Montgomery Subacute And Respiratory Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Plymouth Meeting, Pennsylvania.
- Location
- 251 Stenton Avenue, Plymouth Meeting, Pennsylvania 19462
- CMS Provider Number
- 395847
- Inspections on file
- 19
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Montgomery Subacute And Respiratory Center during CMS and state inspections, most recent first.
The facility failed to maintain safe, comfortable room temperatures as required by its policy, with multiple rooms on three units measuring below the 71°F minimum despite thermostats being set higher. Several residents reported feeling cold, including one who said the room was especially cold at night and another who described temperature fluctuations and weekend coldness, while a resident with significant respiratory and neurological conditions was in a room measured in the mid-60s. One resident with moderate cognitive function reported being cold and requested more warmth, and her family member noted the resident’s arm felt cold on some days. Maintenance air temperature logs for key winter months were found to be copied from a prior year rather than reflecting actual monitoring, and leadership confirmed there was no oversight of air temperature logs and that only the maintenance director, on call after hours, had access to thermostat keys, even as some thermostats were centrally located and previously accessible to visitors.
Two residents received PRN psychotropic medications without documented diagnoses for the conditions being treated, and the orders were not limited to 14 days or supported by clinical rationale for continued use, contrary to facility policy.
Staff administered pain medication to two residents with chronic conditions at pain levels below those specified in physician orders. The DON confirmed that pain medications were given outside the prescribed parameters.
The facility did not ensure that physician responses to pharmacist-identified medication regimen irregularities were documented for two residents. In one case, repeated pharmacist recommendations to evaluate and discontinue a zinc supplement were not reviewed or addressed by a physician. In another case, although a physician agreed to obtain a Valproic acid level for a resident on Depakote, there was no evidence that the lab was ordered or completed.
A resident with a prosthetic joint infection did not receive prescribed Bactrim therapy as ordered after admission, due to staff failing to review the full hospital discharge summary and only following the medication list. This resulted in the resident missing several days of antibiotic treatment until the error was identified after family inquiry.
A facility failed to protect residents from narcotic diversion, with discrepancies in narcotic counts and MARs for five residents prescribed Oxycodone. The DON confirmed missing tablets during shifts of a specific nurse, indicating misappropriation linked to staff actions.
A resident's skin impairment was not promptly reported to their physician or representative. The injury was first observed by a nurse aide and reported to an LPN, who did not act on it. The following day, another aide noticed the injury but did not report it. The resident's wife later discovered the injury, leading to a delayed notification and transfer to the Emergency Department.
The facility failed to provide required advance notice of Medicare non-coverage to three residents discharged with benefit days remaining. The facility's policy mandates issuing a Skilled Nursing Facility Advance Beneficiary Notice and a Notice of Medicare Non-Coverage, but these were not provided. Staff interviews revealed a lack of awareness about the requirement, resulting in the oversight.
The facility did not provide residents access to grievance information on two nursing units. Residents were unaware of the grievance process and how to file grievances, including anonymously. An observation revealed no grievance forms or instructions were available on the First floor Stenton unit and the Second-floor nursing unit.
The facility failed to evaluate the need for restraints and obtain informed consent for two residents. Despite having a policy requiring assessment and consent, the facility did not conduct evaluations or secure consent for the use of hand mitts on residents with medical conditions. The DON confirmed these deficiencies.
A facility failed to conduct a thorough investigation of a resident's forehead injury, as required by its policy. The injury was first noticed by the resident's wife, and although the resident was assessed and sent to the ED, the investigation did not include statements from all relevant staff, including respiratory therapists. Staff interviews revealed inconsistencies in reporting the injury, and the exact cause was not determined.
A resident with contractures in both upper and lower extremities did not receive appropriate care to maintain or improve range of motion. Despite having a care plan with specific interventions, including passive range of motion exercises and splints, there was no evidence of implementation. The DON confirmed the absence of necessary interventions for positioning, leading to a deficiency.
The facility failed to document the date of insertion or dressing change on IV dressings for three residents, as required by their policy. Observations showed that a resident with a mid-line IV catheter in the left arm, another with a mid-line IV catheter in the left arm, and a third with an IV catheter in the right arm all lacked proper documentation. An LPN confirmed the absence of dressing dates, acknowledging that staff should date the IV catheter insertion or dressing change.
A resident with a complex medical history did not receive pain management before wound care, despite having orders for pain medications. During the procedure, the resident showed signs of pain, but staff did not assess or address it, continuing the treatment without administering pain relief. This failure to follow the facility's pain management policy resulted in inadequate care.
The facility failed to provide timely pharmaceutical services for three residents, resulting in delayed administration of prescribed medications. A resident with a urinary tract infection and another with fever did not receive Macrobid as scheduled due to unavailability. Additionally, a resident on intravenous Zosyn for a sputum infection experienced a delay in medication administration due to pharmacy unavailability.
The facility failed to timely implement pharmacist recommendations for two residents. One resident continued receiving hydroxyzine for depression despite recommendations to discontinue it, while another was on Aripiprazole without an appropriate diagnosis. The DON confirmed these delays.
The facility failed to comply with regulations for PRN psychotropic medications for two residents. One resident was prescribed Xanax with an indefinite stop date, lacking required documentation for continuation beyond 14 days. Another resident was given Seroquel without an approved diagnosis, and despite a recommendation for a psych consult, the facility did not implement it.
A facility failed to store and label drugs according to professional standards. During an observation, an employee was seen removing Clonazepam from a narcotic box, crushing it with other pills, and leaving it unattended on a medication cart. This violated the facility's policy, which requires medication carts to be locked when out of sight. The incident involved a resident with a prescription for Clonazepam for anxiety.
The facility failed to meet food service safety standards, with dishwashing temperatures below required levels, expired and unlabeled food in storage, and inadequate cleaning and monitoring of kitchen equipment. A resident with a tracheostomy and moderate cognitive impairment had a refrigerator in their room with unlabeled food and no temperature monitoring.
A facility failed to follow infection control procedures during medication administration for two residents. An employee did not disinfect a nasal spray applicator between nostrils and neglected hand hygiene before and after resident contact, violating facility policies.
The facility did not post the required contact information for the Pennsylvania Department of Health and the State Long-Term Care Ombudsman program on the first floor B unit. During a resident council meeting, several residents were unaware of where to find this information. Observations confirmed the absence of postings on the bulletin board, and the English version of the Ombudsman contact was inaccessible behind the nursing station. A Regional Nurse confirmed these findings.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe, comfortable room temperatures within its own policy range of 71°F to 81°F across three nursing units. The facility’s “Homelike Environment” policy, revised February 11, 2026, requires comfortable and safe temperatures within that range. During a tour of the units, multiple resident rooms were found below the policy minimum despite thermostats being set within the acceptable range. One room measured 69.6°F with large windows near the bed, another measured 66°F with the thermostat at 73°F, and additional rooms were recorded at 66.7°F, 62.9°F, 69.2°F, and 67.4°F, some with baseboard heat or PTAC units and one with a window air conditioning unit still installed. Several residents reported being cold or experiencing fluctuating temperatures. One cognitively intact resident stated the room gets cold, especially at night. Another resident, who preferred a “middle” temperature and kept a window slightly open due to temperature fluctuations, reported that the room sometimes became too cold, particularly on weekends. A resident with a BIMS score of 12 stated she was cold at the time of observation, requested another blanket, and asked for the heat to be turned up; her daughter reported that on some days the resident’s arm felt cold to the touch. One resident with significant medical diagnoses, including chronic respiratory failure with hypoxia, acute respiratory failure, tachycardia, dysphagia, and convulsions, was in a room measured at 66.7°F and could not be interviewed due to cognitive status. The deficiency was further supported by the lack of consistent air temperature monitoring and oversight. The Nursing Home Administrator and DON could not identify recent air temperature logs and confirmed there was no oversight of maintenance air temperature logs for several winter months. The maintenance director admitted that logs for November and December 2025 had been copied from 2024 and that actual air temperature monitoring only began in January after a complaint, with the electronic system set for checks only once a week. It was also noted that some thermostats on one wing were centrally located and accessible to visitors, prompting the purchase of locked covers, and that only the maintenance director had the key to adjust these thermostats, including during evenings and overnights, when he would have to be called in if residents were cold. These conditions occurred during a period that included multiple very cold days in January and February in the facility’s geographic area.
Failure to Ensure Proper Use and Documentation of PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications, as evidenced by the clinical records of two residents. For one resident with chronic respiratory failure, multiple sclerosis, and cognitive communication deficit, there was a physician's order for PRN Clonazepam to be administered for anxiety/insomnia, but there was no documented diagnosis of anxiety or insomnia in the clinical record. Additionally, the PRN order for Clonazepam was set with an indefinite stop date, contrary to facility policy requiring PRN psychotropic medications to be limited to 14 days unless a clinical rationale for extension is documented. Another resident with chronic respiratory failure, anoxic brain damage, and dysphagia had a physician's order for PRN Ativan to be given for teeth grinding, but there was no documented diagnosis of teeth grinding in the clinical record. This PRN order for Ativan also had an indefinite stop date. The facility did not ensure that psychotropic medications were used to treat a specific, documented condition and did not comply with the policy limiting PRN psychotropic medication orders to 14 days or requiring documentation of rationale for continued use.
Pain Medication Administered Outside Physician Order Parameters
Penalty
Summary
Facility staff failed to administer pain medication in accordance with physician orders for two residents. For one resident with chronic respiratory failure, anoxic brain damage, and pain, the physician ordered Oxycodone 2.5 mg every 8 hours as needed for moderate to severe pain, specifically for pain levels of 7-10. However, medication administration records showed that Oxycodone was given multiple times for pain levels of 5 and 6, which were below the ordered threshold. Another resident with chronic respiratory failure, cerebral infarction, and pain had a physician order for Oxycodone-Acetaminophen 5-325 mg, 2 tablets every 6 hours as needed for severe pain, specifically for pain levels of 6-10. Despite this, records indicated that the medication was administered for pain levels of 4 and 5. The DON confirmed that staff administered pain medication outside the parameters of the physician's orders for both residents.
Failure to Document Physician Response to Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that physician documentation was completed in response to pharmacist-identified medication regimen irregularities for two residents. For one resident with multiple diagnoses including diabetes, anemia, hypotension, quadriplegia, and seizure disorder, the pharmacist recommended evaluating and potentially discontinuing a zinc supplement due to possible adverse effects. This recommendation was made on three separate occasions, but there was no evidence that a physician reviewed, signed, or dated the recommendation, nor was there documentation of any action taken regarding the zinc supplement. For another resident with seizure disorder, anxiety, and depression, the pharmacist recommended obtaining a Valproic acid level to monitor Depakote therapy, as no such lab result was present in the clinical record. Although the physician signed and agreed with the pharmacist's recommendation, there was no documentation that the lab was ordered or completed. These findings indicate that the facility did not follow its policy requiring physician review and documentation of actions taken in response to pharmacist recommendations.
Failure to Verify and Administer Discharge Antibiotic Orders
Penalty
Summary
A deficiency occurred when a resident with a history of infection and inflammatory reaction due to an internal joint prosthesis, as well as respiratory failure, did not receive antibiotic treatment as ordered upon admission. The resident was discharged from the hospital with instructions to continue Bactrim (Sulfamethoxazole-Trimethoprim) twice daily for life as suppressive therapy for a prosthetic joint infection. However, upon review of the facility's records, it was found that the facility only followed the medication list and did not review the full hospital discharge summary, which contained the long-term antibiotic order. As a result, the resident missed four days (eight doses) of the prescribed antibiotic, as the order for continued Bactrim was not implemented until the resident's family raised concerns about the missed medication. The facility's staff did not verify the full discharge summary and only acted after the family questioned the antibiotic regimen, leading to a delay in the resident receiving the necessary medication as per professional standards of practice.
Narcotic Diversion and Misappropriation in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically the diversion of narcotic medications. This deficiency was identified for five residents who were prescribed narcotic medications, including Oxycodone. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention was not effectively implemented, as evidenced by discrepancies in the narcotic count and medication administration records (MAR) for these residents. For Resident R18, there were multiple instances where Oxycodone tablets were removed from the narcotic count, but there was no documented evidence in the MAR that the medication was administered to the resident. Similar discrepancies were found for Residents R21, R29, R49, and R165, where tablets were removed without corresponding documentation of administration. The narcotic accountability records showed scribbled-over dates and counts, indicating potential tampering or mismanagement. An interview with the Director of Nursing confirmed the missing Oxycodone tablets and revealed that the discrepancies occurred during shifts when a particular nurse was on duty. This suggests a pattern of misappropriation linked to specific staff actions, highlighting a significant breach in the facility's responsibility to safeguard residents' medications and ensure accurate record-keeping.
Failure to Notify of Skin Impairment
Penalty
Summary
The facility failed to promptly notify a resident's representative and physician of a skin impairment for one of the residents reviewed. The deficiency involved a resident who had a skin tear on the forehead, which was first observed by a nurse aide during the night shift. The nurse aide reported the injury to a Licensed Practical Nurse (LPN), who did not take further action as he was not assigned to the resident and assumed the aide would inform the resident's nurse. The following day, another nurse aide noticed the injury but did not report it to the nurse or supervisor. Consequently, there was no documented evidence that the resident's physician or responsible party was notified of the skin impairment when it was first observed. The resident's wife discovered the injury and reported it to the Life Enrichment Director and Director of Nursing, who then assessed the skin tear and contacted the resident's physician. The physician ordered the resident to be transferred to the Emergency Department for evaluation and treatment. The facility's investigation revealed that the injury was not documented or communicated to the appropriate parties in a timely manner, as required by the facility's policy on changes in a resident's condition or status. Interviews with staff confirmed the lack of documentation and notification regarding the resident's skin impairment.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the required advance notice through a Notice of Medicare Non-Coverage related to the termination of Medicare services for three residents. The facility's policy on Medicare Advance Beneficiary and Medicare Non-coverage Notices requires that residents be informed in advance when changes will occur to their bills. Specifically, the policy mandates that a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) be issued when the facility believes Medicare will not pay for certain services, and a Notice of Medicare Non-Coverage be issued at least two days before benefits end. However, the facility did not issue these notices to the residents or their representatives. The deficiency was identified through a review of clinical records and facility documentation, as well as interviews with staff. It was found that three residents were discharged from a Medicare-covered Part A stay with benefit days remaining, yet they did not receive the required notification of termination of services. An interview with the Regional Administrator confirmed that the business office was unaware of the requirement to send a notice of Medicare non-coverage to residents or their families, leading to the oversight.
Lack of Access to Grievance Information
Penalty
Summary
The facility failed to provide residents access to grievance information on two out of three nursing units, specifically the 2nd floor and the First floor Stenton unit. A review of the facility's undated policy on grievances indicated that residents and their representatives have the right to file grievances orally or in writing, including anonymously. However, during a resident council group meeting, seven alert and oriented residents reported being unaware of the grievance process and how to file grievances, including anonymously. An interview and observation with a Regional Nurse revealed that there were no grievance forms or instructions available on both sides of the First floor Stenton unit and the Second-floor nursing unit, preventing residents from filing grievances, including anonymously.
Failure to Evaluate and Obtain Consent for Restraint Use
Penalty
Summary
The facility failed to ensure proper evaluation and obtain informed consent for the use of physical restraints on two residents. The facility's policy, revised in April 2017, mandates that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully. Restraints must be used to treat medical symptoms and not for discipline, staff convenience, or fall prevention. The policy also requires a pre-restraining assessment to determine the need for restraints and to explore less restrictive interventions. However, the facility did not conduct these evaluations or obtain informed consent for Residents R22 and R56. Resident R22, admitted with a diagnosis of injuries from a motor vehicle accident and diffuse brain injury, was observed using a hand mitt without evidence of evaluation for the need and use of restraints or informed consent. Similarly, Resident R56 had a physician order for bilateral soft hand mitts to prevent dislodging tubes and trach, but there was no documentation of evaluation or informed consent. The Director of Nursing confirmed the lack of evaluation and informed consent for both residents, violating the facility's policy and state regulations.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an alleged violation involving an unknown source of injury for a resident. The facility's policy requires all reports of resident abuse, neglect, exploitation, or injuries of unknown origin to be thoroughly investigated and documented. However, in this case, the investigation was incomplete as it did not include statements or interviews from all relevant staff members who provided care to the resident prior to the injury or those who worked on the unit, including respiratory therapists. The incident involved a resident who was found with a bump and a cut on the forehead, which was first noticed by the resident's wife. The facility's investigation revealed that the injury was reported to the Life Enrichment Director and the Director of Nursing, who assessed the resident and arranged for a transfer to the Emergency Department. Despite these actions, the investigation did not identify the exact cause of the injury, and the facility speculated that it might have been caused by a brace the resident was wearing. Interviews with staff revealed inconsistencies in the reporting and observation of the injury. A nurse aide reported the injury to an LPN, who did not follow up as he was not assigned to the resident. Another nurse aide noticed the injury but did not report it. The facility's investigation lacked comprehensive interviews with all staff involved, which was confirmed by the administrator, indicating a failure to adhere to the facility's policy for thorough investigations.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, leading to a deficiency in maintaining or improving the resident's condition. The resident, identified as having contractures in both upper and lower extremities, was observed seated in a Geri-chair without proper body alignment and was not wearing any splints or braces. Despite having a care plan that included interventions such as passive range of motion exercises and the use of splints, there was no evidence that these interventions were implemented. The care plan for the resident, dated February 14, 2027, outlined specific interventions, including the use of a left resting hand splint, bilateral elbow and knee splints, and positioning aids to prevent further decline in range of motion. However, a review of the resident's active physician orders and treatment documentation revealed no established splint schedule or implementation of the prescribed interventions. The Director of Nursing confirmed the lack of interventions for the resident's head, neck, and extremity positioning, which contributed to the deficiency.
Failure to Document IV Dressing Changes
Penalty
Summary
The facility failed to provide adequate treatment and care for intravenous catheter (IV) lines in accordance with professional standards of practice for three residents. The facility's policy on Peripheral and Midline IV Dressing Changes, dated March 2022, outlines specific procedures to prevent complications associated with intravenous therapy, including catheter-related infections. Key steps include assembling equipment, performing hand antisepsis, removing old dressings, cleaning the insertion site, and labeling the new dressing with the date and time of the dressing change. However, during observations, it was noted that the IV dressings for Residents R6, R51, and R28 did not have documentation of the date of insertion or dressing change. On July 16, 2024, observations revealed that Resident R6 had a mid-line IV catheter in the left arm, Resident R51 also had a mid-line IV catheter in the left arm, and Resident R28 had an IV catheter in the right arm. None of these residents had their IV dressings labeled with the date of insertion or dressing change, as required by the facility's policy. An interview with Employee E12, an LPN, confirmed the absence of dressing dates on the IV lines for these residents. Employee E12 acknowledged that staff should date the IV catheter insertion or dressing change, indicating a lapse in adherence to the facility's established procedures.
Failure to Provide Pain Management Before Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident R50, prior to wound care, which is inconsistent with professional standards of practice. The facility's policy on pain assessment and management outlines a comprehensive approach to pain management, including assessing and addressing pain before procedures. However, during an observation, it was noted that Resident R50 did not receive any pain medication before wound care, despite having multiple wounds and a history of severe pain. Resident R50, who has a complex medical history including multiple sclerosis, quadriplegia, and chronic respiratory failure, was observed during a wound care procedure. The resident's clinical records indicated orders for various pain medications, including Fentanyl, Acetaminophen, and Dilaudid, to manage unspecified pain. Despite these orders, the medication administration record showed that the resident did not receive any pain medication prior to the wound care on the day of observation. During the wound care procedure, Resident R50 exhibited signs of pain, such as moaning, but the staff did not assess or address the resident's pain. Interviews with the staff confirmed that no pain medication was administered before the procedure, and the staff continued with the treatment despite the resident's apparent discomfort. This oversight highlights a failure to adhere to the facility's pain management policy and ensure the resident's comfort during medical procedures.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for three residents, resulting in delayed administration of prescribed medications. Resident R22 had a physician's order for Macrobid to treat a urinary tract infection, scheduled to start on July 12, 2024, at 8:00 p.m. However, the medication was not administered until July 13, 2024, at 1:00 p.m. due to unavailability. Similarly, Resident R44 was prescribed Macrobid for fever, with the medication scheduled to start on July 15, 2024, at 8:00 p.m., but it was not administered until July 16, 2024, at 9:00 p.m. due to the same issue of unavailability. Resident R2 was on intravenous Zosyn for a sputum infection, with the medication supposed to start on July 17, 2024, after the successful placement of an intravenous line. However, the medication was not available from the pharmacy, leading to a delay in administration. Additionally, Resident R2 had a physician's order for Macrobid for fever, scheduled to start on July 15, 2024, at 8:00 p.m., but it was not administered until July 17, 2024, at 9:00 p.m. due to unavailability. Interviews with the Regional Nurse confirmed that the medications were not available as ordered, which contributed to the delay in treatment for these residents.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to respond promptly to the consultant pharmacist's recommendations regarding potentially unnecessary medications for two residents. For one resident, the pharmacist recommended discontinuing hydroxyzine, which was being used inappropriately for depression. Although the physician agreed and signed the recommendation, the facility did not implement the change until several weeks later. This delay occurred despite multiple recommendations and physician agreements over a span of months, indicating a lack of timely action by the facility. Another resident was receiving the antipsychotic agent Aripiprazole without an appropriate diagnosis to support its use. The physician agreed to the pharmacist's recommendation to address this issue, but the facility did not implement the change as per the approved diagnosis. The Director of Nursing confirmed that the recommendations for both residents were not completed in a timely manner, highlighting a deficiency in the facility's response to pharmacy consultant recommendations.
Non-compliance with PRN Psychotropic Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN psychotropic medications for two residents. For one resident, admitted with conditions including acute respiratory failure and anxiety disorder, a physician order for Xanax was initiated with an indefinite stop date, lacking the required 14-day limit or a clinical rationale for continuation beyond this period. This deficiency was confirmed by a regional nurse during an interview, highlighting the absence of necessary documentation to justify the extended use of the medication. Additionally, another resident was prescribed Seroquel for restlessness and agitation without an approved diagnosis to support its use. A pharmacy consultant recommended a psychosocial and medical workup to assess the necessity of the medication, suggesting a tapering schedule if no significant behaviors were identified. Although the physician acknowledged the recommendation and signed for a psych consult, there was no evidence that the facility implemented this recommendation, further contributing to the deficiency.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with professional standards, as observed in one of the three medication carts. During a medication administration observation, Employee E3 was seen removing Clonazepam, a controlled drug, from the medication cart's narcotic box and logging it into the narcotic book. However, Employee E3 crushed the Clonazepam tablet along with other pills and placed the crushed medication on top of the medication cart. This action was contrary to the facility's policy, which requires medication carts to be kept closed and locked when out of sight of the medication nurse or aide. The incident involved Resident R8, who had a physician's order for Clonazepam to be administered for Generalized Anxiety Disorder. Employee E3 left the crushed Clonazepam tablet unattended on the medication cart while attending to another resident's vital signs in a different room. This action violated the facility's policy on administering medications safely and securely, as the medication was left accessible and unattended, posing a risk of unauthorized access.
Deficiencies in Food Service Safety and Monitoring
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. The dishwashing machine was not reaching the required temperatures for washing and rinsing, with observed temperatures at 140°F and 130°F, respectively, instead of the required 150°F and 180°F. Despite this, dishes were removed and stored as if they were clean. The Food Service Director acknowledged that dishes are not clean and disinfected if the required temperatures are not met. Additionally, expired food items were found in the refrigerator, and some items lacked expiration or open dates, which the Food Service Director confirmed should be discarded. Further observations revealed that the ice machine in the kitchen had not been cleaned since May, despite a monthly cleaning schedule being displayed. In a resident's room, a refrigerator contained unlabeled leftover food and other items, with no temperature monitoring documentation available. The resident, who had a tracheostomy tube and a BIMS score indicating moderate cognitive impairment, was in a room where staff were responsible for cleaning, dating, and monitoring the refrigerator, but this was not being done. The Food Service Director confirmed the lack of temperature monitoring for the refrigerator in the resident's room.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control procedures during medication administration for two residents. During an observation, Employee E3 administered Fluticasone nasal spray to a resident by inserting the nasal applicator into one nostril and then into the other without disinfecting the applicator in between. This action was contrary to the facility's infection control policy, which emphasizes the importance of hand hygiene and antiseptic techniques to prevent the spread of infections. In another instance, Employee E3 did not wash or sanitize her hands before putting on gloves while administering medication to another resident. She proceeded to check the resident's heart rate and PEG placement without changing gloves or performing hand hygiene. Additionally, she attempted to administer artificial tears eye drops with the same gloves, which the resident refused. These actions were in violation of the facility's hand hygiene policy, which requires hand hygiene before and after resident contact and glove removal.
Failure to Post Required Contact Information
Penalty
Summary
The facility failed to post the required contact information for the Pennsylvania Department of Health and the State Long-Term Care Ombudsman program on one of its nursing units, specifically the first floor B unit. During a resident council meeting, it was revealed that five out of seven residents were unaware of where to find this contact information. Observations confirmed that the contact information was not available on the bulletin board of the first floor B unit. Additionally, while the State Long-Term Care Ombudsman program contact information was posted in Spanish, the English version was placed behind the nursing station, making it inaccessible to residents. An interview with the Regional Nurse confirmed the absence of the required postings on Floor B.
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A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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