Masonic Village At Lafayette Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette Hill, Pennsylvania.
- Location
- 801 Ridge Pike, Lafayette Hill, Pennsylvania 19444
- CMS Provider Number
- 395818
- Inspections on file
- 16
- Latest survey
- July 21, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Masonic Village At Lafayette Hill during CMS and state inspections, most recent first.
Surveyors found that food items in storage areas were not consistently labeled, dated, or discarded according to facility policy, with multiple items in the freezer, refrigerator, and dry storage either expired, unlabeled, or uncovered. An unattended tray of produce was also observed outside the dining kitchen.
The facility did not ensure the grievance process was visibly posted or understandable to residents, and grievance forms were not readily available. Multiple alert and oriented residents were unaware of how to file a grievance, and the posted procedure lacked a contact name and was not accessible to wheelchair users. Leadership confirmed the absence of postings and forms in common areas.
A resident who was transferred to the hospital after a fall did not receive written notice of the facility's bed-hold policy or the reason for the transfer in a language and manner understood by the resident and their representative. Staff confirmed that these notifications were not provided and that no system was in place to ensure this requirement was met.
A resident and their representative were not provided with a written summary of the baseline care plan, including physician orders, dietary orders, and social service goals, within 48 hours of admission. Review of records and staff interviews confirmed the absence of documentation showing that the required information was given.
A cognitively impaired resident with a history of using razors unsupervised was found with multiple razors accessible in her room, resulting in a skin abrasion after self-shaving. Despite the resident's known cognitive deficits and prior incident, staff observed razors in her wheelchair and bathroom, and an electric razor on the counter, indicating the environment was not kept free from accident hazards.
A resident with multiple medical conditions experienced significant weight loss, and the facility did not obtain a timely re-weight to confirm the loss as required by policy. The delay in re-weighing meant that necessary interventions to address the resident's nutritional status were not implemented promptly.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
A resident receiving hemodialysis through a left arm AV fistula was not consistently monitored or assessed for complications as required by facility policy and care plan. There was no documentation of regular checks for bruit and thrill, nor was there a physician order for these assessments, as confirmed by the Infection Control Nurse.
A nurse left six medications unattended in a resident's room while retrieving the resident, with another resident present in the room. Additionally, two opened bottles of medication on a medication cart were not labeled with open dates, contrary to facility policy. Both the nurse and DON confirmed the labeling deficiency.
Dietary staff served hot soup to residents at temperatures above facility policy and safe guidelines, failing to check or allow the soup to cool before serving. Some residents, including those with cognitive and visual impairments, received the hot soup, and several alert residents reported the soup was too hot to consume immediately.
A resident with a history of falls and left-sided weakness fell after being left unassisted by a nurse and a friend while attempting to adjust a wheelchair seatbelt. The resident required hands-on assistance due to impulsivity and poor balance, which was not provided, leading to the fall.
A facility failed to store and label medications properly in a second-floor medication room. An unlocked refrigerator contained vaccines, insulin, and lorazepam, with some boxes unsecured and lacking proper labeling. Staff interviews confirmed that narcotics should be locked, but the facility did not adhere to this policy.
The facility failed to follow infection control practices during medication administration and enhanced barrier precautions. An LPN did not perform hand hygiene between administering medications to two residents. Additionally, two nursing assistants did not wear gowns while providing care to a resident under enhanced barrier precautions, despite the requirement. The facility's policies on infection prevention and control were not adhered to, leading to these deficiencies.
A facility failed to adhere to infection control practices for droplet precautions, as staff entered a resident's room without proper PPE. Despite signage and available PPE, a phlebotomist and a nurse practitioner did not follow the required protocols. The resident was on isolation due to respiratory issues, and the facility could not prove that staff were informed of the precautions, leading to a deficiency in infection control.
Failure to Properly Label, Date, and Discard Food Items
Penalty
Summary
The facility failed to ensure that food stored in the refrigerator, freezer, and dry storage areas was labeled, dated, and stored according to professional food service safety standards and the facility's own policies. During an inspection of the Food Service Department, multiple items were found in the walk-in freezer and refrigerator that were either opened and not labeled, not covered, or past their expiration dates. Specific examples included opened chicken nuggets, pureed and regular steak, beef burgers, and frozen bisques in the freezer, as well as opened cauliflower, celery, carrots, cheese, coleslaw, and chopped tomatoes in the refrigerator, many of which were not labeled or had expired. In the refrigerator for premade items, chicken salad, turkey cold cuts, ham, imitation crab meat, and defrosted turkey were found to be expired, and some baked goods were not labeled. In the dry storage area, opened rice, bowtie pasta, and dye/frosting food coloring were not labeled, while Israeli couscous, cooked apples, and sprinkles were found to be expired. Additionally, whipping cream was not labeled. An unattended rolling tray with full-sized romaine lettuce and cucumbers was also found outside the dining kitchen. These findings indicate that the facility did not follow its own policies regarding the labeling, dating, and rotation of food items, nor did it ensure that expired or potentially unsafe food was discarded in a timely manner.
Failure to Post and Provide Accessible Grievance Process and Forms
Penalty
Summary
The facility failed to ensure that the grievance process was clearly posted in a location visible and understandable to residents, and that grievance forms were readily available for residents to complete. During a Resident Council meeting, seven alert and oriented residents reported being unaware of how to file a grievance if they had a concern. One resident stated she would speak to the receptionist, indicating a lack of knowledge about the formal grievance procedure. An interview with the Administrator confirmed that they served as the grievance officer, but there was no posting in the building to communicate this to residents. Observations with facility leadership confirmed that no information related to grievance forms or a contact person for grievances was available in the areas where information is typically posted. There was also no dedicated place for residents to confidentially pick up a grievance form, and the general grievance procedure that was posted lacked a contact name and was not accessible to residents in wheelchairs.
Failure to Provide Written Bed-Hold Policy and Transfer Reason at Hospitalization
Penalty
Summary
A review of the clinical record and staff interviews revealed that the facility failed to provide a resident and their representative with written notice of the facility's bed-hold policy at the time of a facility-initiated transfer to the hospital. Specifically, after the resident experienced a fall and was transferred to the emergency room for evaluation, there was no documented evidence that the required written notice regarding the bed-hold policy—including information about the duration of the bed-hold, bed hold reserve payment, and the right to return to a bed at the facility—was given to the resident or their representative. Additionally, the clinical record lacked documentation that the resident and their representative were provided with the reason for the transfer in writing and in a language and manner they could understand. An interview with the social worker confirmed that these notifications were not provided and that there was no system in place to ensure compliance with these requirements at the time of a facility-initiated transfer.
Failure to Provide Baseline Care Plan Summary Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to a resident and/or the resident's representative within 48 hours of admission. Review of the clinical record showed that the resident was admitted on May 30, 2025, but there was no documented evidence that the baseline care plan, including physician orders, dietary orders, and social service goals, was given to the resident or their representative. The resident's representative confirmed in an interview that they did not receive a copy of the baseline care plan after admission. Further requests for documentation from facility staff, including the Infection Control Nurse and the Director of Nursing, did not yield any evidence that the required summary was provided.
Failure to Prevent Accident Hazards for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with multiple diagnoses, including dementia, encephalopathy, and depression, was found to have unsupervised access to razors in her room. The resident had a documented history of using her husband's razor without supervision, which resulted in a skin abrasion on her left jaw. Clinical records and nursing notes confirmed that the resident admitted to using the razor and sustained an abrasion as a result. The facility's incident report corroborated these findings. During a subsequent observation, a blue razor without a protective top was found in the resident's wheelchair, and another blue razor was discovered in the bathroom cabinet. An electric razor belonging to the resident's husband was also observed plugged in on the bathroom counter. A licensed nurse removed the razors from the room and informed the resident that she should not have them. The facility failed to ensure that the resident's environment was free from accident hazards, as required by regulations, by allowing a cognitively impaired resident unsupervised access to razors.
Delayed Re-Weight Following Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident's weights were completed in a timely manner, as required for monitoring nutritional status and care planning. A resident with multiple diagnoses, including dysphagia, cerebral infarction, hypertension, diabetes, glaucoma, and dementia, experienced a significant weight loss of 8.4 pounds, or 6.3%, over the course of one month. The initial weight loss was identified when a weight was recorded, but the facility did not obtain a re-weight promptly to confirm the loss and address any related issues. According to the facility's policy, re-weights should be obtained within 7 days of the previous weight when significant weight loss is suspected. However, in this case, the re-weight was not completed until 6 days after the initial suspected weight loss, confirming the significant loss. This delay in obtaining a timely re-weight meant that interventions or services to address the resident's nutritional status were not implemented as quickly as required by policy.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Monitor and Document Dialysis Access Site Care
Penalty
Summary
The facility failed to consistently monitor and document the care of a resident receiving hemodialysis through a left arm arteriovenous (AV) fistula. According to the facility's policy, licensed nurses are required to maintain the patency of the access area, monitor for signs of infection or complications, and check for bruit and thrill every shift, documenting these assessments in the resident's electronic health record. The care plan for the resident also specified the need to assess for bruit and thrill and monitor for symptoms such as pain, numbness, redness, swelling, warmth, exudate, and tenderness at the fistula site. However, a review of the resident's clinical and treatment administration records revealed no documented evidence that these required assessments were being performed consistently. Additionally, there was no physician order in place for staff to check bruit and thrill or to assess the AV fistula site. This was confirmed by the Infection Control Nurse, who stated that staff were expected to complete and document these checks every shift, but this was not being done for the resident in question.
Failure to Properly Label and Secure Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were properly labeled and stored according to accepted professional standards. During medication administration, a licensed nurse prepared medications for a resident and left them unattended on a tray inside the resident's room while retrieving the resident, leaving both the medications and the resident's roommate unsupervised in the room. This resulted in six medications being left unattended for approximately one minute. Additionally, inspection of the Wisteria medication cart revealed two opened bottles of medication, Fluticasone Propionate and Salmeterol, that were not labeled with the date they were opened. One bottle was marked with an arrival date that exceeded the facility's 30-day discard policy, while the other was still within the acceptable timeframe. Both the nurse and the Director of Nursing confirmed that the bottles were not labeled with open dates, as required by facility policy.
Hot Liquids Served Above Safe Temperatures
Penalty
Summary
During a lunch meal observation, dietary staff served hot pea soup to residents at temperatures exceeding the facility's policy and stated safe serving guidelines. The facility's policy required hot liquids to be served below 150°F, and the Dietary Director confirmed the preferred serving temperature was 140°F or below. However, the soup was measured at 159°F when served. Dietary aides were observed pouring and serving the soup directly to residents without allowing it to cool or checking the temperature, despite being trained to do so. One aide admitted to not checking the temperature due to being preoccupied, and another only checked after being prompted by the Dietary Director. Training on serving hot liquids had not been provided to one aide for two years. Multiple residents, including those who were not alert and oriented and one who was legally blind, received the hot soup. During a Resident Council meeting, several alert and oriented residents reported that the soup was very hot, with some needing to wait for it to cool or using ice cubes to lower the temperature. The Dietary Director later confirmed that hot liquids were not served at the preferred temperatures, in violation of facility policy and state regulations.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance, resulting in a fall for Resident R16, who was at risk for falls due to a cerebrovascular accident with left-sided weakness and a history of falls. The resident's care plan included the use of a seatbelt on the wheelchair due to poor trunk control and spasticity. On the day of the incident, a licensed nurse, Employee E9, noticed that the resident's seatbelt was not fastened and asked the resident to stand up to adjust it. The resident stood up with the aid of a stand-up walker but was left unassisted when the nurse and the resident's friend attempted to retrieve the stuck seatbelt, leading to the resident falling sideways and hitting his head on the wall. Interviews with facility staff confirmed that Resident R16 was not safe to stand unassisted, as the resident was impulsive and required hands-on contact guard assistance. The Director of Therapy, Employee E10, confirmed the resident's need for assistance, while the Director of Nursing, Employee E2, stated that having the resident's friend assist was inappropriate as the friend was not trained by the facility. This lack of proper supervision and assistance directly contributed to the resident's fall.
Failure to Secure and Label Medications Properly
Penalty
Summary
The facility failed to store and label drugs according to professional standards of practice in the medication room on the second floor. During an observation, it was found that the medication refrigerator, which was supposed to be locked at all times, was unlocked. This refrigerator contained vaccines, insulin, and other medications requiring low temperatures, including four boxes of lorazepam. One box was labeled with a resident's name and dosage information, while another was in a see-through locked box without a resident name or prescription. Two unopened boxes of lorazepam were found unsecured on a shelf, accessible to anyone in the medication room. Interviews with staff revealed that the box with the resident's name was recorded in the narcotic book on the medication cart, while the other boxes were considered pharmacy extras. According to the licensed nurse, all narcotics in the medication refrigerator should be in a locked box, with access to the key controlled through the pyxis system by a supervisor. The Director of Nursing confirmed that the lorazepam boxes should have been secured in a locked box, indicating a failure to adhere to the facility's medication storage policy.
Infection Control Deficiencies in Medication Administration and Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration and while implementing enhanced barrier precautions. During an observation, a licensed nurse, Employee E8, was seen administering medication to two residents in the hallway without performing hand hygiene between the residents. Despite the presence of a hand sanitizer on the wall, Employee E8 did not use it and later denied the observation when questioned by the Director of Nursing. Additionally, the facility did not follow enhanced barrier precautions for a resident under such precautions. Resident R5, who had a urinary catheter and required maximal assistance for activities of daily living, was observed receiving care from two nursing assistants, Employees E6 and E5, who wore gloves but did not don gowns as required. The sign indicating enhanced barrier precautions was mistakenly left on the door, according to Employee E5, but the Infection Preventionist confirmed that the resident was indeed under these precautions. The facility's policies on infection prevention and control, hand hygiene, and infection transmission prevention were not followed, leading to these deficiencies. The failure to perform hand hygiene and to use appropriate personal protective equipment during care activities for residents under enhanced barrier precautions were the main issues identified during the survey.
Inadequate Infection Control Practices for Droplet Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices, specifically regarding droplet precautions, for a resident identified as R1. The facility's policy on infection transmission prevention and interventions was not adequately followed, as evidenced by observations of staff entering Resident R1's room without appropriate personal protective equipment (PPE). Despite signage indicating droplet precautions and the availability of PPE outside the resident's room, a contracted phlebotomist and a nurse practitioner entered the room without wearing the necessary protective gear. Resident R1, who was admitted with multiple diagnoses including acute respiratory failure and cognitive communication deficit, was placed on isolation and droplet precautions due to wheezing and the possibility of infection. During the observations, it was noted that the phlebotomist initially entered the room with only a mask and later had to search for additional PPE. The nurse practitioner entered the room without any PPE, citing unawareness of the droplet precautions. These actions were contrary to the facility's infection control policy, which mandates the use of masks, face shields, and gloves for staff entering rooms under droplet precautions. Interviews with the Director of Nursing and other staff confirmed that all personnel should adhere to PPE protocols when entering rooms with droplet precautions. However, the facility could not provide evidence that the nurse practitioner and phlebotomist were informed of Resident R1's precautionary status before their contact with the resident. This oversight contributed to the deficiency in maintaining a safe and sanitary environment to prevent the transmission of communicable diseases.
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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