Markley Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norristown, Pennsylvania.
- Location
- 550 East Fornance Street, Norristown, Pennsylvania 19401
- CMS Provider Number
- 395483
- Inspections on file
- 38
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 54
Citation history
Health deficiencies cited at Markley Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and complex wound care needs experienced new wounds, adverse reactions to treatments, and frequently refused or altered recommended care. The care plan was not updated to address the resident's self-application of dressings, use of unapproved supplies, or refusals of prescribed interventions, resulting in noncompliance with care planning requirements.
Three residents experienced significant medication errors, including a resident receiving another's medication due to pre-poured cups being mixed up, a resident being given an inhaled medication orally, and a resident missing doses of seizure medications because of an electronic medical record entry error. These errors were confirmed through documentation review and staff interviews.
A resident with multiple chronic conditions and wounds was not provided with a timely updated care plan that addressed their self-application of wound dressings, refusals of prescribed treatments, and inconsistent use of recommended interventions. The care plan did not reflect the resident's evolving clinical status, preferences, or refusals, nor did it document the risks associated with self-administered care, as confirmed by staff interviews and record review.
Surveyors observed that multi-dose over-the-counter medications and eyedrops on two medication carts were not labeled with the date of opening, as required by facility policy and professional standards. Licensed nurses confirmed that labeling was their responsibility and acknowledged the omission, resulting in noncompliance with medication storage and labeling regulations.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not follow its antibiotic stewardship protocols, as several residents who received antibiotics—some for complex infections and others prophylactically—were not properly documented or tracked in the required surveillance logs. The Infection Preventionist did not review or record all antibiotic use as required, and there was a lack of follow-up or outcome documentation for some cases.
A resident with Multiple Sclerosis, who was alert and oriented, was not provided morning care or assistance with dressing at his preferred time due to staff availability issues. The resident also experienced issues with his urinal not being emptied, leading to spillage. Staff confirmed the facility did not accommodate the resident's preferences.
A resident admitted with multiple infections and on IV antibiotics, as well as under contact precautions for CRE, did not have a baseline care plan developed within 48 hours to address infection management, antibiotic use, or infection control measures, as required by facility policy. This was confirmed by the DON and through review of clinical records and physician orders.
A resident with natural teeth and multiple health conditions required staff assistance with oral hygiene due to documented plaque buildup and gum inflammation. Despite repeated dental instructions for twice-daily oral care and recommendations for antiseptic mouthwash, the care plan only addressed denture care, not the resident's actual oral health needs, as confirmed by the unit manager.
A resident with Multiple Sclerosis who required assistance with ADLs did not receive timely morning care, including incontinence care, due to staff availability and assignment to lounge duty. The resident's urinal was not emptied, resulting in a spill and delayed hygiene support, as confirmed by staff and management interviews.
A resident with multiple medical conditions was found to have extremely inflamed gums during a dental exam, with a recommendation for Peridex and physician consultation. Staff did not notify the physician of this recommendation, as confirmed by record review and staff interviews.
A resident with significant dental issues, including broken teeth and rampant decay, was not provided with timely referral or access to an oral surgeon as repeatedly recommended by the consulting dentist. Despite multiple documented recommendations and ongoing dental problems, the resident was not scheduled for or seen by a specialist, and staff confirmed the lack of follow-through.
A resident with severe cognitive impairment and a diagnosis of dementia was asked to verbally consent to a binding arbitration agreement, despite clinical documentation showing significant confusion and impaired decision-making. The facility's admission director obtained and documented the resident's verbal consent without involving a representative, contrary to facility policy requiring informed understanding.
A resident receiving hospice care did not have documented communication or evidence of services provided by the hospice agency in their clinical record. Review of the hospice communication book also showed no notes or records of care, and an LPN confirmed that this hospice service did not document the care provided, unlike other hospice agencies used by the facility.
The facility did not maintain comfortable temperatures in two nursing units, with temperatures in the 3rd floor common room and Unit C reaching 82–83°F. Two residents reported feeling hot and uncomfortable, and a portable AC unit was observed in use while about 22 residents were present in the affected area.
A resident with multiple medical conditions was injured during a mechanical lift transfer when a nurse aide attempted the procedure alone, resulting in the resident sliding from the lift and sustaining bruises. Facility documentation and staff interviews confirmed that the transfer was performed without the required second staff member, and post-incident skin assessments were incomplete.
A resident with multiple complex diagnoses exhibited inappropriate sexual behaviors and was involved in an alleged abuse incident. Although staff provided detailed witness statements about these behaviors and incidents, there was a lack of corresponding documentation in the resident's clinical record over an extended period, violating professional standards for medical recordkeeping.
The facility did not ensure that nurse aides and nurses received the required annual in-service education and abuse prevention training. Documentation was missing or incomplete for multiple staff members, including lack of evidence for abuse training and mechanical lift competency, as confirmed by the DON.
The facility failed to provide disposable paper towels on the second floor, as observed in several resident and visitor bathrooms. This deficiency was noted during a tour and confirmed by staff interviews, revealing that the issue was known but not promptly addressed. The lack of supplies contradicts the facility's hand hygiene policy, which requires that hand hygiene products be readily accessible to encourage compliance.
The facility did not meet the required minimum of 3.2 hours of direct resident care per resident on two days during a specified week. Staffing levels were 3.00 hours on one day and 2.97 hours on another, as identified through a review of nursing schedules and confirmed in an interview with the administrator.
A resident with dementia and unsteadiness on feet was found with a fracture in her left lower leg, but the facility failed to thoroughly investigate the cause. Despite progress notes indicating a displaced fracture and interviews with staff, no clear mechanism of injury was identified. The investigation lacked documentation of the resident's activities, statements from activities personnel, and evidence of a skin assessment during a shower or bath.
Two residents in the facility did not have comprehensive care plans addressing their specific needs. One resident with dementia lacked a care plan for managing the condition, while another resident with a history of stroke and muscle weakness had an order for a hand splint that was not implemented due to staff turnover and the resident's refusal. The care plan did not document the splint goals, interventions, or refusal education.
A resident with dementia and limited mobility, requiring two-person assistance for transfers, was inadequately supervised during a transfer by a nurse aide who performed a stand pivot transfer alone. This led to the resident being found with swelling and warmth in her leg, indicating a potential injury.
The facility failed to maintain complete medical records for two residents, as their medication regimen review notes lacked documentation of recommendations or the absence thereof. The Director of Nursing confirmed that the pharmacy company does not document when there are no new recommendations, leading to incomplete records.
Failure to Update Care Plan for Resident with Complex Wound Care Needs
Penalty
Summary
Markley Rehabilitation and Healthcare Center was found noncompliant with federal and state regulations following an abbreviated survey triggered by a complaint. The deficiency centered on the facility's failure to timely update a resident's care plan to reflect evolving clinical findings, resident preferences, and refusals of care. The facility's policy requires that care plans be comprehensive, person-centered, and promptly revised as new information about a resident's condition becomes available or as their needs change. The resident involved had multiple complex diagnoses, including anemia, peripheral vascular disease, diabetes, arthritis, cellulitis, narcolepsy, Sjogren's syndrome, vasculitis, and a history of falls. Clinical documentation showed that the resident experienced new open wounds, reported adverse reactions to prescribed wound treatments, and frequently refused or altered recommended care. The resident also self-ordered and applied dressings, sometimes removing prescribed treatments and using unapproved supplies, and was inconsistent with recommended interventions such as compression therapy and wheelchair leg lifts. Despite these ongoing changes and refusals, the resident's care plan, initiated after admission, did not address the resident's practice of purchasing and applying their own treatment supplies or the associated risks and consequences. The care plan also failed to incorporate interventions related to the resident's refusals and preferences, as required by facility policy and regulatory standards.
Plan Of Correction
1. The resident's Care Plan was reviewed and revised upon readmission to the facility on 11/3/25 to ensure it accurately reflected the most current clinical findings, personal preferences, and any refusals of care. 2. Upon identification of this issue, the facility conducted a review of all residents with documented treatment refusals to verify that each resident's Care Plan accurately reflects those refusals. Any necessary updates were completed. 3. Nursing administration staff received education on the importance of updating Care Plans to reflect residents' treatment of refusals. 4. Residents with documented refusals of treatment will be audited weekly for two months to ensure their Care Plans reflect current status and include documentation of any alternative interventions or measures implemented. Audit results will be submitted to the QAPI Committee for review and recommendations as needed.
Medication Administration Errors Involving Multiple Residents
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by incidents involving three residents. For one resident with atrial fibrillation, anxiety, and depression, a nurse administered oxybutynin chloride 5 mg to the wrong resident by pre-pouring medications for two roommates and giving the medication cup intended for one resident to the other. The error was identified when the resident who received the wrong medication noticed the name on the cup was not theirs, and the nurse confirmed the mistake. In another incident, the same resident was prescribed Spiriva 10 mcg via inhalation, but a nurse administered the medication orally instead of through the inhaler. The resident questioned the unfamiliar pill but was told by the nurse that it was the correct medication in oral form. The nurse later confirmed that the medication was given by mouth rather than inhaled, contrary to the physician's order. A third resident with epilepsy was affected when their seizure medications, Keppra and Lacosamide, were not administered as ordered. The error occurred due to a software default when a registered nurse entered the physician's orders into the electronic medical record, causing the medications to be scheduled to start a day later than intended. As a result, the resident missed doses of both medications. These incidents were confirmed through review of clinical records, facility documentation, and staff interviews.
Failure to Update Care Plan for Resident's Evolving Clinical Needs and Refusals
Penalty
Summary
The facility failed to timely update a resident's care plan to reflect evolving clinical findings, resident preferences, and refusals of care. Specifically, the care plan did not address the resident's actions of purchasing and applying their own wound treatment supplies, nor did it include interventions related to the risks and consequences of these self-administered treatments. The care plan also did not incorporate the resident's refusals of prescribed wound care treatments, such as Dakin's cleansing, gauze, wound gel, and calcium alginate, which the resident declined due to reported burning sensations. Additionally, the care plan did not reflect the resident's inconsistent use of compression therapy, refusal of heel lift boots, and non-compliance with PCP recommendations for wheelchair leg lifts. The resident in question had multiple complex medical diagnoses, including anemia, peripheral vascular disease, diabetes, arthritis, cellulitis, narcolepsy, Sjogren's syndrome, vasculitis, and a history of falls. Despite these conditions and ongoing changes in wound status, the care plan was not revised to address the resident's self-management behaviors or to document the involvement of the interdisciplinary team in response to these changes. Observations and staff interviews confirmed challenges in assessing treatment effectiveness due to the resident's removal of prescribed dressings and application of unapproved dressings, as well as discrepancies between staff and resident reports regarding treatment refusals.
Failure to Label Multi-Dose Medications on Medication Carts
Penalty
Summary
Surveyors determined that the facility failed to ensure all drugs and biologicals were stored and labeled according to professional standards on two medication carts. During medication passes on the third-floor nursing unit, observations revealed that all over-the-counter multi-dose medications and multi-dose eyedrops stored in the top drawers of two medication carts were not labeled with the date of opening. Specifically, 35 bottles of multi-dose over-the-counter medications and 21 multi-dose eyedrops on one cart, and 34 bottles of multi-dose over-the-counter medications and 10 multi-dose eyedrops on another cart, were found without the required labeling. Interviews with licensed nurses confirmed that it was the responsibility of all nurses working on the medication carts to label multi-dose medications with the date of opening, and acknowledged that this had not been done. The facility's policy requires opened multi-dose medications to be dated and discarded within 28 days unless otherwise specified by the manufacturer, and that only authorized personnel have access to locked medication storage. The observed failure to label these medications constituted noncompliance with both facility policy and regulatory requirements.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program as required by its own policies and regulatory standards. Review of facility policies indicated that all antibiotic use should be monitored and documented using an approved surveillance tracking form, with oversight by the Infection Preventionist (IP). However, documentation and clinical record reviews revealed that three out of five residents reviewed for antibiotic use were not properly tracked or reviewed. Specifically, one resident received multiple antibiotics for various infections, but the use and outcomes were not consistently documented on the surveillance logs. Another resident was prescribed prophylactic antibiotics for an indefinite period, and this was not reflected in the infection surveillance logs. A third resident was also treated prophylactically for suspected cellulitis without lab results, specific infection site, or follow-up notes, and this case was similarly omitted from the surveillance documentation. The residents involved had complex medical histories, including diagnoses such as multi-drug resistant organism infections, urinary tract infection, wound infection, diabetes, hypertension, dementia, and asthma. Despite receiving antibiotics, the required documentation and review processes were not followed, as evidenced by missing entries in the surveillance logs and lack of follow-up or outcome data. These omissions indicate that the facility did not adhere to its antibiotic stewardship protocols, resulting in incomplete monitoring and oversight of antibiotic use for these residents.
Failure to Honor Resident's Morning Care Preferences
Penalty
Summary
A deficiency occurred when the facility failed to accommodate a resident's stated preference for morning care. The resident, who has Multiple Sclerosis and requires assistance with dressing, was assessed as alert and oriented, and his care plan indicated that the timing of his morning routine was very important to him. On the day in question, the resident was not assisted with morning care or dressing at his preferred time of 9:00–9:30 a.m., and was still waiting for care at 11:00 a.m. The resident also reported that his urinal was not emptied, resulting in spillage and wetness. The nurse aide responsible stated she could not provide care earlier because she required another aide's assistance and was unable to find help. The unit manager confirmed that the facility did not accommodate the resident's preferences.
Failure to Develop Baseline Care Plan for Infection and Antibiotic Use
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was admitted with multiple infections, including a multi-drug resistant organism (MDRO), urinary tract infection, wound infection, enterococcus infection, and a fracture of the left lower leg. Upon admission, the resident was receiving intravenous (IV) antibiotic therapy, including cefepime, daptomycin, and doxycycline, and was placed on contact precautions for Carbapenem-resistant Enterobacteriaceae (CRE). Facility policy requires that a baseline care plan addressing immediate health and safety needs be developed within 48 hours of admission. A review of the resident's clinical record, physician orders, and progress notes confirmed the presence of active infections and ongoing antibiotic therapy, as well as the implementation of contact precautions. However, the care plan initiated at admission did not address the resident's infection status, use of antibiotics, or the need for contact precautions. This omission was confirmed by the Director of Nursing during an interview, who acknowledged that no care plan had been developed for these critical aspects of the resident's care.
Failure to Develop Care Plan for Oral Health Needs
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan addressing the oral health needs of a resident with natural teeth who required assistance with oral hygiene. The resident, admitted with diagnoses including anemia, major depression, anxiety, and abnormal gait and mobility, was documented in multiple dental exams as having moderate plaque buildup, inflamed and bleeding gums, and extremely inflamed gingivae. Dental professionals instructed staff to perform oral hygiene twice daily and recommended the use of Peridex mouthwash, yet the resident's care plan only addressed denture care and not the care of natural teeth. The unit manager confirmed that the resident did not have dentures, indicating the care plan did not reflect the resident's actual oral health needs.
Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with Multiple Sclerosis, who had an ADL self-care deficit and required assistance with activities of daily living, did not receive timely care and assistance. The resident was heard calling out from his room that he had not received morning care, specifically stating that his urinal had not been emptied since the previous night. As a result, when the resident attempted to use the full urinal while lying down, urine spilled, causing the resident to become wet. The resident reported having to wait until the nurse aide completed lounge duty before being cleaned. Staff interviews confirmed that the nurse aide was unable to provide care sooner because the resident required two staff members for assistance, and the aide was assigned to supervise residents in the lounge area during the relevant time period. The urinal was not emptied until care was provided later in the morning. The unit manager confirmed that the resident did not receive timely incontinence care and that the resident's preferences were not accommodated, which was not in accordance with the facility's policy on providing appropriate support for activities of daily living.
Failure to Notify Physician of Dental Recommendation
Penalty
Summary
A deficiency was identified when staff failed to notify a physician of a dental recommendation for a resident diagnosed with anemia, major depression, anxiety, and abnormal gait and mobility. The resident's dental exam documented extremely inflamed gingivae and recommended the use of Peridex, an antiseptic mouthwash, with instructions for staff to consult the physician regarding its use. Review of the clinical record showed no evidence that the physician was informed of this recommendation. Staff interviews confirmed that the physician had not been notified of the dental recommendation.
Failure to Provide Required Dental Services and Specialist Referral
Penalty
Summary
The facility failed to provide necessary dental services to meet the needs of a resident who required evaluation and treatment by an oral surgeon. The resident reported ongoing dental problems that had not been addressed, specifically stating the need for an oral surgeon's evaluation and x-rays. Clinical record reviews showed repeated dental examinations over several months, each documenting numerous broken teeth and rampant decay, with consistent recommendations for referral to an oral surgeon for radiographic examination and extractions of teeth with poor prognosis. Despite these documented recommendations, there was no evidence in the clinical record that the resident was examined by or scheduled to see an oral surgeon. Interviews with facility staff confirmed that the resident had not been seen by an oral surgeon as recommended by the consulting dentist. The facility's own policy required dental care to be provided through a consultant dentist, yet the necessary follow-up and referral for specialized dental care were not completed. This lack of action resulted in the resident's dental needs remaining unaddressed over an extended period, as evidenced by repeated notations in the clinical record and staff confirmation.
Failure to Ensure Resident Capacity for Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement, as required by its own policy. For one resident with a diagnosis of dementia and a BIMS score of 00, indicating severe cognitive impairment, the facility proceeded with obtaining verbal consent for a binding arbitration agreement. Clinical documentation, including psychological, nursing, and social service notes, consistently described the resident as having significant cognitive deficits, such as confusion, disorientation, impaired memory, and a need for supervision and assistance with decision-making. Despite these documented impairments, the admission director read the arbitration agreement to the resident and recorded a verbal consent, which was then documented as the resident's agreement. The facility's policy required that residents or their representatives be informed of the nature and implications of the agreement and that understanding be verbally acknowledged and documented. However, the evidence in the clinical record indicated that the resident lacked the cognitive capacity to provide informed consent, and there was no indication that a representative was involved in the process.
Lack of Documented Communication with Hospice Agency
Penalty
Summary
The facility failed to ensure documented communication and collaboration with a hospice agency regarding a resident's condition. Review of the clinical record for one resident who was admitted and placed on hospice care revealed no documentation or evidence of the hospice services provided while under their care. Additionally, examination of the hospice communication book did not show any notes or records of the care delivered. During an interview, a licensed nurse stated that other hospice companies typically provide written notes detailing the care given, such as information about the resident's activities, intake, and hygiene, but this particular hospice service did not document such information for the resident.
Failure to Maintain Comfortable Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain a comfortable environment in two of six nursing units, specifically the 3rd floor common room and Unit C. During a facility tour, temperatures in the 3rd floor multipurpose room were recorded at up to 83 degrees Fahrenheit, and the room was described as hot, humid, and uncomfortable. Approximately 22 residents were present in this room, supervised by two nurse aides, and a large portable air conditioning unit was observed in one corner. Additionally, interviews with two residents in Unit C confirmed that they felt hot and uncomfortable, with the air temperature in their room measured at 82 degrees Fahrenheit. These findings were based on direct observations and interviews conducted by facility staff and surveyors.
Resident Neglect During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from neglect during a mechanical lift transfer. According to facility documentation and staff interviews, a nurse aide attempted to transfer a resident using a mechanical lift (hoyer) without the required assistance of a second staff member. During the transfer, one of the sling loops became loose, causing the resident to slide from the lift and make contact with the floor. The resident sustained a large bruise on the left thigh and reported pain in the left elbow and hip area. The resident was subsequently sent to the hospital for evaluation, where no fractures or dislocations were found. The resident involved had multiple medical conditions, including heart failure, hyperlipidemia, hypothyroidism, lymphedema, a high body mass index, bradycardia, anxiety disorder, and mobility abnormalities. Facility records indicated that the resident had ongoing skin assessments, with documentation of bruising on the lower and upper extremities following the incident. However, some sections of the skin assessment forms, such as the type of skin impairment and body diagram, were left incomplete or lacked detailed descriptions immediately after the event. Interviews with nursing staff and the Director of Nursing confirmed that the nurse aide performed the transfer alone, contrary to facility policy and standard practice, which require two staff members for mechanical lift transfers. The incident was witnessed and reported by staff, and the resident and her family were informed. The facility's policies on abuse, neglect, and skin assessment were reviewed, highlighting the expectation for comprehensive assessments and proper use of equipment, which were not followed in this case.
Failure to Maintain Accurate Medical Records for Resident Behaviors and Allegations
Penalty
Summary
The facility failed to maintain medical records according to accepted professional standards for one resident. The facility's policy on charting and documentation requires that all pertinent changes in a resident's condition, reactions to treatments, and behaviors be accurately and completely documented in the clinical record. However, a review of the clinical record for a resident with multiple diagnoses, including Multiple Sclerosis and Acute Respiratory Failure, revealed significant gaps in documentation related to reported inappropriate sexual behaviors and alleged abuse. Multiple staff witness statements described incidents where the resident made inappropriate and offensive remarks, attempted to touch staff, and engaged in other concerning behaviors. These incidents were reported by several licensed nurses and nurse aides, who documented their observations and actions in separate incident witness statements. Despite these detailed accounts, there was no corresponding documentation in the resident's clinical record for an extended period, specifically from November through the following year, regarding the inappropriate sexual behaviors or the actions taken in response. Additionally, the facility's investigation into an allegation of sexual abuse included several staff witness statements that contained information not reflected in the resident's clinical record. The lack of documentation in the clinical record failed to provide a complete account of the resident's care and behaviors, as required by facility policy and regulatory standards. This deficiency was cited under relevant state codes for medical records and nursing services.
Failure to Provide Required Annual In-Service and Abuse Training for Staff
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of annual in-service education, including training in abuse prevention and mechanical lifts, as evidenced by personnel records and staff interviews. Specifically, one nurse aide did not have documentation of completing the required annual in-service hours for two consecutive years and had not received abuse training since March 2024. Additionally, there was no documentation to confirm that this nurse aide was trained or deemed competent in the use of mechanical lifts. Another nurse aide only had half an hour of abuse training documented for the year, with no further evidence of additional required training provided by the facility. Further review of personnel files revealed that two licensed nurses also lacked up-to-date abuse training, with their last documented abuse training occurring in early 2024. The Director of Nursing confirmed that the facility could not provide proof of completion of the required annual in-service education for the nurse aides. These findings indicate a failure to comply with state regulations regarding staff development and personnel policies.
Failure to Maintain Adequate Hand Hygiene Supplies
Penalty
Summary
The facility failed to ensure the availability of disposable paper towels on the second floor, which is a requirement under 42 CFR Part 483, Subpart B, and the 28 PA Code. During a tour of the second floor, it was observed that there were no paper towels in the dispensers in several resident bathrooms, including rooms 235, 212, 255, 217, and the visitor's bathroom across from the nursing station. This lack of supplies is contrary to the facility's hand hygiene policy, which mandates that hand hygiene products and supplies be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Interviews with staff revealed that the issue was known but not promptly addressed. A licensed nurse, identified as Employee E14, reported calling the front desk twice to request housekeeping to replenish the paper towels on the second floor. The facility administrator, Employee E1, confirmed the shortage of paper towels and acknowledged that some dispensers in resident bathrooms and the hall bathroom were empty. This deficiency indicates a failure to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public as required by the regulations.
Plan Of Correction
No Resident were negatively affected by not having adequate supply of paper towels. The facility completed an audit of all resident rooms to identify any areas that did not have paper towels. The Environmental services director was in serviced on the importance of always having adequate supplies in the center. The environmental services department in serviced on ensuring all paper towel dispensers are properly stocked. The Administrator /designee will audit 5 random rooms 3 times per week for 4 weeks then 5 random rooms weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.
Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per resident for two days during the week of December 29, 2024, through January 4, 2025. Specifically, on December 31, 2024, the staffing level was 3.00 hours of direct care per resident, and on January 4, 2025, it was 2.97 hours. This deficiency was identified through a review of nursing staffing schedules and confirmed during an interview with the facility administrator on February 13, 2025.
Plan Of Correction
No residents were negatively impacted by not meeting 3.20 PPD. The facility completed an audit of HPPD for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool. The Administrator re-educated the staffing coordinator on the required HPPD. The Administrator has reviewed staff recruitment and retention initiatives and has communicated those initiatives to the facility recruitment manager. The Administrator / Designee will audit centers HPPD 3 times per week for 4 weeks, then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.
Failure to Investigate Resident's Fracture
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an alleged violation concerning a fracture sustained by a resident. The resident, a female with a BIMS score of 2 and a medical history including dementia, Alzheimer's disease, and unsteadiness on feet, was found with swelling and warmth in her left lower leg. The facility's investigation report, completed on July 3, 2024, did not include a clear mechanism of injury or a specific date of the incident. Progress notes from the facility's provider indicated a closed displaced oblique fracture of the left tibia, with the possible injury date being June 30, 2024. However, there was no documentation of the resident's activities or any incidents that could have led to the fracture. Interviews with staff members who worked during the relevant time frame revealed no concerns or incidents related to the fracture. The resident was transferred using a Hoyer lift, and there were no reports of issues during these transfers. A licensed nurse noted that the resident expressed discomfort when a sock was removed, but this was not further investigated. The facility's investigation lacked statements from activities personnel and documentation related to wheelchair and footrest accommodations. Additionally, there was no evidence of a skin assessment during a shower or bath the resident allegedly received, which could have provided further insight into the cause of the injury.
Deficiencies in Care Plan Development for Residents
Penalty
Summary
The facility failed to ensure that comprehensive, resident-centered care plans were developed for two residents, leading to deficiencies in their care. For one resident with dementia and a neurocognitive disorder with Lewy bodies, no specific care plan was created to address the management and treatment of dementia. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the expectation for such a care plan to be in place for residents with dementia. Another resident, who had a history of cerebral infarction, hemiplegia, and muscle weakness, had an order for a hand splint that was not implemented. Despite the order for the splint to be worn for up to four hours daily, it was not applied due to frequent turnover of physical therapy staff and the resident's history of refusing the splint. The resident's care plan lacked documentation of the splint goals, interventions, or any record of the resident's refusal and subsequent education about the treatment. This oversight was noted in multiple progress notes over several months, indicating a persistent issue in the resident's care management.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to provide adequate supervision during the transfer of a resident, identified as Resident R27, which led to an accident hazard. Resident R27, a female with a BIMS score of 2, had a medical history of dementia, Alzheimer's disease, unsteadiness on feet, unspecified lack of coordination, fatigue, muscle wasting, and atrophy. Her care plan, initiated in April 2021, required two-person assistance and a full mechanical lift for transfers due to her limited mobility and other health conditions. However, during the month of June 2024, she was receiving physical therapy with recommendations for a two-person assist transfer, with a goal of reducing to one-person assistance. On June 29, 2024, a nurse aide, Employee E11, assisted Resident R27 from her wheelchair to bed using a stand pivot transfer without additional assistance, despite the care plan's requirement for two-person assistance. This action was confirmed during a phone interview with Employee E11, who worked the evening shift on that day. Subsequently, on July 1, 2024, Resident R27 was found with swelling and warmth in her left lower leg, indicating a potential injury related to the inadequate supervision and assistance during the transfer.
Incomplete Medical Records for Medication Regimen Reviews
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as identified during a clinical record review and staff interviews. Resident R15, who was admitted with multiple diagnoses including Huntington's disease, cerebral infarction, and major depressive disorder, had medication regimen review (MRR) pharmacy consultant progress notes for six months that only indicated the MRR was completed by a pharmacist. However, there was no documentation indicating whether recommendations were made or not. Similarly, Resident R60, admitted with diagnoses such as adjustment disorder and anxiety disorder, also had MRR notes for the same period that lacked documentation of recommendations or the absence thereof. During an interview with the Director of Nursing, it was revealed that the pharmacy company used by the facility does not document when there are no new recommendations for residents. The Director of Nursing confirmed that for all the residents reviewed, including R15 and R60, there were no recommendations made for the months in question. This lack of documentation violates the accepted professional standards for maintaining medical records, as it does not provide a complete and accurate account of the residents' medication regimen reviews.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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