List Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and medication list to a resident or the resident's representative within 48 hours of admission, as required by policy. During an interview, the resident stated that he had not received a copy of the baseline care plan or medication list since his admission. Review of the clinical record confirmed there was no evidence that these documents were provided. The Social Service Director also confirmed that the facility did not have a process in place to provide a written copy of the baseline care plan or medication list to residents or their representatives.
Failure to Update Physician Orders for Dialysis Schedule
Penalty
Summary
The facility failed to update a resident's physician orders to accurately reflect the current dialysis schedule. Clinical record review showed that a resident with end stage renal disease had a physician's order for hemodialysis three days a week (Monday, Wednesday, and Friday) at a local dialysis center. However, nursing progress notes and staff interviews confirmed that the resident had been attending dialysis four days a week, including Thursdays, for several weeks. Staff acknowledged that the physician's order had not been updated to include the additional day, despite the change in the resident's treatment schedule.
Failure to Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), major depressive disorder, and a traumatic subdural hemorrhage. Review of the resident's clinical record and care plan revealed that, although there was a care plan in place for a history of traumatic event, it did not address possible triggers that could cause re-traumatization for the resident. The quarterly Minimum Data Set (MDS) assessment confirmed the PTSD diagnosis, but the care plan lacked specific interventions or considerations for the resident's past experiences and preferences related to trauma. During an interview, the Social Service Director confirmed that the care plan for PTSD did not include identification or management of potential triggers for re-traumatization. This omission was found for one of four residents sampled for PTSD care, out of 33 residents reviewed. The deficiency was cited under 28 Pa. Code 211.12(c)(d)(3)(5) for nursing services, as the facility did not meet professional standards of practice in providing trauma-informed, culturally competent care.
Failure to Offer or Provide Required Immunizations
Penalty
Summary
The facility failed to offer and/or provide influenza and pneumococcal immunizations to three out of five residents reviewed during the survey. Specifically, for two residents, there was no evidence in their clinical records that they received or were offered the influenza vaccine. For another resident, there was no documentation that the pneumococcal vaccine was administered or offered. These findings were based on a review of clinical records and staff interviews, which did not show any record of the required immunizations or offers being made to the affected residents at the time of their admission.
Failure to Follow Mechanical Lift Policy for Resident Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, as required by their policy. The policy mandates that two staff members must be present during the transfer process to control the lift and reposition the resident safely. However, during an observation, it was noted that only one nurse aide, Employee E2, was present while transferring the resident, who was totally dependent on staff for transfers and required a wheelchair. This was contrary to the facility's policy, which was updated in April 2023, and required two staff members to perform such transfers. Resident R1, who had diagnoses including muscle atrophy, dysphasia, dementia, and malnutrition, was observed being transferred by a single staff member, Employee E2, using a mechanical lift. Employee E2 acknowledged awareness of the two-person requirement but stated that the assisting employee, Employee E3, had left the room to attend to another resident. Both employees had previously signed an inservice attendance record indicating they were educated on the proper use of the mechanical lift, yet the policy was not followed during this incident.
Failure to Submit Required Medical Information for Imaging Study
Penalty
Summary
The facility failed to ensure that the required information for obtaining an imaging study was submitted for a resident, identified as Resident R4. Resident R4 was admitted to the facility with a complex medical history, including a left basal ganglia intraparenchymal hemorrhage, status post craniectomy, stroke affecting the right dominant side, cognitive communication deficit, and other conditions. On April 16, 2024, a neurosurgery consult recommended a stealth CT scan for prosthetic manufacturing. However, the necessary medical information was not submitted to the insurance company, resulting in the denial of the CT scan approval. Despite multiple attempts by a nurse aide to contact the insurance company regarding the approval of the stealth CT scan, the insurance company reported that they had not received the required medical information. The insurance company specified that they needed prior imaging tests, current or completed treatment details, and any lab work, scope study, or physical exams to approve the scan. The facility was unable to provide evidence that this information was submitted, and the deficiency was confirmed through interviews with the facility's Administrator and Assistant Director of Nursing.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations during a tour of the main kitchen. Boxes of dry cereal were found placed directly on the floor, and various food items in the freezer, such as premade meatballs and raw burger patties, were not properly sealed or packaged. Additionally, there was a significant build-up of dust on an industrial fan near the dish machine, and a small red bucket with dirty water was found beneath the coffee maker. The dry storage room contained a plastic bin with condiment packets and a red liquid build-up, as well as an open bag of grits that was not sealed or dated. Cooking equipment, including the fryer, stove, and tilt skillet, was observed to have significant grease build-up. Furthermore, a pool of water with fruit flies was found behind the ice machine due to a floor drain backup, and a black bin with pooled water and shelf-stable milks was observed in the three-compartment prep sink, also attracting fruit flies. Additionally, the facility failed to ensure the safe storage of food items in resident rooms. A resident was observed to have nutritional health shakes and yogurt cups on their bedside counter, which required refrigeration but were kept at room temperature for several days. The resident refused to discard these items, insisting they did not spoil. Nursing staff were aware of the resident's hoarding behavior and acknowledged that the dairy products were unsafe to consume. These observations were confirmed through interviews with the Food Service Director and a licensed nurse, highlighting ongoing issues with food safety and storage within the facility.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific needs. Resident R38, who had a diagnosis of hemiplegia and muscle weakness, was observed to have a contracture in the left hand. Despite this, there was no documented evidence of a care plan to address the contracture, indicating a lack of comprehensive planning for the resident's condition. Resident R129, diagnosed with depression and moderate cognitive impairment, exhibited hoarding behaviors by keeping perishable food items in his room at room temperature. The care plan for this resident only included interventions to anticipate needs and educate about the hazards of hoarding, but lacked additional strategies to manage the behavior effectively. Staff interviews confirmed awareness of the issue but also highlighted their uncertainty on how to address the resident's refusal to discard the food items. Resident R117, who had a history of cerebral infarction and was non-compliant with a prescribed diet, did not have a care plan developed to address this non-compliance. Additionally, Resident R100, diagnosed with dementia and malnutrition, was found with a ball of foil in the mouth, yet the care plan did not include interventions to prevent access to such items. These omissions in care planning demonstrate a failure to adequately address the residents' specific needs and risks, as required by facility policies.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain effective infection control practices, particularly concerning the use of barrier precautions and personal protective equipment (PPE) for certain residents. Specifically, Resident R43, who required Enhanced Barrier Precautions due to an indwelling PEG tube, was administered medication by a licensed nurse who only wore gloves and was unaware of the location of other necessary PPE. Additionally, during a breakfast meal service, a nurse aide was observed handling a resident's food with bare hands, further indicating lapses in infection control practices. In another instance, during wound care for Resident R81, licensed nurses wore gowns and gloves but faced issues with the proper disposal of used PPE. There was no designated container for disposing of the gowns in the vicinity of the resident's room, leading to improper handling and disposal of potentially contaminated materials. This issue was compounded by the lack of accessible PPE stations on the third-floor nursing unit, as confirmed by staff interviews. Resident R52, who required enhanced barrier precautions due to a colostomy bag and tracheostomy, was also subject to inadequate infection control measures. Nurse aides providing colostomy care were observed wearing only gloves, and a licensed nurse admitted to not wearing any PPE while administering medications. The absence of PPE stations and proper disposal bins for used PPE in several rooms further highlighted the facility's failure to adhere to its own infection control policies.
Improper PASRR Handling for a Resident
Penalty
Summary
The deficiency identified in the report pertains to the improper handling of the PASRR (Preadmission Screening and Resident Review) process for a resident, referred to as Resident R77. The facility failed to appropriately revise the PASRR according to the resident's assessment. The facility's policy requires coordination with the PASRR program, including incorporating recommendations from the PASRR evaluation into the resident's care planning and notifying the state mental health or intellectual disability authority after a significant change in the resident's condition. However, the PASRR Level I assessment for Resident R77, dated July 21, 2017, did not list any serious mental illnesses, despite the resident having diagnoses of dementia, depression, bipolar disorder, and psychotic disorder as per the quarterly MDS and care plan. The report highlights that the PASRR for Resident R77 was not updated to reflect the resident's current mental health conditions, which include major depressive disorder, unspecified delusional disorder, and other psychotic disorders. The Nursing Home Administrator confirmed that the PASRR from 2017 was the most current assessment available for Resident R77. This oversight indicates a failure to comply with the facility's policy and the requirements of the PASRR program, which aims to ensure that residents with mental illnesses or intellectual disabilities receive appropriate placement and services.
Failure to Develop Timely Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, identified as R362, which is necessary to provide effective and person-centered care. Observations noted that the resident's left hand was in a fist and they had unkempt facial hair. The resident was admitted with diagnoses including cerebral infarction due to embolism, aphasia, and cerebral atherosclerosis. Despite these conditions, a baseline care plan addressing the resident's ADL needs was not developed within the required timeframe. The resident's MDS assessment indicated a need for extensive assistance with bed mobility, transfers, and toilet use, requiring one-person physical assistance. However, a care plan for ADL self-care performance deficit related to impaired balance was only developed and initiated five days after admission. This delay in care planning is a violation of the regulatory requirements, as the facility did not meet the 48-hour timeframe to address the resident's immediate needs upon admission.
Failure to Provide ROM Treatment for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as Resident R38, to maintain or improve range of motion, specifically for a left-hand contracture. Resident R38, who is cognitively intact, has diagnoses of hemiplegia, muscle wasting, and muscle weakness, and was observed to have a contracture of the left hand without a splint. The resident reported previously having a splint but was unsure of its current whereabouts. Interviews with staff, including a licensed nurse and a restorative nurse aide, confirmed the absence of a splint and the lack of a restorative nursing program for the resident. Further investigation revealed that the physical therapist, who started in September 2024, did not have access to previous therapy treatment notes for Resident R38, and the occupational therapist, who began on November 4, 2024, was unfamiliar with the resident's treatment for the contracture. A review of the resident's clinical record showed no documented evidence of treatment or services provided for the left-hand contracture, indicating a deficiency in the facility's nursing services as per the cited regulations.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication with the dialysis provider for a resident requiring dialysis services. The facility's policy, dated April 1, 2022, mandates adequate management of dialysis services, including ongoing communication and collaboration with the dialysis provider. However, the review of Resident R22's dialysis communication binder revealed multiple instances of incomplete documentation. Specifically, on several dates, the documentation lacked dialysis assessments, pre and post-treatment weights, and signatures from the dialysis nurse. Resident R22, who entered the facility with a diagnosis of end-stage renal disease and is dependent on dialysis, was affected by this deficiency. The facility's failure to document necessary information and maintain communication with the dialysis provider was confirmed by a licensed nurse, unit manager Employee E32, who acknowledged the incomplete documentation and stated that communication with the dialysis staff had occurred regarding these issues.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by a 20.69 percent error rate observed during a medication administration review. This deficiency was identified through the observation of 29 medication administration opportunities, during which six medication errors were noted. Specifically, the errors involved the improper administration of medications to two residents, R43 and R108, during the morning medication pass. For Resident R43, a licensed nurse crushed and combined multiple medications, including enteric-coated aspirin and delayed-release omeprazole, which were not supposed to be crushed, and administered them via a PEG tube. This was contrary to the physician's orders and facility policy, which required medications to be administered separately with a water flush between each to prevent interactions. For Resident R108, a licensed nurse administered polyethylene glycol without a physician's order, based on the resident's request for bowel movement assistance. These actions were in violation of the facility's medication administration policies and physician orders.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and dating of medications on two of three medication carts reviewed. On the fourth floor unit B medication cart, a vial of lispro insulin for a resident was found open and undated, along with two vials of lantus insulin that were also opened without labels or dates. Similarly, on the fourth floor unit A medication cart, two vials of lantus insulin and an aspart insulin pen for another resident were found open and undated, as well as a vial of lispro insulin for a different resident. Additionally, two medication cups containing unmarked pills and capsules were found, with a licensed nurse identifying them as senna and probiotics for different residents. The facility also failed to keep a medication cart locked when not in use during medication administration on the third-floor nursing unit. The medication cart was observed unlocked and unattended for ten minutes while the assigned licensed nurse was in a resident's room with the door closed, obstructing the view of the cart. The nurse confirmed that the facility policy requires medication carts to be locked at all times, acknowledging the oversight.
Deficiency in Qualified Dietitian and Food Service Director Employment
Penalty
Summary
The facility failed to employ a qualified Registered Dietitian and Director of Food and Nutrition Services, as required by regulations. The Registered Dietitian, identified as Employee E8, was confirmed to work only part-time at the facility and lacked the necessary state licensure to practice dietetics-nutrition in Pennsylvania. This was corroborated by an interview with the Regional Registered Dietitian, Employee E19, who confirmed that Employee E8 was not licensed by the State of Pennsylvania. Additionally, the Food Service Director, identified as Employee E4, did not meet the statutory qualifications for the position. The personnel file review revealed that Employee E4 was neither a certified dietary manager nor a certified food manager, nor did they possess a national certification for food service management and safety. Furthermore, Employee E4 did not hold an associate's or higher degree in food service management or hospitality from an accredited institution, which are required qualifications for the role.
Insufficient Dietary Staffing Delays Breakfast Service
Penalty
Summary
The facility failed to employ sufficient dietary personnel to carry out the functions of the food and nutrition service during the breakfast meal observed on November 3, 2024. The posted mealtime for breakfast on the fourth-floor nursing unit was from 7:40 a.m. to 8:40 a.m. However, observations in the main kitchen at 9:00 a.m. revealed that dietary staff were still preparing for the breakfast meal service, with only one dietary personnel cooking and three dietary aides preparing beverages and meal trays. An interview with the Assistant Food Service Director indicated that the scheduled cook did not show up for the breakfast shift, resulting in the Assistant Food Service Director preparing breakfast at 9:15 a.m. The breakfast tray line did not start until 9:35 a.m., and residents began receiving breakfast around 9:50 a.m. The last nursing unit, the fourth floor, did not receive their last truck of breakfast trays until 11:05 a.m. It was revealed that there are usually four dietary aides for breakfast service, but only three were present on this occasion.
Failure to Follow Planned Menus and Provide Nutritional Supplements
Penalty
Summary
The facility failed to adhere to the planned menus for meals on multiple occasions, as observed on November 3 and 4, 2024. On November 3, the planned lunch menu was not followed due to time constraints, resulting in beef stew over rice being served instead of the scheduled crispy ranch chicken meal. Additionally, breakfast was served late, and the items provided did not match the posted menu, with residents receiving pancakes and scrambled eggs instead of oat cereal and eggs of choice. Furthermore, some residents did not receive items listed on their meal tickets, such as orange juice and bran flakes cereal, and a nutritional supplement was substituted with a pudding cup. On November 4, the facility again deviated from the planned menu, substituting mushrooms with a California vegetable blend due to resident preferences, and failing to provide zucchini as a side option. Residents received meatballs with orzo instead of the planned chateau potatoes, leading to dissatisfaction among residents. Additionally, there were issues with the availability of Ensure Clear supplements, which were not provided to residents as indicated on their meal tickets. The Food Service Director confirmed difficulties in ordering sufficient quantities of Ensure Clear, resulting in residents not receiving their required nutritional supplements.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was palatable and served at appetizing temperatures, as evidenced by multiple resident complaints and observations. The food council minutes from September and October 2024 indicated ongoing issues with cold food temperatures, with a significant number of residents reporting that breakfast foods were not served at appropriate temperatures. On November 3, 2024, observations during breakfast service on the fourth floor revealed that residents were served cold pancakes, coffee, and scrambled eggs. Several residents expressed dissatisfaction with the food, describing it as cold, terrible, and disgusting. Further investigation revealed that the dietary staff used a tray line system to plate meals, but the steam table and plate warmer, which are essential for maintaining food temperatures, were broken. A test tray conducted on November 3, 2024, confirmed that the hot foods were served at temperatures too low to be palatable, and the cold beverage was served too warm. The Food Service Director acknowledged these issues, confirming that the equipment failures contributed to the deficiency in food service quality.
Failure to Provide Properly Prepared Pureed Diets
Penalty
Summary
The facility failed to prepare foods in a form that met the needs of residents on a pureed diet, affecting eight residents. The facility's diet manual, which follows the International Dysphagia Diet Standardization Initiative (IDDSI) Framework, specifies that pureed foods should be smooth, homogenous, and cohesive. However, observations revealed that the scrambled eggs served to residents on a pureed diet were crumbly and not in accordance with the required consistency. The Assistant Food Service Director mistakenly believed that regular scrambled eggs were suitable for residents on a pureed diet. Further observations and interviews with the Food Service Director confirmed that the pureed eggs and hot oatmeal were not prepared according to the IDDSI framework. The oatmeal was found to be lumpy and not in a pureed consistency. These deficiencies were identified during a review of the facility's diet manual and through staff interviews, highlighting a failure to adhere to prescribed dietary standards for residents requiring pureed diets.
Failure to Provide Appropriate Beverages for Residents
Penalty
Summary
The facility failed to provide beverages consistent with the needs of two residents during meal service. Resident R152, who is lactose intolerant, was observed receiving a breakfast tray containing whole milk despite her meal ticket indicating no dairy products. She had requested almond milk or other non-dairy options but had not received them. Additionally, Resident R145's meal ticket incorrectly specified thickened beverages, while the physician's order dated August 6, 2024, indicated thin liquids. The kitchen continued to send thickened beverages despite the physician's order for thin liquids, as confirmed by interviews with the Speech Therapist and a Licensed Nurse.
Failure to Serve Timely Meals and Provide Scheduled Snacks
Penalty
Summary
The facility failed to serve meals timely and provide snacks as required, affecting multiple nursing units and residents. Observations on November 3, 2024, revealed that breakfast was served late on the second, third, and fourth-floor nursing units. The posted breakfast time was from 7:40 a.m. to 8:40 a.m., but residents did not start receiving breakfast until about 9:50 a.m., with the last unit receiving trays at 11:05 a.m. This delay was due to the absence of the scheduled cook, requiring the Assistant Food Service Director to prepare the meal, which delayed the tray line start to 9:35 a.m. Residents expressed hunger and frustration due to the delay, and lunch was also served late, with the fourth-floor unit receiving it at 2:05 p.m. Additionally, the facility failed to provide scheduled snacks to residents R68 and R34, who had documented nutritional needs requiring snacks at specific times. Resident R68's care plan indicated snacks at 10 a.m., 2 p.m., and bedtime, while Resident R34's care plan required snacks three times daily. On November 3, 2024, none of the residents on the fourth floor received their 10:00 a.m. and 2:00 p.m. snacks because they were not sent from the kitchen, as confirmed by a unit clerk. These failures were documented in the facility's food council minutes, where residents consistently reported late breakfast service in September and October 2024.
Failure to Provide Rehabilitation Records
Penalty
Summary
The facility failed to submit complete records related to rehabilitation services for three residents. On November 6, 2024, requests for rehabilitation documents for two residents revealed that the facility was unable to provide the requested rehab notes. An interview with an employee indicated that the facility had changed its rehab company and could not access therapy notes from the previous provider. Additionally, a request for another resident's most recent physical and occupational therapy notes and discharge summary was made, but the facility was unable to provide these documents due to a change in ownership. Interviews with the physical therapist and the nursing home administrator confirmed the inability to obtain and provide the necessary therapy notes.
Failure to Ensure Resident Capacity for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement, as evidenced by the case of Resident R259. This resident, who was admitted to the facility, had a documented severe cognitive impairment with a BIMS score of 3, indicating they were not cognitively intact. Despite this, Resident R259 signed a binding arbitration agreement upon admission. The Minimum Data Set (MDS) assessment dated January 17, 2021, confirmed the resident's cognitive communication deficit, further supporting the resident's inability to comprehend the agreement. The Nursing Home Administrator (NHA) acknowledged that the arbitration agreement is part of the admission packet and is typically signed at admission. However, the facility did not have a consistent Admission Director, having had four different individuals in this role since 2021. The NHA confirmed that a resident with a BIMS score of 3 should not have been allowed to sign the arbitration agreement, as they lacked the capacity to understand its terms. This oversight highlights a deficiency in the facility's admission process and management of residents with cognitive impairments.
Equipment Maintenance Deficiencies Impact Resident Care and Food Service
Penalty
Summary
The facility failed to maintain essential equipment in proper working order, affecting both resident care and food service operations. Resident R38 experienced a malfunction with their wheelchair, as the headrest fell off, leaving them without support when leaning back. Despite a maintenance request being sent to the Nursing Home Administrator on November 1, 2024, the issue had not been addressed by November 6, 2024. Additionally, Resident R26's air mattress was consistently alarming for low pressure over several days, causing discomfort and pain as the resident could feel the metal frame beneath them. This issue was confirmed by licensed nurses, yet remained unresolved. In the kitchen, several pieces of essential equipment were found to be broken, impacting the facility's ability to serve meals properly. The steam table, plate warmer, slicer, and garbage disposal were all non-functional, with the steam table and plate warmer being out of order for months. The dish machine had a plumbing issue causing water to flood the floor, and the sink in the dishwasher area had a large crack, further contributing to the flooding. These deficiencies were confirmed through interviews and observations with the Food Service Director, highlighting significant lapses in equipment maintenance and repair within the facility.
Inadequate Emergency Water Supply
Penalty
Summary
The facility failed to ensure an adequate supply of potable water for emergency purposes, as required by regulations. During an interview with the Food Service Director, it was revealed that the facility, with a census of 156 residents, should maintain 468 gallons of emergency water, calculated at 3 gallons per resident. However, an observation of the emergency water storage showed that only 294 gallons were available. The Food Service Director confirmed the insufficiency of the emergency water supply, which would not meet the residents' needs in case of a water supply disruption.
Pest Control Deficiency in Kitchen and Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations and documentation. The pest control reports from October 28, 2024, and November 4, 2024, indicated live roach activity in the kitchen, particularly in the dishwasher area, and recommended improved sanitation practices and timely trash disposal. Additionally, the reports highlighted the need to fix leaks under the dishwasher, which were causing water to wash away pest control chemicals. During a kitchen tour, significant grease buildup was observed on cooking equipment, and fruit flies were found near the ice machine and in a bin at the prep sink. The Food Service Director confirmed these observations and acknowledged plumbing issues contributing to water flooding in the dishwasher area. The deficiency also affected two residents, R81 and R309, who were observed to have flies in their rooms. Resident R81, who had a wound and a feeding tube, was seen with multiple flies on their body, which was confirmed by a licensed nurse. The pest control logs did not report any flies for Resident R81, and no resident rooms were treated during pest management services on November 4, 2024, due to a lack of a list of rooms needing treatment. Resident R309, who had open areas on their lower extremities, also reported flies in their room, which was confirmed by a licensed nurse. These observations indicate a failure to address pest issues in resident areas, potentially increasing the risk of infection for residents with open wounds.
Failure to Post and Follow Menus on Third Floor
Penalty
Summary
The facility failed to ensure that menus were posted and followed as required on the third floor. Residents reported that food was cold, food tickets were blank, and they were not offered food choices according to their preferences. Specifically, one resident mentioned that menus were not provided to bedbound residents, and the food was described as disgusting and gross. Observations confirmed that menus were only posted at the nursing station, and there was no system in place to inform bedbound residents of the menu options. The Assistant Director of Nursing confirmed the lack of menu distribution to bedbound residents, and the Director of Service acknowledged that food tickets were blank due to a recent change in the meal tracking system. The Nursing Home Administrator also confirmed these issues, attributing the blank food tickets to a transition to a new company.
Failure to Monitor Hot Beverage Temperature Leads to Resident Burn
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by not monitoring the temperature of hot water beverages served to a resident. This oversight resulted in actual harm to a resident who spilled a hot water beverage and sustained a second-degree burn on the abdomen and chest. The facility's policy on hot liquids, revised in January 2019, mandates that hot beverages be served at a palatable temperature that will not burn the skin, with specific temperature guidelines for serving. The incident involved a resident with a history of cerebrovascular accident, bipolar disorder, and chronic obstructive pulmonary disease, who was cognitively intact according to a recent assessment. The resident was care planned for safety awareness impairment and had difficulty navigating the skilled nursing facility environment. On the day of the incident, the resident requested lunch in the main dining room and was given a tray by a dietary aide, who did not check the temperature of the hot water. Despite offers of assistance from staff, the resident insisted on carrying the tray and subsequently spilled the hot water, resulting in burns. Interviews with staff revealed that the dietary aide was not assigned to check the temperature of the beverages and that the facility's practice involved random temperature checks by cooks. The dietary aide and other staff members offered assistance to the resident, but the resident declined. The facility's failure to adhere to its policy on hot liquid temperatures and the lack of supervision in ensuring the resident's safety led to the incident, which was captured partially on security camera footage.
Failure to Provide Assistance with Showers
Penalty
Summary
The facility failed to provide assistance with showers for Resident R4, who had not received a shower for the last three weeks. Despite having a care plan indicating the need for assistance with personal hygiene and physician orders for twice-weekly showers, the resident only received bed baths on specified dates. There was no documentation of shower refusals or reasons for not providing the showers, and the resident was unaware that they could receive a shower given their condition. Interviews with staff and the Nursing Home Administrator confirmed the lack of documentation and failure to offer alternative interventions or involve the interdisciplinary team to address the issue. The facility's policy on Activities of Daily Living (ADL) was not followed, resulting in the resident not receiving the necessary services to maintain personal hygiene.
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A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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