Milford Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Pennsylvania.
- Location
- 264 Route 6 & 209, Milford, Pennsylvania 18337
- CMS Provider Number
- 395466
- Inspections on file
- 39
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Milford Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility permitted RNs to access and administer IV antibiotics through an implanted port-a-cath for a resident with colon cancer and pneumonia without documented specialized training or demonstrated competency. Policy required additional training and proven competency for personnel accessing implanted venous ports, and state nursing regulations prohibit RNs from engaging in highly specialized practice without adequate knowledge and skills. When staff could not obtain a peripheral IV, a physician authorized use of the resident’s port with a Huber needle, and three RNs documented IV antibiotic administration via the port on the MAR. The facility could not produce any evidence of initial or ongoing competency validation, skills checklists, return demonstrations, or formal education specific to port access, and the DON confirmed that such documentation was not maintained.
Surveyors observed multiple unsanitary practices in the dietary department, including undated and improperly stored food items, cleaning equipment stored among food supplies, and a lack of proper sanitizing procedures for kitchen equipment. Staff demonstrated inadequate knowledge of sanitation protocols, and food service staff handled food containers after improper glove use, all of which increased the risk of food contamination.
A resident with dementia and lactose intolerance did not receive a prescribed enzyme medication with meals on over thirty occasions due to the medication being unavailable for several weeks. The MAR lacked documentation explaining the missed doses, and the DON later notified the physician of the ongoing unavailability.
The facility did not ensure that a licensed pharmacist conducted monthly medication regimen reviews for two residents with diagnoses such as dementia, anxiety, and PTSD, as required by policy. This lapse was confirmed through record review and DON interview, showing missing reviews for two consecutive months.
Surveyors found that the facility failed to discontinue an unnecessary antibiotic for a resident without infection symptoms, did not provide clinical justification for duplicate antidepressant use in another resident, and administered PRN antianxiety medication beyond 14 days without proper documentation or attempted non-pharmacological interventions. The facility also lacked sufficient clinical rationale for the continued use of multiple psychoactive medications.
A resident reported that a staff member failed to administer prescribed Xanax and exhibited unprofessional behavior. The facility did not notify the resident of the grievance resolution within the required timeframe, violating its policy. Additionally, a grievance filed by the resident's daughter lacked documentation of an investigation or communication of the resolution. Interviews confirmed the lack of timely follow-up and documentation.
The facility was found to have improperly disposed of garbage and refuse. During an inspection, it was observed that the dumpster was not fully covered, with one lid open, and food containers and debris were scattered around it. The food service director confirmed that the dumpster lid should be closed and the area kept sanitary.
A resident with dementia and a risk of elopement was given a wanderguard bracelet without specific placement instructions or routine skin checks. The bracelet caused a skin tear on the resident's shin, which worsened due to lack of monitoring. The facility did not assess the bracelet's placement after the injury, leading to further skin damage.
A resident with a Midline catheter experienced dislodgement and removal of the catheter, but the facility failed to promptly notify the attending physician and the resident's representative. The incident was documented on August 12, but the physician was not informed until two days later, and there was no evidence that the resident's representative was notified at all. This lack of timely communication violated the facility's policy and regulatory requirements.
A resident with multiple diagnoses, including congestive heart failure and rheumatoid arthritis, had a skin condition that was not addressed in their care plan. Despite receiving treatment for moisture-associated skin damage (MASD) on the sacrum, the care plan lacked documentation of the condition and specific interventions to prevent recurrence, as confirmed by the DON.
A resident with multiple health issues, including amputations and diabetes, developed a pressure ulcer in the left groin area. The facility failed to accurately assess and manage the wound, leading to discrepancies in wound evaluation and delayed appropriate treatment. The wound care consultant later identified the wound as full-thickness, requiring a change in treatment.
A resident with a urinary tract infection and sepsis did not receive a timely dose of a prescribed IV antibiotic due to a delay in pharmacy delivery. The facility failed to administer the first dose of Ceftazidime as scheduled and did not notify the attending physician of the missed dose, as confirmed by the DON.
A facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. The resident, with end-stage renal disease, had a care plan requiring emergency clamps at the bedside, but none were found during an observation. Interviews with staff confirmed the absence of these supplies, indicating a failure to adhere to the care plan.
A resident with unspecified dementia exhibited suicidal ideations, but the facility failed to update her care plan to address these behavioral health needs. Despite recommendations for continued psychological services, the care plan did not reflect these needs, and social services were not informed of the resident's statements. The NHA could not provide evidence of psychological services being provided.
A resident with a urinary tract infection and sepsis did not receive a timely dose of the prescribed antibiotic, Ceftazidime, due to a delay in delivery from the facility's pharmacy. The medication was scheduled for administration but was unavailable, as confirmed by the DON.
The facility failed to comply with EPA and state requirements for drinking water testing, resulting in violations for not monitoring/reporting routine samples for 30 contaminants. The SOC testing was overdue due to non-payment, with the last tests conducted in 2021. The facility's COO confirmed payments were being made for outstanding balances, but no additional payment was submitted for the required tests.
The facility failed to store food items under sanitary conditions in both the kitchen and resident pantry areas. Observations revealed multiple unlabeled and undated food items in the kitchen's prep cooler and the first-floor nurses' station pantry. On the second floor, dietary staff were observed attempting to date opened items, but several items remained unlabeled and undated. The Dietary Manager confirmed that food and beverage items should be labeled and dated per policy and discarded once expired or beyond their use-by date.
The facility failed to provide physician-ordered nutritional supplements as prescribed to three residents. Observations revealed that supplements were not administered as documented in the MAR, and interviews confirmed inconsistencies in following physician orders.
The facility failed to store and maintain oxygen equipment in a safe, functional, and sanitary manner. Observations revealed improper storage of oxygen cylinders in the medication/pantry area and a designated storage area outside the building, where both empty and full tanks were mixed together. Additionally, the storage area was located near a staff smoking area, posing a safety risk.
The facility failed to ensure adherence to use by/expiration dates of pharmaceutical products in the central supply room. Observations revealed expired Hydrogen Peroxide bottles and IV starter kits. Interviews with the DON and Nursing Home Administrator confirmed that these expired supplies should have been discarded.
The facility failed to provide written notices of facility-initiated transfers to the hospital in a language that was easily understood for three residents. The notices were written in medical terms, which may not be easily understood by the residents and their representatives.
The facility failed to notify a resident's representative of a significant change in condition and the need for a new treatment. The resident, diagnosed with dementia, had a dermatology consult and a biopsy for a cancerous lesion, but the representative was not informed. The DON confirmed this failure.
The facility failed to ensure that licensed nurses accurately administered prescribed medications to a resident. Despite specific instructions to hold Metoprolol Tartrate if the resident's systolic blood pressure was less than 100 or heart rate was less than 60, the medication was administered on multiple occasions when these conditions were not met. The DON confirmed the non-compliance.
The facility failed to provide sufficiently detailed written notices of facility-initiated transfers to the resident and the residents' representative for three residents. The written transfer notices lacked the reason for the transfer and only indicated that the residents needed a higher level of care. The facility did not provide documented evidence of the provision of written transfer notices that identified the reasons for the move in writing and in a language and manner the residents and their representatives understand.
Lack of RN Competency Validation for Implanted Venous Port Access
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by allowing RNs to access and administer IV medications through an implanted venous port without documented specialized training and demonstrated competency. Facility policy on implanted venous port accessing, last reviewed April 23, 2025, required that medical personnel who access or de-access an implanted venous port complete additional training and demonstrate proven clinical competency prior to performing the procedure. Pennsylvania Code Title 49, State Board of Nursing, 21.11(c) states that an RN may not engage in areas of highly specialized practice without adequate knowledge and skills in the practice area involved. Clinical record review showed that one resident, admitted with malignant neoplasm of the colon and with a surgically placed port-a-cath in the upper chest, required IV antibiotics. A nursing progress note documented that staff were unable to establish a peripheral IV, and the physician authorized nursing staff to access the port-a-cath with a Huber needle to administer IV antibiotics. Physician orders directed daily IV Ceftriaxone for five days for pneumonia, and the MAR showed that three RNs administered the IV antibiotic through the implanted port over that period. The facility was unable to provide documentation that these RNs had completed additional training or competency validation specific to accessing an implanted venous port with a Huber needle, including lack of skills checklists, return demonstrations, formal education records, or internal training. The DON confirmed that the facility did not maintain evidence of education, specialized training, or competency validation for RNs administering medications through a port-a-cath.
Deficient Food Storage and Sanitation Practices in Dietary Department
Penalty
Summary
The facility failed to maintain proper food storage and service practices in the dietary department, as evidenced by multiple unsanitary conditions and improper procedures observed during a survey. Open bottles of chocolate and caramel syrup in the cook's reach-in cooler were not dated, and pre-portioned cold cereals in the dry storage room also lacked dates. Gallon jugs of water were stored directly on the floor, and an open package of brown gravy mix was found without an open date. Additionally, a bulk bag of thickener powder was left unsealed with an uncovered ladle resting on top. Cleaning equipment, such as a dirty hand broom and dusters, was stored among food items and pots, and a corroded, dust-laden ceiling fan was present in the dish room. In the janitor's closet, mop buckets with dirty water and mops were stored with brooms placed across the tops, further contributing to unsanitary conditions. During the survey, dietary staff demonstrated a lack of knowledge regarding proper sanitizing procedures for the 3-compartment sink, as litmus strips to test sanitizer strength could not be located and the sanitizer concentration was measured at 0 ppm, indicating no sanitizer was present. Additionally, a server was observed dipping gloved hands into a sanitizer bucket and then handling food containers before changing gloves, which was not in accordance with safe food handling practices. These findings were confirmed by the Nursing Home Administrator, who acknowledged the need for the dietary department to be maintained in a sanitary manner to prevent food contamination and foodborne illness.
Failure to Timely Acquire and Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed medication for one resident. According to the clinical record, a resident with dementia and lactose intolerance was prescribed Lactaid Fast oral tablets to be given with meals. The medication administration record (MAR) showed that the Lactaid was not administered on multiple occasions, specifically thirty-three times between early and late June, with no documented reason for the omissions. The MAR was marked to indicate 'other/see progress note,' but no explanation was found in the clinical record for the missed doses. A nursing progress note later indicated that the DON informed the physician that the Lactaid had been unavailable for several weeks. It was also noted that the resident did not receive milk on meal trays due to their intolerance. Staff interviews confirmed the findings related to the failure to ensure the timely acquisition and administration of the prescribed medication, as required by facility policy and physician orders.
Failure to Complete Required Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews (MRR) for two out of five sampled residents, as required by facility policy and state regulations. The policy, last reviewed in April 2025, mandates that the consultant pharmacist conduct a thorough monthly review of each resident's medical record to identify, report, and resolve medication-related problems, errors, and irregularities. However, a review of clinical records for two residents revealed no evidence that the pharmacist had conducted these reviews for the months of February and March 2025. One resident had diagnoses including dementia and anxiety, while the other had post-traumatic stress disorder (PTSD) and dementia. The absence of documented monthly MRRs for these residents was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the required reviews had not been completed as stipulated by facility policy and regulatory requirements.
Failure to Ensure Residents' Drug Regimens Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications in several instances. For one resident with dementia and chronic kidney disease, an antibiotic (Bactrim DS) was administered for a urinary tract infection despite the absence of urinary symptoms and without laboratory confirmation of infection. The McGreer Criteria Checklist, reviewed by the medical doctor, DON, and infection control preventionist, indicated that the resident did not meet criteria for antibiotic use, yet the resident received twenty doses of the medication without supporting documentation. Another resident with dementia and anxiety was prescribed two antidepressant medications, Trazodone and Remeron, concurrently. The clinical record lacked documentation justifying the use of duplicate antidepressant therapy. The DON confirmed that there was no clinical justification available for this medication regimen. A third resident with PTSD and dementia received an as-needed (PRN) antianxiety medication, Ativan, on multiple occasions over several months. The facility did not limit the PRN order to 14 days as required, nor did it provide documentation of physician assessment or clinical justification for continued use. Additionally, there was no evidence that non-pharmacological interventions were attempted prior to administration of the medication. The consultant pharmacist had recommended a review and possible gradual dose reduction of psychoactive medications, but the physician's response did not provide sufficient clinical rationale for continued use. The facility was unable to provide documentation supporting the ongoing use of multiple psychoactive medications for this resident.
Failure to Resolve Resident Grievances Timely and Adequately
Penalty
Summary
The facility failed to demonstrate timely and adequate efforts to resolve a grievance filed by a resident, which is a violation of the facility's grievance policy. The resident, who was admitted with a history of falls, anxiety, and a need for rehabilitation therapy services, reported that a staff member failed to administer their prescribed Xanax when requested and exhibited unprofessional behavior. The grievance was documented by staff, noting previous complaints about the staff member's behavior, but there was no evidence that the resident was notified of the grievance resolution within the required timeframe. The facility's policy requires that grievances be addressed promptly, with both verbal and written communication of the findings and actions taken within five working days. However, the resident was only verbally notified by phone after discharge, and no written documentation was provided. Additionally, a grievance filed by the resident's daughter regarding concerns about the resident's care lacked documentation of an investigation or communication of the resolution to the family. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, confirmed the lack of timely follow-up and documentation. The facility did not provide evidence of evaluating whether its efforts effectively resolved the grievances, further violating the resident's rights as outlined in the facility's policy and state regulations.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on August 13, 2024. During an inspection at 10:20 AM, it was noted that the facility's dumpster, which contained bags of garbage, was not fully covered, with one of the two lids left open. Additionally, food containers and debris were scattered on the ground surrounding the dumpster. An interview with the food service director confirmed that the dumpster lid should have been kept closed and the area around the dumpster should have been maintained in a sanitary condition.
Failure to Monitor Wanderguard Placement Leads to Resident Injury
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident diagnosed with dementia. The resident was admitted with a risk of elopement, necessitating the use of a wanderguard bracelet. However, the physician's order did not specify the placement of the bracelet or the need for routine skin checks beneath it. An incident report noted a skin tear on the resident's right shin, which later worsened due to swelling and the bracelet digging into the skin. The facility did not assess the appropriateness of the wanderguard's placement after the skin tear was identified, leading to further injury. The lack of monitoring and evaluation of the resident's skin condition where the bracelet was placed resulted in the deterioration of the wound. This deficiency was confirmed through interviews with the Nursing Home Administrator and the Director of Nursing.
Failure to Notify Physician and Representative of Catheter Dislodgement
Penalty
Summary
The facility failed to promptly notify the attending physician and the resident's representative of a significant change in the resident's condition, specifically the dislodgement and removal of a Midline catheter. Resident 115, who had been readmitted to the facility with a urinary tract infection, cerebral infarction, and seizures, had a Midline catheter in place upon readmission. On August 12, 2024, a nurse's note documented that the Midline catheter was dislodged and subsequently removed after leaking was observed around the dressing. However, the physician was not notified of this incident until two days later, as indicated by a late entry nurse's note dated August 14, 2024. Additionally, there was no documented evidence that the resident's representative was informed about the dislodgement and removal of the Midline catheter. An interview with the Director of Nursing confirmed the lack of timely notification to both the physician and the resident's representative. This failure to communicate promptly with the necessary parties is a violation of the facility's policy on notifying changes in a resident's condition, as well as a breach of the regulatory requirements under 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services.
Failure to Address Skin Condition in Care Plan
Penalty
Summary
The facility failed to address a resident's skin condition in the comprehensive care plan, which is a deficiency identified during the survey. Resident 23, who was admitted with diagnoses including congestive heart failure, cerebrovascular accident, and rheumatoid arthritis, had a physician's order to apply Zinc to the buttocks every shift as a skin protectant. Despite this, the care plan did not include the resident's moisture-associated skin damage (MASD) or the specific interventions required to manage and prevent recurrence of the condition. The deficiency was confirmed through a review of clinical records and an interview with the Director of Nursing. The records showed that the resident's sacrum had MASD, which was being treated with Zinc ointment and other interventions such as limiting sitting time and repositioning. However, these treatments and preventative measures were not documented in the resident's care plan, indicating a failure to comprehensively address the resident's skin condition and associated risks.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to consistently provide care and services to prevent the development and/or worsening of pressure sores and promote healing for a resident. The resident, who was admitted with diagnoses including end-stage renal disease, diabetes, and bilateral leg amputations, was identified as being at risk for skin integrity issues. Despite having a care plan in place with interventions such as repositioning and preventative skin care, a wound was discovered in the resident's left groin. The initial assessment of the wound was inaccurate, and there was no evidence that the wound was properly evaluated by the treatment team. Further observations revealed discrepancies in the wound's condition, with the wound being larger and having visible depth compared to initial reports. The wound care consultant later assessed the wound as a full-thickness wound with moderate drainage and recommended a change in treatment. The Director of Nursing confirmed that the facility failed to properly assess the pressure area and implement timely interventions to prevent worsening and promote healing.
Failure to Administer IV Antibiotic Timely
Penalty
Summary
The facility failed to ensure the timely administration of a physician-ordered intravenous antibiotic for a resident, identified as Resident 115, who was readmitted with a Midline Catheter and diagnosed with a urinary tract infection and sepsis. The physician's order, dated August 8, 2024, prescribed Ceftazidime 1000 MG to be administered intravenously twice daily for three days, with the first dose scheduled for 10:00 PM on the same day. However, the Medication Administration Record indicated that the first dose was not administered as prescribed. A nurse's progress note on August 8, 2024, documented that the 10:00 PM dose was missed due to awaiting delivery from the pharmacy. The Director of Nursing confirmed that the facility did not administer the first dose of the IV antibiotic therapy on time and failed to notify the attending physician about the missed dose. This oversight was identified during a review of clinical records, facility policy, and interviews with staff and residents.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis. Resident 6, who was admitted with end-stage renal disease and dependent on renal dialysis, had a care plan that required emergency clamps to be kept at the bedside for the dialysis access site. However, during an observation conducted on August 13, 2024, it was noted that there were no emergency supplies available in the resident's room or on the resident's wheelchair. Interviews with a registered nurse and the Director of Nursing confirmed the absence of the required emergency supplies at the resident's bedside. The Director of Nursing acknowledged that the facility failed to ensure the availability of these supplies, which were part of the care plan for the resident's dialysis access site in case of an emergency. This deficiency was identified for one of the 16 residents sampled during the survey.
Failure to Provide Timely Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident 59, who was admitted with a diagnosis of unspecified dementia. The resident exhibited behaviors including suicidal ideations, which were documented in the clinical record. Despite these documented behaviors, the resident's care plan, initiated on May 18, 2024, did not address these specific behavioral problems or symptoms. A psychological evaluation conducted on June 6, 2024, recommended continued psychological services for the resident, but the care plan was not updated to reflect these needs. On August 13, 2024, a nursing progress note indicated that the resident expressed suicidal thoughts to her daughter. Although the physician was informed, social services and psychological services were not notified of these statements. During an interview on August 15, 2024, the Nursing Home Administrator was unable to provide evidence that the resident was receiving psychological services to maintain her mental and psychosocial well-being. This oversight resulted in a failure to update the resident's care plan to address her mental health needs adequately.
Failure to Provide Timely Antibiotic Administration
Penalty
Summary
The facility failed to provide timely pharmacy services for a resident who was readmitted with diagnoses including a urinary tract infection and sepsis. A physician ordered Ceftazidime, an intravenous antibiotic, to be administered twice daily for three days. The first dose was scheduled for administration on the evening of the same day the order was made. However, the medication was not administered as prescribed because it was not available in the facility. The director of nursing confirmed that the delay was due to the facility's pharmacy not delivering the antibiotic on time.
Failure to Conduct Required Drinking Water Testing
Penalty
Summary
The facility failed to comply with the Environmental Protection Agency (EPA) and Pennsylvania Department of Agriculture and Pennsylvania Drinking Water Information System (PADWIS) requirements, as well as Title 25 Pa. Code Chapter 109 Subchapter C Monitoring Requirements relating to Title 40, Code of Federal regulations 40 CFR. The deficiency was identified through a review of the facility's water testing results and interviews with laboratory and facility staff. The facility received violations for failing to monitor and report routine samples for 30 types of contaminants, resulting in a violation for each contaminant on July 23, 2024. The Certified Water Systems Operator/Laboratory Director revealed that the facility was required to conduct synthetic organic chemical (SOC) testing of their drinking water every three years during the second quarter. However, the SOC testing was not completed because the facility did not submit payment for the tests. The last SOC tests were performed on April 20, 2021, and as of July 26, 2024, the facility was overdue for the required 2024 SOC testing. The facility's Chief Operating Officer confirmed that payments were being made for outstanding balances, but no additional payment was submitted for the required tests, leading to non-compliance with federal, state, and local laws regarding drinking water safety.
Failure to Store Food Items Under Sanitary Conditions
Penalty
Summary
The facility failed to store food items under sanitary conditions in both the kitchen and resident pantry areas on the first and second floors. Observations revealed multiple food items in the kitchen's prep cooler that were not labeled or dated, including containers of mandarin oranges, cupcakes, lemon juice, sandwiches, turkey base, liquid egg whites, sandwich thins, a protein shake, and chopped garlic. Employee 4, a cook/dietary aide, confirmed that these items should have been labeled and dated when first opened, put into use, or received. Additionally, the first-floor nurses' station pantry contained a bag of salad in a shopping bag with no name or date, a Ready Shake with no thaw date, a package of sliced cheese with a resident's name but no date, a half-consumed container of chocolate ice cream with no date, and a box of Hot Pockets that was not kept frozen as per manufacturer directions. Employee 3, the Dietary Manager, confirmed that these items should have been labeled and dated per policy and discarded once expired or beyond their use-by date. On the second floor, dietary staff were observed attempting to date opened items in the refrigerator with a red marking pen. The refrigerator contained two bottles of Boathouse Farms berry juice and a bottle of nectar thick apple juice, all dated with the same date, making it impossible to determine the actual date of opening. Additionally, an opened jar of jam and a container of fresh blueberries were found without labels or dates. Employee 3 confirmed that food and beverage items should be labeled and dated per policy and discarded once expired or beyond their use-by date. The facility's failure to adhere to its food storage policies resulted in unsanitary conditions and potential health risks for the residents.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide physician-ordered nutritional supplementation as prescribed to three out of 11 sampled residents (Residents A4, A5, and A6). For Resident A4, the clinical record showed an order for Ensure to be administered daily at 2:00 PM, with Boost allowed as a substitution. However, during an observation, it was found that the supplements labeled for March 15, 16, and 17 were still in the medication room, despite documentation indicating that the resident had received them on March 15 and 16 and refused them on March 17. Similarly, Resident A5 had an order for Glucerna to be administered at 2:00 PM for weight loss, with Boost Glucose Control as a substitution. Observations revealed that the supplements for March 17, 21, and 22 were still in the medication room, although the MAR indicated that the resident had received them on those dates. Resident A5 also reported inconsistencies in receiving the supplement daily. For Resident A6, an order for Ensure at 2:00 PM with a straw was noted, but a Boost supplement dated March 21 was found in the medication room, despite documentation showing it was provided as ordered on that date. Interviews with the Dietary Manager and the DON confirmed that the physician orders for nutritional supplements were not consistently followed. The Dietary Manager explained that the date on the supplement indicates when it should be consumed, and the presence of these supplements in the medication rooms indicated they were not provided to the residents as ordered. The DON confirmed that staff had documented the provision or refusal of the supplements, which were still observed in the medication rooms, indicating a failure to follow physician orders consistently.
Improper Storage and Maintenance of Oxygen Equipment
Penalty
Summary
The facility failed to store and maintain oxygen equipment in a safe, functional, and sanitary manner on the second floor nursing unit and in the general storage area. During an observation, four oxygen cylinders were found in the medication/pantry area, with two cylinders having regulators attached, indicating they were used or empty. An LPN interviewed at the time was unaware of the proper storage procedures, and an RN confirmed that used oxygen tanks should be taken outside to a designated storage area. However, the RN also mentioned that a few new tanks are stored in the medication/pantry for immediate use if needed. Further inspection of the designated oxygen storage area revealed that it was located outside the building in a caged area near the boiler room and laundry area, which was also a staff smoking area. More than 40 oxygen tanks were stored in this caged area, with both empty and full tanks mixed together, indicating improper segregation of used and clean tanks. The facility's failure to maintain oxygen cylinders in a safe and sanitary manner was evident from the improper storage practices and the proximity of the storage area to a heat source, such as the staff smoking area.
Expired Pharmaceutical Products in Central Supply Room
Penalty
Summary
The facility failed to ensure adherence to use by/expiration dates of pharmaceutical products in the central supply room. Observations revealed 35 bottles of Hydrogen Peroxide and 10 IV starter kits that were expired. An interview with the Director of Nursing confirmed that the expired pharmacy supplies should have been discarded. Additionally, the Nursing Home Administrator confirmed that expired pharmacy products should have been removed from the storage room and discarded.
Failure to Provide Easily Understandable Transfer Notices
Penalty
Summary
The facility failed to provide written notices of facility-initiated transfers to the hospital in a language that was easily understood for three residents. Resident CR1 was transferred to the hospital due to respiratory distress and did not return to the facility. Resident A7 was transferred to the hospital due to tachycardia and hypotension and later returned to the facility. Resident A8 was transferred to the hospital due to respiratory distress and remained in the hospital. The notices of transfer or discharge letters for these residents were written in medical or diagnosis terms, which may not be easily understood by the residents and their representatives. During an interview with the Nursing Home Administrator and Director of Nursing, it was confirmed that the reasons for the residents' transfers were written in medical terms. This failure to provide easily understandable notices was identified as a deficiency under 28 Pa. Code 201.14(a) Responsibility of Licensee.
Failure to Notify Resident's Representative of Significant Change in Condition
Penalty
Summary
The facility failed to timely notify a resident's representative of a significant change in condition and the need to potentially commence a new form of treatment. Resident 1, who was admitted with a diagnosis of dementia and was moderately cognitively impaired, had a dermatology consult ordered for a cancerous lesion on the left side of the face. However, there was no documentation that the resident's representative was informed about this change in condition or the dermatology consult. Further review revealed that the resident had a biopsy completed during a dermatology appointment to rule out cancer, but again, there was no documented evidence that the resident's representative was informed about the appointment or the biopsy. An interview with the Director of Nursing confirmed that the facility failed to notify the resident's representative of these significant changes in the resident's condition.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses accurately administered prescribed medications to one of the sampled residents. Specifically, Resident 4, who was admitted with diagnoses including hypertension, congestive heart disease, and orthopedic aftercare following a left hip fracture, had a physician order for Metoprolol Tartrate 50 mg to be administered twice daily. The order included instructions to hold the medication if the systolic blood pressure was less than 100 or the heart rate was less than 60. However, the medication administration record for February 2024 showed that the medication was administered on multiple occasions despite the resident's heart rate or blood pressure being below the specified thresholds. For instance, on February 6, 2024, the medication was given when the resident's heart rate was 59, and on February 7, 2024, it was administered with a blood pressure of 98/43. Similar non-compliance was noted on February 20, 2024, when the medication was given with a heart rate of 58. An interview with the Director of Nursing on March 5, 2024, confirmed that the facility's licensed nurses did not consistently follow the prescribed instructions for administering the antihypertensive medication to Resident 4. This failure to adhere to the physician's orders and professional standards of nursing conduct, as outlined in the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, resulted in a deficiency in the quality of care provided to the resident.
Failure to Provide Detailed Written Transfer Notices
Penalty
Summary
The facility failed to provide sufficiently detailed written notices of facility-initiated transfers to the resident and the residents' representative for three residents. The clinical records of these residents revealed that they were transferred to the hospital and returned to the facility on different dates. However, the written transfer notices lacked the reason for the transfer and only indicated that the residents needed a higher level of care. During an interview with the Nursing Home Administrator and Director of Nursing, it was confirmed that the facility did not provide documented evidence of the provision of written transfer notices that identified the reasons for the move in writing and in a language and manner the residents and their representatives understand.
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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