Montgomeryville Skilled Nursing And Rehabilitati
Inspection history, citations, penalties and survey trends for this long-term care facility in Montgomeryville, Pennsylvania.
- Location
- 640 Bethlehem Pike, Montgomeryville, Pennsylvania 18936
- CMS Provider Number
- 395796
- Inspections on file
- 22
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Montgomeryville Skilled Nursing And Rehabilitati during CMS and state inspections, most recent first.
Staff did not follow physician orders for two residents, including administering blood pressure medications outside of prescribed parameters and failing to document medication administration as required. Additionally, a resident with a contracture did not consistently have a palm guard with finger separators in place as ordered, with observations confirming missing devices and improper positioning.
The facility did not employ a full-time qualified dietitian or a qualified dietary services manager, as confirmed by both the Food Service Director and the Administrator during staff interviews.
The facility did not provide two residents and/or their representatives with written summaries of their baseline care plans within 48 hours of admission, as required by policy. Although the baseline care plans were developed, there was no evidence that the necessary summaries, including all required healthcare information, were given to the residents or their representatives.
Surveyors observed that food items in the Rehabilitation unit pantry were not stored in accordance with sanitary standards, with multiple items in the freezer and refrigerator lacking required labels or dates, and some items past their use-by dates. The Administrator confirmed the pantry is for resident food only.
A resident was billed for services not covered by Medicare or co-insurance due to the facility's failure to conduct a required 72-hour financial meeting. This meeting was supposed to discuss financial responsibilities and set payment expectations, but there was no documentation that it occurred, as confirmed by the Administrator.
The facility did not provide scheduled showers to two residents, affecting their quality of life. A resident with chronic conditions and cognitive impairment missed two scheduled showers, while another resident with heart failure was not offered showers on three occasions despite her preference. The administrator confirmed the lack of documentation for these showers.
A facility failed to notify a resident's representative of changes in the resident's condition, including a red and irritated right buttock and a new neck abrasion, despite having physician orders for treatment. The resident had chronic respiratory failure, seizures, and diabetes, with cognitive impairment. The DON confirmed the notification failure.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as open and undated food items, debris on preparation surfaces, and improper glove use during food handling. Observations included a dusty fan blowing onto plates and various food items left unsealed or improperly stored.
The facility failed to maintain a safe, clean, and homelike environment in the Rehab and Second floor units. Observations included missing tiles, paint damage, and stained ceiling tiles in resident rooms, as well as unlabeled food items and soiled refrigerator drawers in the pantry. Additionally, a linen cart with personal items and a soiled fall mat were found in the hallway and a resident's room, respectively.
The facility failed to monitor and assess weights for five residents at risk for weight loss, contrary to its policy. One resident lost 23.6 lbs in 30 days without timely intervention, while another lost 35.6 lbs in less than 30 days. Two residents were not weighed weekly after admission, and another had no monthly weights recorded for several months. The DON confirmed the facility's failure to adhere to its policy.
A resident with depression and at risk for falls was repeatedly observed without access to a call bell. On several occasions, the resident was found lying in bed without a call bell plugged in or within reach, contrary to their care plan requirements.
The facility failed to complete comprehensive assessments for two residents. A resident was transferred to the hospital without an MDS assessment documenting the discharge, and another resident was placed on hospice services without a significant change MDS assessment. These deficiencies were confirmed by the DON.
The facility failed to develop comprehensive care plans for three residents, resulting in unmet needs for conditions such as acute pulmonary edema, congestive heart failure, bacteremia, and renal dialysis dependence. The care plans lacked interventions for critical areas like urinary catheter care, ADL function, and pressure ulcers, as confirmed by the DON.
The facility failed to administer medications and follow care plans for three residents. One resident did not receive the full course of antibiotics for sepsis, another was not provided with pressure-reducing boots as ordered, and a third did not receive epoetin alpha for renal dialysis. These deficiencies were confirmed by the DON and family members.
A resident with hemiplegia due to a stroke was not provided with a left resting hand splint as ordered by a physician to prevent contractures. Despite the care plan's directive, the splint was missing, and the resident was observed without it on multiple occasions. The DON confirmed the absence of the splint, indicating a deficiency in care.
The facility failed to provide adequate supervision and interventions for two residents at risk for accidents. One resident with a history of falls was not given the prescribed interventions like music or videos, while another resident requiring meal supervision due to aspiration risk was left unsupervised during meals. The DON confirmed these lapses.
A facility failed to complete dialysis pre-treatment reports for a resident with hypertension, heart failure, and end-stage renal disease. The facility's policy required ongoing communication with the dialysis center, including a pre-treatment report by the facility nurse. However, these reports were incomplete on several occasions, as confirmed by the DON.
A facility did not create an individualized care plan for a resident with PTSD, failing to address specific needs for minimizing triggers and preventing re-traumatization. The resident also had bipolar disorder, depression, anxiety, and aphasia. This deficiency was confirmed by the DON.
A facility failed to ensure that a physician acted on pharmacy recommendations for a resident with dementia and insomnia. The resident was prescribed melatonin, and the pharmacist twice noted the need for dosage clarification. However, there was no evidence that the physician addressed these recommendations, as confirmed by the DON.
The facility failed to honor the meal preferences of two residents, leading to a deficiency. A resident with dysphagia and atrial fibrillation did not receive the requested spinach, egg, and cheese casserole, instead receiving turkey, mashed potatoes, and carrots. Another resident with hypertension and hyponatremia was served fish despite ordering a burger with raw onions, as indicated on her tray card.
A facility failed to provide a therapeutic diet as recommended by a dietician for a resident at risk for weight loss. Despite the resident's diagnoses of rhabdomyolysis, diabetes, and anemia, and a dietician's recommendation for double portions at meals, the resident was observed receiving only single portions. The DON confirmed the resident was supposed to receive double portions.
The facility failed to serve meals at scheduled times on the second floor nursing unit. Lunch, scheduled between 11:30 a.m. and 1:00 p.m., was served late on multiple occasions. On a specific day, a resident's family member reported frequent delays, and two residents expressed hunger while waiting for their meals, which were served 40 minutes late.
The facility failed to serve food at acceptable temperatures across three nursing units. Multiple residents reported that their food was often cold. A test tray audit confirmed that food items were served below the required temperature of 140 degrees F, with chicken, rice, and corn measuring at 120 degrees F, 119 degrees F, and 118 degrees F, respectively. The Director of Dietary acknowledged the issue.
A resident with a history of brain bleed, stroke, and bipolar disorder, who was non-ambulatory and required two staff members for transfers, was transferred by only one staff member, resulting in the resident's head being bumped. The facility's investigation confirmed the failure to follow the care plan.
The facility failed to implement a physician's order for a cardiology consultation for a resident with multiple diagnoses, including diabetes and chronic pressure ulcers. The consultation, ordered on January 3, 2024, had not been scheduled as of February 12, 2024, as confirmed by the DON.
The facility failed to notify the responsible party of a treatment change for a resident with atrial fibrillation, seizures, and diabetes. The resident's medications were altered based on electrocardiogram results, but there was no documentation to support that the responsible party was informed. This was confirmed by the DON.
Failure to Follow Physician Orders for Medication Administration and Medical Devices
Penalty
Summary
Staff failed to follow physician orders for two residents, resulting in improper medication administration and lack of required medical devices. For one resident with hypertension, staff administered multiple blood pressure medications outside of the prescribed parameters, including giving hydralazine hydrochloride when the systolic blood pressure (SBP) was below 100 mmHg, and administering amlodipine besylate and lisinopril when the SBP was below 110 mmHg. Additionally, metoprolol was given when the resident's heart rate was less than 60, contrary to the physician's instructions. There were also instances where there was no documentation that scheduled medications were offered as required. The Director of Nursing confirmed that these medications were administered outside of the established parameters and that documentation was lacking. For another resident with a history of traumatic brain injury and left elbow contracture, staff did not ensure that a left palm guard with finger separators was in place at all times as ordered by the physician. The clinical record and direct observation showed that the palm guard was not in place on certain days, and when it was in place, the finger separators were missing, resulting in the resident's fingers being contracted and overlapping. The Administrator confirmed that the finger separators should have been in place according to the physician's order.
Failure to Employ Qualified Dietary Manager or Full-Time Dietitian
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. During an interview, the Food Service Director confirmed that there was no qualified dietary manager employed, and this was further corroborated by the Administrator, who stated that the facility did not have a full-time dietitian or a qualified dietary manager. There was no evidence provided to show that the facility had either a full-time dietitian or a qualified dietary services manager, as required by regulation.
Failure to Provide Baseline Care Plan Summaries to Residents
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to two residents and/or their representatives within 48 hours of admission, as required by facility policy. The policy specifies that a baseline care plan must be developed within 48 hours and must include healthcare information necessary for proper care, such as initial goals based on admission, physician, dietary, and therapy orders, as well as social services and pre-admission screening information if applicable. The baseline care plan is to be updated as needed until the comprehensive care plan is developed, and a written summary must be given to the resident or their representative. Clinical record reviews showed that for two residents, the baseline care plans were developed, but there was no evidence that the required written summaries were provided to the residents or their representatives. This was confirmed by the Administrator during an interview, who acknowledged the absence of documentation showing that the summaries had been given as required.
Failure to Store Resident Food Items in Accordance with Sanitary Standards
Penalty
Summary
The facility failed to store food in a sanitary manner on the Rehabilitation unit, as required by facility policy and regulatory standards. During an observation of the resident pantry, surveyors found multiple food items in both the freezer and refrigerator that were not labelled or dated, including a container of ice cream, a bottle of water, a juice drink, a sandwich, a bagel wrapped in foil, and a large plastic bag containing chips, pretzels, pickles, and grapes. Additionally, a cup of coffee was dated but not labelled, and there were opened containers of nectar thick lemon-flavored water and yogurt with use-by dates that had already passed. A large plastic lid labelled 'fresh fruit' was found directly touching the refrigerator shelf without the bottom part of the container. The Administrator confirmed that the pantry is intended for resident food items only.
Failure to Provide Timely Notice of Non-Covered Expenses
Penalty
Summary
The facility failed to provide timely notice of non-covered Medicare and other expenses for a resident who had been discharged. According to the facility's policy, a 72-hour financial meeting should be conducted with all new admissions to discuss financial responsibilities and set expectations for payment of services. This meeting should include a review of the resident's current payer coverage and any private liability for co-insurance, co-pays, and deductibles. The resident or their representative is required to sign off on the financial meeting handout to confirm that all terms of payment have been discussed. In this case, the clinical record review revealed that the resident was admitted to the facility, sent to the hospital, readmitted, and then discharged. The resident received a bill for services not covered by Medicare or co-insurance for 44 days. There was no documented evidence that the facility conducted the required 72-hour financial meeting with the resident or discussed his financial responsibilities during his stay. The Administrator confirmed that there was no documentation of the meeting or discussion as per the facility's policy.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers to two residents, impacting their quality of life and dignity. Resident 1, who has chronic respiratory failure, seizures, and diabetes, with cognitive impairment requiring staff assistance for bathing, was not documented as having received showers on two scheduled dates. Resident 7, diagnosed with heart failure and having no cognitive impairment, also required staff assistance for bathing. She reported not being offered showers on three of six scheduled occasions in the past month, despite her preference for twice-weekly showers. The facility's administrator confirmed the lack of documentation for these scheduled showers.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative of a change in condition for one of the sampled residents. The resident had diagnoses including chronic respiratory failure, seizures, and diabetes, and was noted to have cognitive impairment. On June 30, 2024, a nurse's note indicated that the resident's right buttock was red and irritated, leading to new physician orders for treatment. Additionally, a wound care progress note on July 19, 2024, documented a new left-sided anterior neck abrasion with specific care instructions. However, there was no documented evidence that the resident's representative was informed of these changes in condition. The Director of Nursing confirmed the lack of notification during an interview on July 30, 2024.
Sanitation Deficiencies in Kitchen and Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed on May 19, 2024. The kitchen had several issues, including an open Pepsi bottle, a staff drink cup, an apron, a mask, crumbs, debris, Styrofoam cups, and plastic lids on a food preparation surface. The corner of the wall at the entryway was marred and peeling, and there was an accumulation of food in the dish machine trap, which had not been used that day. Additionally, there was debris, dust, and crumbs on a case of corn starch, and a rolling cart with a ladle and an open container of powdered potatoes left uncovered from the previous day. The oven doors had a dried, white substance, and the bulk rice and flour bins had an unidentified substance on them. An open container of peanut butter with a spoon was stored inside. In the walk-in refrigerator, there were undated pans of raw beef, pork, macaroni and cheese, and rice, along with open packages of hard-boiled eggs and chicken patties left unsealed. The walk-in freezer had a box of frozen potatoes stored on the floor and open boxes of frozen bread dough and pizzas left unsealed. In dry storage, a bag of baking powder was left open. During tray line service on May 21, 2024, a fan with accumulated dust was blowing onto plates, and a staff member, while wearing gloves, handled ready-to-eat food without changing gloves or performing hand hygiene after retrieving items from the refrigerator.
Deficiencies in Maintaining a Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two of its nursing units, specifically the Rehab and Second floor units. On the Rehab unit, several deficiencies were observed, including a missing piece of tile next to the door in one resident's room, chunks of paint missing on the walls in another room, and small holes in the wall where a glove rack had been removed. Additionally, there was white splatter at the bottom of a door, stained ceiling tiles in a resident's room and hallway, and the central bathing area lacked soap in the dispenser and a toilet tank cover. On the second floor nursing unit, the pantry refrigerators contained multiple unlabeled and undated food items, including a carton of thickened lemon-flavored water that was opened and dated beyond the manufacturer's recommended usage period. The refrigerator drawers were soiled with a red liquid, and the freezer contained unlabeled and undated opened food items. Further observations revealed a small linen cart in the hallway with a bottle of lotion, a dirty glove, a soiled cup, and opened disposable razors. Additionally, a fall mat in a resident's room was soiled, and there was damage to the wall below the handrail near the entrance of another room.
Failure to Monitor and Assess Resident Weights
Penalty
Summary
The facility failed to monitor and assess resident weights and weight changes for five residents who were at risk for weight loss. The facility's policy required residents to be weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. However, the facility did not adhere to this policy. For instance, Resident 36 experienced a significant weight loss of 23.6 pounds in 30 days, but there was no documented evidence that this weight loss was addressed in a timely manner. Similarly, Resident 73 did not have monthly weights recorded for several months, and Resident 84 experienced a significant weight loss of 35.6 pounds in less than 30 days without timely intervention. Additionally, Resident 95 was not weighed weekly after admission as required by the facility's policy, and Resident 122 was not weighed weekly after admission, with a significant gap between the initial and subsequent weight recordings. Interviews with the Director of Nursing confirmed that the facility did not follow its policy for weighing and assessing residents, leading to a failure to maintain acceptable parameters of nutritional status for these residents.
Failure to Provide Call Bell Access for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident by not providing access to the call bell system. The resident, who had a diagnosis of depression and was at risk for falls, was observed on multiple occasions without access to a call bell. On May 19, 2024, the resident was seen lying in bed without a call bell plugged into the system. Similarly, on May 20, 2023, the resident was again observed in bed without a call bell. On May 21, 2024, the call bell was found on the nightstand, out of the resident's reach. This lack of access to the call bell system was a failure to meet the resident's needs as outlined in their care plan.
Failure to Complete Comprehensive Assessments for Residents
Penalty
Summary
The facility failed to complete a comprehensive assessment for two residents, leading to deficiencies in their care documentation. Resident 106 was transferred to the hospital due to a change in condition on April 14, 2024, but the facility did not complete a Minimum Data Set (MDS) assessment to document the resident's discharge. This was confirmed by the Director of Nursing during an interview on May 22, 2024. Additionally, Resident 107 was ordered hospice services on March 29, 2024, and continued to receive these services as of a doctor's note dated May 1, 2024. However, the facility did not complete a significant change MDS assessment to reflect this change in the resident's status. This oversight was also confirmed by the Director of Nursing during an interview on May 22, 2024.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in meeting their individual needs. Resident 121, who was readmitted with acute pulmonary edema and congestive heart failure, did not have a care plan addressing these conditions. Similarly, Resident 124, admitted with bacteremia and benign prostatic hyperplasia, had a physician's order for an indwelling urinary catheter, but there was no evidence of interventions for urinary status and catheter care in the care plan. Resident 296, admitted with dependence on renal dialysis, nontraumatic ischemic infarction of the right lower leg muscle, and peripheral vascular disease, also lacked a comprehensive care plan. The Minimum Data Set (MDS) Care Area Assessment summary indicated that the resident's ADL function, urinary incontinence, pressure ulcers, and pain should be addressed, but these areas were not included in the care plan. The Director of Nursing confirmed the absence of documented evidence addressing these care areas.
Failure to Administer Medications and Follow Care Plans
Penalty
Summary
The facility failed to follow physician orders for three residents, leading to deficiencies in care. Resident 107, with a history of sepsis and Alzheimer's disease, was prescribed an antibiotic regimen of amoxicillin to be administered twice daily for seven days. However, the first dose was missed due to unavailability, resulting in the resident receiving only 13 out of the 14 prescribed doses. This incomplete treatment was confirmed by the Director of Nursing. Resident 115, diagnosed with a traumatic brain injury and pressure ulcers, had a care plan that included the use of pressure-reducing boots while in bed. Observations over two days revealed that the resident was not wearing the boots as ordered. Additionally, Resident 296, who required epoetin alpha three times a week for renal dialysis and ischemic infarction, did not receive the medication at all during their stay, as confirmed by the resident's wife and the Director of Nursing. These failures to administer medications and follow care plans were noted as deficiencies.
Failure to Apply Resting Hand Splint for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide necessary services and treatment to prevent further limitations in range of motion for a resident who had experienced a stroke with hemiplegia on the non-dominant left side. The resident's clinical records indicated memory impairment and limitations in range of motion on one side of the lower and upper extremities. The care plan included an intervention for staff to apply a left resting hand splint daily to prevent contractures, as ordered by a physician since March 8, 2024. However, an occupational therapy evaluation on May 16, 2024, revealed that the left resting hand splint was missing. Observations on May 19, 2020, confirmed that the resident was without the splint while seated in a reclining chair. The Director of Nursing acknowledged on May 22, 2024, that the splint was missing, confirming the deficiency in care.
Failure to Provide Adequate Supervision and Interventions
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents for two residents at risk for accidents. Resident 2, who had a history of traumatic brain injury and falls, was observed on multiple occasions sitting in his wheelchair in the hallway without the interventions outlined in his care plan, such as music, YouTube videos, or a laptop to watch baseball games. These interventions were intended to mitigate his risk of falls, yet they were not provided during the observed times. Resident 100, diagnosed with hemiparesis, dysphagia, and pneumonitis due to inhalation of food, required supervision during meals as per physician orders to prevent aspiration. However, on two separate occasions, Resident 100 was observed eating lunch in bed without the necessary staff supervision. The Director of Nursing confirmed that staff should have been supervising Resident 100 during meals to adhere to the aspiration precautions ordered by the physician.
Incomplete Dialysis Pre-Treatment Reports
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice for a resident who required dialysis. The facility's policy on hemodialysis care emphasized the importance of ongoing communication and collaboration with the dialysis facility, including the completion of a pre-treatment report by the facility nurse. This report was to include information such as code status, medications administered prior to dialysis, vital signs, falls, and relevant changes since the last treatment. However, a review of the resident's dialysis communication forms revealed that the pre-treatment report section was incomplete on multiple dates in April and May 2024. The Director of Nursing confirmed that these reports were supposed to be completed but were not, indicating a lapse in the required communication and documentation process for the resident receiving dialysis.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The clinical record review revealed that the resident, who also had diagnoses of bipolar disorder, depression, anxiety, and aphasia, did not have specific interventions in place to address their needs for minimizing triggers or preventing re-traumatization. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of an individualized care plan for the resident's PTSD.
Failure to Act on Pharmacy Recommendations for Resident's Medication
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were acted upon by the physician for one of the sampled residents, identified as Resident 111. According to the facility's policy on Medication Regimen Review, the attending physician, Medical Director, and Director of Nursing (DON) should receive copies of the medication regimen reviews, and the attending physician is required to document any irregularities and actions taken in the resident's record. Resident 111, who had diagnoses including dementia and insomnia, was prescribed melatonin for insomnia. On two occasions, February 22, 2024, and May 3, 2024, the pharmacist noted that the melatonin dosage needed clarification from the physician. However, there was no evidence that the physician acknowledged or acted upon these recommendations. This was confirmed in an interview with the DON on May 22, 2024.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to accommodate the meal preferences of two residents, leading to a deficiency in providing food that aligns with resident preferences. Resident 49, who has dysphagia and atrial fibrillation, was noted to have no cognitive impairment according to her MDS assessment. Her care plan included an intervention to honor her food preferences. However, during an interview, she reported not receiving the food she ordered. On the day of observation, she had requested a spinach, egg, and cheese casserole for lunch but was served turkey, mashed potatoes, and carrots instead, which she stated she did not like. Similarly, Resident 126, who was admitted with hypertension and hyponatremia, also had no cognitive impairment as per her MDS assessment. Her care plan included an intervention to honor her food preferences. During an observation, she was served fish, although she had ordered a burger with raw onions, as indicated on her tray card. The resident expressed her dislike for fish, highlighting the facility's failure to adhere to her meal preferences.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as recommended by a registered dietician for a resident at risk for weight loss. The resident, who had diagnoses including rhabdomyolysis, diabetes, and anemia, was noted to have experienced weight loss and was on a therapeutic diet. A dietician's note from March 7, 2024, indicated that the resident should receive double portions at meals due to a good appetite and the resident's feedback that breakfast portions were sometimes too small. However, on May 20, 2024, the resident was observed receiving only single portions of lunch items, contrary to the dietician's recommendation. The Director of Nursing confirmed that the resident was supposed to receive double portions at meals.
Late Meal Service on Second Floor Nursing Unit
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times and in accordance with residents' needs on the second floor nursing unit. The facility's meal schedule indicated that lunch should be served between 11:30 a.m. and 1:00 p.m. However, on May 19, 2024, staff interviews revealed that lunch was served late on that day and had been served late on other occasions. A family member of a resident confirmed that meals were frequently served late, and observation showed that the resident did not receive lunch until 1:15 p.m., which was 15 minutes past the latest scheduled time. Additionally, two residents on the second floor expressed that they were waiting for their lunches and were hungry, as the meals were very late. These residents did not receive their meals until 1:40 p.m., which was 40 minutes past the latest scheduled time for meals to arrive on the nursing units. This deficiency was identified under 28 Pa. Code 201.14(a), which pertains to the responsibility of the licensee.
Failure to Serve Food at Acceptable Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at acceptable temperatures across three nursing units: Rehab, First floor, and Second floor. Multiple residents reported that their food was often served cold during interviews conducted over two days. A review of the facility's Food and Nutrition Services Test Tray Evaluation indicated that hot food items should be served at temperatures greater than 140 degrees Fahrenheit. However, a test tray audit revealed that the temperatures of chicken, rice, and corn were significantly below this standard, measuring at 120 degrees F, 119 degrees F, and 118 degrees F, respectively. The Director of Dietary confirmed that the food items did not maintain acceptable temperatures at the point of service.
Failure to Implement Safety Interventions During Resident Transfer
Penalty
Summary
The facility failed to implement safety interventions during a transfer from bed to chair for a resident. The resident, who was admitted with diagnoses including brain bleed, stroke, and bipolar disorder, was non-ambulatory and dependent on staff for care. The care plan required the assistance of two staff members with a lift for all transfers out of bed. However, on March 28, 2024, nursing documentation indicated that the resident was heard yelling for staff after her head was bumped during a transfer. The facility's investigation revealed that only one staff member used the lift for the transfer, contrary to the care plan. The Director of Nursing confirmed this failure to provide the required assistance during the transfer.
Failure to Implement Physician's Orders for Cardiology Consultation
Penalty
Summary
The facility failed to ensure that physician's orders were implemented for one of three sampled residents. Resident 1, who had diagnoses including diabetes, anemia, sepsis, and chronic pressure ulcers, was directed by a physician on January 3, 2024, to have a cardiology consultation scheduled. However, a clinical record review revealed that as of February 12, 2024, the consultation had not been scheduled. This was confirmed by the Director of Nursing during an interview on February 12, 2024, at 12:05 p.m.
Failure to Notify Responsible Party of Treatment Change
Penalty
Summary
The facility failed to notify the responsible party of a change in treatment for a resident with diagnoses including atrial fibrillation, seizures, and diabetes. The resident, who had memory impairment, was directed by the physician to hold certain medications and start a new one based on electrocardiogram results. However, there was no documentation to support that the responsible party was informed of these medication changes. This was confirmed by the Director of Nursing during an interview.
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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