Monumentalpostacutecare At Woodside Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 4001 Ford Road, Philadelphia, Pennsylvania 19131
- CMS Provider Number
- 396076
- Inspections on file
- 27
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Monumentalpostacutecare At Woodside Park during CMS and state inspections, most recent first.
A resident who required a two-person mechanical lift transfer was manually transferred by an LPN after the mechanical lift was found to be non-functional. The LPN did not seek an alternative battery or lift, and the manual transfer resulted in the resident sustaining a comminuted fracture of the upper arm. Staff statements and resident interviews confirmed the transfer was not performed according to the care plan, leading to actual harm.
A nurse aide reported finding a resident in a Geri chair with saturated clothing and an incorrectly sized Hoyer pad, with no documentation of recent toileting or care. The administration did not report the allegation of neglect to the State Survey Agency or conduct an investigation, despite multiple requests and facility policy requirements.
Two residents were placed at risk when staff failed to provide adequate supervision during care and did not properly secure air mattresses to beds. One resident with severe cognitive and physical impairments fell from bed when the mattress shifted during incontinence care, while another was found with an unsecured air mattress, a practice confirmed by maintenance staff.
A resident was involved in an incident in the front lobby during a family visit, but staff did not document the event in the clinical record as required by facility policy. Interviews with the Administrator and weekend supervisor confirmed the absence of documentation for this occurrence.
A resident identified as an elopement risk was able to exit the facility by breaking and climbing through a first-floor window. The resident's care plan required staff to monitor his whereabouts and display his photograph at the reception desk, but the photograph was not present as required. This failure to implement established elopement prevention measures allowed the resident to leave the facility unsupervised.
Staff did not assist several residents out of bed by the expected time, despite facility policy and resident preferences. One resident with paralysis who requires transfer assistance preferred to be in a wheelchair during the day shift but remained in bed, along with eight other residents, past the designated time.
Multiple areas of the facility were found unclean and not maintained in a homelike manner, including a common shower room with used towels and hygiene products left on the floor, resident rooms with stained ceiling tiles, water leaks, soiled linens, foul odors, and discarded personal care items. A family member also reported finding used gloves, tissues, and improperly stored dentures in a resident's room.
The facility failed to maintain smoke-resistant separation in hazardous areas across all three levels. Observations revealed that doors in the basement's Laundry and Boiler Rooms did not close and latch, soiled linen carts were stored in second-floor corridors, and the Annex Diaper Room on the first floor had unsealed door penetrations. These deficiencies were confirmed by the Facility Administrator and Maintenance Director.
The facility did not maintain its fire alarm system properly, as the fire alarm panel at the 2 B Well Nurses Station showed multiple trouble codes. This issue was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain and inspect its emergency generator system, lacking documentation for required tests and inspections. Observations revealed multiple trouble lights on the annunciator panel and inadequate emergency lighting in the generator set location, with access to the manual stop station obstructed by a locked room.
The facility failed to maintain operable egress doors with Special Locking Arrangements, as observed when one leaf of the East Annex double doors near the reception desk on the first floor did not close properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility did not maintain the smokeproof enclosure of a stairwell, as observed when a cleaning cart was stored under basement Stairway number 3. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain the kitchen suppression system according to NFPA 101 standards. Documentation review revealed the absence of records for semi-annual inspections and servicing of the system. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain alcohol-based hand rub dispensers according to safety regulations. An ABHR dispenser was observed mounted directly above an electrical outlet on the first floor, East, near room 124, which violates the requirement that dispensers should not be installed within 1 inch of an ignition source. This was confirmed during an interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain its sprinkler system documentation, affecting two out of four inspections. During a document review, it was found that the facility could not provide records for the First and Third Quarter sprinkler inspections conducted in the previous 12 months. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting two of four smoke compartments. Observations revealed unsealed penetrations around data wires above smoke doors near a resident room on the second floor. This issue was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain smoke-tight resistance in smoke barrier doors, as observed when the double smoke doors on the second floor, West, next to a resident room, did not close properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director, affecting two of the three levels in the facility.
The facility did not maintain its HVAC systems according to NFPA 101 standards, as a portable AC unit was improperly used as a permanent part of the system in the basement corridor next to Boiler Room #2. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain heating units free of combustible materials, as required by NFPA 101. Combustible materials were observed on heating units in two resident rooms, affecting two of the three facility levels. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility was found to have a non-GFCI outlet within 6 feet of the kitchen hand wash sink, violating safety standards for electrical systems in wet locations. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain proper oxygen storage requirements, as observed in the second floor west nursing station medical room. The entry door lacked the required precautionary signage, and there was no signage to differentiate between "Empty" and "Full" oxygen cylinders inside the room. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
Monumental Post-Acute Care at Woodside Park was found deficient in its Emergency Preparedness Training program, lacking written policies and procedures for training all staff and volunteers. This deficiency was confirmed during a survey and an exit interview with facility leadership.
The facility was found to have unprotected structural steel columns and beams above the suspended ceiling assemblies, and pan-style ceiling diffusers lacked full 'blanket' protection. This led to the building being classified as unprotected ordinary construction, with the story height exceeding the maximum allowed for such construction by one story. The deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain and inspect portable fire extinguishers as per NFPA 10 standards, affecting the entire facility. During a document review, it was discovered that the facility lacked an appropriate certificate for the technician conducting the annual fire extinguisher inspections. This issue was confirmed in an interview with the Facility Administrator and Maintenance Director.
The facility failed to meet food safety standards, with observations of unsanitary practices such as a bucket with soapy water on a preparation table and unlabeled food items in the refrigerator. Additionally, dishes were improperly dried with limited airflow, and hot food was placed near drying dishware, violating professional food service safety standards.
The facility failed to properly dispose of garbage and refuse, as observed during a survey of the Food Service Department. The blue dumpster was found fully open and overflowing with cardboard boxes, with additional piles of refuse on the ground around it. A follow-up observation confirmed the ongoing issue, and the FSD acknowledged the findings.
Monumental Post Acute Care at Woodside Park failed to notify the State Long-Term Care Ombudsman and a resident's representative about emergency hospital transfers. The deficiency was identified through a review of nursing notes and clinical records, revealing that the facility did not provide the required notifications in writing and in a language and manner understood by the resident's representative.
A facility failed to provide a resident's representative with the required bed hold notice during a transfer to the hospital. The resident, who had severely impaired cognition, was transferred following a seizure, but there was no documentation of the bed hold policy being communicated. The Social Services Director confirmed the absence of such documentation.
The facility inaccurately documented restraint use in the MDS for two residents. One resident was noted as having a chair that prevents rising, but was observed ambulating freely. Another resident was documented as using limb restraints, but had no restraints and no physician order for them. Staff confirmed the facility was restraint-free and the MDS was inaccurately coded.
A facility failed to update the PASRR for a resident who was newly diagnosed with Undifferentiated Schizophrenia. Initially, the resident's PASRR Level I Form indicated no need for further evaluation. However, after the new diagnosis, there was no documented evidence of a referral for a Level II PASARR evaluation, as confirmed by the Director of Social Services.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with dementia did not have a care plan for dementia care, another resident who smoked lacked a safety plan, and a resident with cancer did not have a pain management plan despite having physician orders for pain medications. These oversights were confirmed by the facility's administration.
A resident's care plan was not updated in a timely manner after a change in hospice status. Despite a physician order to discontinue hospice care, the care plan remained unchanged, contrary to facility expectations for prompt updates with major changes.
The facility failed to provide evidence of competency evaluations for licensed nurses in key areas such as medication administration and wound care. During a survey, the facility's educator admitted that the necessary documentation was not available, indicating a deficiency in ensuring nursing staff had the required skills to meet residents' care needs.
A facility failed to dispose of controlled medications for a resident in a timely manner. The resident, who was discharged against medical advice, had prescriptions for Morphine Sulfate and Lorazepam. These medications were not disposed of until 11 weeks after discharge, as confirmed by the DON. This delay constitutes a deficiency in the facility's pharmacy services.
A facility failed to maintain effective infection control by not using PPE for a resident on Enhanced Barrier Precautions. A nurse was observed cleansing a resident's G-tube site without PPE, despite the resident's room indicating the need for such precautions. This oversight was confirmed with the nurse at the time.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day on four days in January 2025. Staffing hours were insufficient, with care hours ranging from 3.04 to 3.18 PPD, as confirmed by the Nursing Home Administrator.
A facility failed to create a care plan to prevent lice reinfestation for a resident with bipolar disorder. The resident experienced two lice infestations after visits with his sister, requiring treatment for himself, his roommate, and their room. Despite these incidents, no care plan was developed to prevent future infestations related to family visits or infested items. Interviews with the LNAC and DON confirmed the lack of a preventive care plan.
The facility failed to maintain an effective pest control program, resulting in multiple structural and housekeeping deficiencies. Observations revealed unsealed doors, plumbing issues, and food debris attracting pests. Interviews confirmed the presence of pests and rodents throughout the facility, with multiple voids, holes, and gaps identified by the pest control operator. Residents also reported issues with mice in their rooms, and the facility's failure to address these issues compromised resident health and safety.
The facility failed to ensure that food was prepared appropriately for nine residents on a pureed diet. Observations revealed that the pureed chicken and vegetables had a watery appearance and were runny on the plate, which was confirmed by the Food Service Director.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in infection surveillance, antibiotic usage, and isolation precautions for four residents. Incorrect implementation of policies and lack of infection data and analysis were noted, along with an ineffective infection committee.
The facility failed to maintain an effective antibiotic stewardship program, lacking protocols and systems for monitoring antibiotic use for four residents. The Infection Preventionist and DON could not provide recent data or documentation related to antibiotic stewardship, highlighting a significant gap in infection control and antibiotic management practices.
A resident with multiple health conditions was observed using an improperly fitted wheelchair despite a re-assessment indicating the need for a larger one. The resident expressed discomfort, and the issue was only addressed after a surveyor's observation.
A resident with severe cognitive impairment and serious medical conditions had a POLST form indicating DNR status, but the active physician orders indicated Full Code status. The unit manager confirmed the inconsistency but could not explain the discrepancy.
The facility failed to maintain a safe, comfortable, and homelike environment, with issues such as an open window without a screen, a falling front panel of the heating/air conditioning system, holes in walls, broken drawers, and missing baseboard panels. These deficiencies were confirmed by the Maintenance Director.
The facility failed to conduct a thorough investigation of an incident where a resident was left wet and soiled for hours. The investigation lacked statements from the resident and the morning shift nurse aide, leading to an incomplete assessment of the situation.
The facility failed to provide adequate nail care for two residents who were unable to perform this task themselves. Both residents were observed with long, dirty fingernails despite their care plans and the facility's grooming policy requiring staff to provide such care. Staff interviews confirmed the residents' need for assistance, yet it was not provided.
The facility failed to complete annual performance reviews for two nurse aides, one hired in 2022 and the other in 2009. The Nursing Home Administrator confirmed the reviews were not completed during an interview.
A facility failed to keep a medication cart locked on a secured nursing unit. An unlocked cart was found in the hall with no staff present, and a resident was observed next to it. A nurse confirmed the cart was left unlocked while assisting another resident.
Failure to Follow Transfer Protocol Results in Resident Fracture
Penalty
Summary
A resident with a history of muscle weakness and difficulty walking was care planned to require a two-person transfer using a mechanical lift for all transfers, as documented in the clinical record and care plan. On the day of the incident, nurse aides attempted to use two different mechanical lifts to transfer the resident from a wheelchair to bed, but both lifts were not functioning. The aides requested assistance from a licensed nurse, who, upon entering the room, observed the resident seated on a lift pad in the wheelchair with the non-functioning lift nearby. Due to the limited space and the lift not working, the licensed nurse decided to perform a one-person manual transfer, contrary to the resident's care plan requirements. Following the transfer, the resident reported hearing a pop in the shoulder but initially felt okay once in bed. Over the next two days, swelling and bruising developed on the resident's left upper arm and lateral breast area. The injury was reported to nursing staff, and subsequent assessments revealed pain, swelling, and discoloration. The resident consistently reported to multiple staff members that the injury occurred during a manual transfer by a male caregiver who lifted the resident under the arms because the mechanical lift was not working. An in-house x-ray was inconclusive, and the resident was sent to the emergency room, where imaging confirmed an acute comminuted fracture of the proximal left humerus. Interviews with staff confirmed that there were two mechanical lifts per floor and that extra batteries were available in the medication room. The licensed nurse involved admitted to performing the manual transfer because the lift's battery was not charged and did not attempt to locate another battery. The facility's failure to follow the resident's care plan for mechanical lift transfers resulted in actual harm, specifically a left humeral fracture, constituting neglect as defined by facility policy and regulatory requirements.
Failure to Report and Investigate Alleged Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency and did not conduct an investigation as required. Specifically, a nurse aide reported via email to the Nursing Home Administrator that, at the start of a shift, a resident was found seated in a Geri chair with clothing, a Hoyer pad, and the chair itself saturated with urine. The Hoyer pad in use was not the correct size for the resident according to the care plan, and there was no documentation indicating the resident had been toileted or changed prior to the shift. This information was communicated to the facility administration, but there was no documented evidence that the incident was reported or investigated. Interviews with facility staff confirmed that the administration was not aware of any incontinence neglect related to the resident, and the personnel file for the nurse aide involved was not immediately available due to the Human Resources Director being out sick. Despite multiple requests for investigation, there was no response from administration, and no documentation was provided to show that the required reporting and investigation procedures were followed in response to the allegation of neglect.
Failure to Provide Adequate Supervision and Secure Air Mattresses
Penalty
Summary
The facility failed to provide adequate supervision and ensure that air mattresses were properly secured for two residents. One resident, who had severe cognitive impairment, muscle weakness, and a history of falls, required two-person assistance for transfers and incontinence care, as well as a mechanical lift. During routine care, two staff members were providing incontinence care when the mattress shifted, causing the resident to fall from the bed onto a floor mat, resulting in a small hematoma on the forehead. The nurse aide involved admitted to standing approximately two feet away from the bed, which created a gap that allowed the resident to fall, contrary to his training to close the gap with his body. Additionally, another resident was observed with an air mattress that was not fastened to the bed with the required six straps. The Maintenance Director confirmed that it was common practice for evening or night staff to not secure air mattresses after changing them, which could result in the mattress shifting. Both deficiencies were confirmed by staff interviews and direct observation, indicating a failure to follow facility policy and care plan interventions designed to prevent accidents and ensure resident safety.
Failure to Document Resident Incident in Clinical Record
Penalty
Summary
The facility failed to maintain complete documentation in the clinical record for one resident following an incident. According to the facility's Incident and Accidents Documentation policy, all unusual occurrences, including actual, alleged, or suspected abuse, must be documented. On August 24, 2025, an incident involving a resident occurred in the front lobby during a family visit. Staff confirmed during interviews that there was no documentation of this incident in the resident's clinical record, despite the policy requirements. This lack of documentation was verified by both the Administrator and the weekend supervisor.
Failure to Implement Elopement Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free of potential hazards for a resident identified as being at risk for elopement. According to facility documentation, the resident was able to break a window block, kick out the screen, and exit through a first-floor window without injury. The resident subsequently left the premises and was later found at his family home by police, who returned him to the facility. The resident's care plan identified him as an elopement risk and included interventions such as staff checking on his whereabouts throughout the shift and placing his picture at the receptionist desk. Upon review, it was observed that the required photograph of the resident was not present at the reception area, as specified in both the facility's elopement policy and the resident's care plan. Staff interviews confirmed that this intervention was not implemented following the resident's elopement. The failure to follow established policies and care plan interventions contributed to the resident's ability to leave the facility unsupervised.
Failure to Accommodate Resident Preferences for Assistance Out of Bed
Penalty
Summary
Facility staff failed to reasonably accommodate the needs and preferences of nine residents regarding assistance out of bed. According to facility policy, residents' abilities in activities of daily living should not diminish unless clinically unavoidable. Observations on unit 2-West at 11:15 am found nine residents still in bed, despite at least one resident expressing a preference to be assisted into a wheelchair during the day shift. An interview with a licensed nurse confirmed that residents are to be assisted out of bed by 11:00 am, yet this was not done for the identified residents. One resident, who is paralyzed on the right side and requires assistance with transfers, specifically stated a preference to be in a wheelchair during the day shift, but was observed still in bed.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for residents in multiple areas. Observations in the common shower room revealed used towels and paper towels on the floor, shower gel and shampoo bottles left on the floor, and used hygiene products on an unclean shower bed. These findings were confirmed with the facility's director of nursing. In one resident room, a stained ceiling tile was observed near a bed, and a resident reported that water leaks through the ceiling tile and HVAC during rainy weather, with a towel placed under the HVAC to address the leak. Further observations included a resident sitting on a bed stained with feces, urine-soaked linen on the bed, a foul odor, and trash on the floor, with the resident attempting to pick up a soiled brief. In another room, a used urinal was attached to a trash bin, briefs and a washbasin were on the floor, and used washcloths and toilet paper were on the bedside table. A grievance report from a family member described finding used latex gloves, tissues, and a wet washcloth left in a resident's room, and dentures left in an unsafe location. These findings indicate a lack of adherence to facility policy regarding the maintenance of a safe and clean environment.
Deficient Smoke-Resistant Separation in Hazardous Areas
Penalty
Summary
The facility failed to ensure that hazardous areas were adequately protected with smoke-resistant separation in sprinklered locations, affecting all three levels of the building. During an observation conducted on January 22, 2022, several deficiencies were noted. On the basement level, the Maintenance and Housekeeping Laundry Room door and Boiler Room door #2 were found to be defective as they failed to close and latch properly. This failure in door functionality compromised the smoke-resistant separation required for these hazardous areas. Additionally, on the second floor, soiled linen carts filled with linen were improperly stored in the corridors, which is against the regulations for hazardous area management. On the first floor, the Annex Diaper Room was found to have multiple unsealed penetrations in the entry door, further compromising the smoke-resistant barrier. These observations were confirmed during an exit interview with the Facility Administrator and Maintenance Director, indicating a lack of maintenance in hazardous enclosures.
Plan Of Correction
Maintenance and Housekeeping Basement level laundry room doors have been repaired. Boiler rm #2 door has been repaired. Soiled linen carts have been removed. Annex Diaper Room penetrations have been sealed with an approved through-penetration fire sealant. Maintenance conducted environmental rounds throughout the facility and there were no further hazardous areas. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0321: Hazardous Areas. The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system in proper operating condition, as evidenced by an observation on January 22, 2025. At 1:05 p.m., the fire alarm panel located at the 2 B Well Nurses Station displayed multiple trouble codes, indicating issues with the system. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director at 2:00 p.m. on the same day.
Plan Of Correction
Corrected on site. The generator company was in the facility at the same time of Life Safety Inspection. They were working on the generator, which caused the trouble codes. The Fire Alarm Panel at 2nd Floor Be Well nurses station does not have any further trouble codes. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0345- Fire Alarm Testing and Maintenance. Maintenance team will inspect Fire Alarm Panel weekly x 4 weeks to ensure there are no trouble codes. Results will be reported on monthly QAPI.
Failure to Maintain and Inspect Emergency Generator System
Penalty
Summary
The facility failed to maintain and inspect its emergency generator system, which is crucial for ensuring the safety and functionality of the facility during power outages. During a document review, it was found that the facility could not provide documentation for several required tests and inspections, including weekly inspections of battery electrolyte levels or voltage, a December 2024 test of battery electrolyte specific gravity or conductance, monthly 30-minute under load tests, evidence of wet-stacking, an annual 90-minute load bank test, a 3-year 4-hour load test, and an annual fuel quality test. These omissions were confirmed during an exit interview with the Facility Administrator and Maintenance Director. Additionally, observations revealed further deficiencies in the emergency generator system. The emergency generator annunciator panel, located on the second floor at the 2 B Well Nurses Station, had multiple trouble lights illuminated when tested, indicating potential issues with the system. Furthermore, the emergency generator set location on the second floor lacked battery back-up emergency lighting, and the manual stop station was located inside a locked room, obstructing access to emergency equipment. These issues were also confirmed during the exit interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The following inspections have been scheduled/ conducted for the Generator: a. Weekly Visual inspection b. Battery electrolyte levels/ or battery voltage c. Battery Electrolyte specific gravity or conductance d. Monthly 30-minute load test e. Evidence of Wet Stacking f. 3 yrs., 4 hrs. load test g. Annual 90 min. Load Bank h. Monthly Load Test i. Annual Fuel Quality test j. Monthly testing and recording of battery specific gravity or conductance testing Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0918 Electrical Systems- Essential Electric Systems. The maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in monthly QAPI.
Failure to Maintain Operable Egress Doors
Penalty
Summary
The facility failed to maintain doors with Special Locking Arrangements (SLA's) in operable condition, specifically affecting one of the three levels. During an observation on January 22, 2025, at 1:40 p.m., it was noted that the East Annex double doors near the reception desk on the first floor had a malfunction. One leaf of the door failed to close when tested, despite being equipped with a magnetic locking feature. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m. The failure of the door to close properly indicates a lapse in maintaining the required egress door standards as outlined by NFPA 101, which mandates that doors in a required means of egress must be operable and not require a tool or key from the egress side unless specific conditions are met.
Plan Of Correction
East doors near reception desk are now functioning appropriately (SLA part replaced). All other egress doors in the facility were inspected and are functioning as designed. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0222: EGRESS. Maintenance Director or Designee will conduct weekly inspections on all egress doors weekly x 3 weeks to ensure all are working as designed. Results will be reported in monthly QAPI.
Failure to Maintain Smokeproof Enclosure in Stairwell
Penalty
Summary
The facility failed to maintain the smokeproof enclosure of a stairwell, specifically affecting one of the three levels. During an observation on January 22, 2025, at 1:15 p.m., it was noted that basement Stairway number 3 had a cleaning cart stored under the stairwell. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
Storage cleaning cart has been removed from stairway #3. Maintenance conducted rounds and there were no other items stored under any stairs. Maintenance Director or Designee will conduct in-service education for housekeeping staff on the importance of adherence to 0225: Stairways and smoke proof enclosures. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.
Failure to Maintain Kitchen Suppression System
Penalty
Summary
The facility failed to maintain the kitchen suppression system as required by NFPA 101 standards. During a document review on January 22, 2025, it was discovered that the facility could not provide documentation showing that the kitchen suppression system had been inspected and serviced on a semi-annual basis. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The Kitchen Suppression System will be repaired on 2/6/25 and inspected prior to 3/21/25. The Maintenance Director will in-service Maintenance staff on the importance of adherence to: 0324 - Cooking Facilities. The Maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in Monthly QA.
Improper Placement of ABHR Dispenser
Penalty
Summary
The facility failed to maintain alcohol-based hand rub dispensers in compliance with safety regulations. During an observation on January 22, 2025, it was noted that on the first floor, East, near room 124, an alcohol-based hand rub dispenser was mounted directly above an electrical outlet. This placement does not adhere to the requirement that dispensers should not be installed within 1 inch of an ignition source. The deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The ABHR dispensers near rm 124 has been removed. Maintenance Staff inspected all other ABHR dispensers in the facility. None are too close to receptacles/outlets. All are in compliance with the code. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0325: Alcohol Based Hand Rub Dispenser (ABHR). The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.
Failure to Maintain Sprinkler System Documentation
Penalty
Summary
The facility failed to maintain its sprinkler system as required, affecting two out of four inspections. During a document review on January 22, 2025, it was discovered that the facility could not provide documentation for the First and Third Quarter sprinkler inspections conducted in the previous 12 months. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
Sprinkler inspections are up to date and documentation is available. The Maintenance Director or Designee will conduct in servicing for maintenance staff on the importance of adherence to 0353- Sprinkler System Maintenance and Testing. The Maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in Monthly QA.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on January 22, 2025, at 12:55 p.m., it was noted that on the second floor, above the smoke doors near resident room 253, there were unsealed penetrations around data wires. This deficiency affected two of the four smoke compartments in the facility. The issue was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
The unsealed penetrations near 253 have been sealed with an approved through-penetration fire sealant. Environmental rounds have been conducted through the facility. There were no further penetrations. The Maintenance Director or Designee will conduct in servicing for maintenance staff on the importance of adherence to 0372 Subdivision of Building spaces - Smoke Barrier. The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors with smoke-tight resistance, as required by NFPA 101 standards. During an observation on January 22, 2025, at 12:30 p.m., it was noted that the double smoke doors on the second floor, West, next to resident room 227, did not close properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director later that day at 2:00 p.m. The issue affected two of the three levels in the facility, indicating a lapse in maintaining the required fire safety measures.
Plan Of Correction
Double smoke door near rm 227 is working as designed. It only closes if the fire alarm is activated. Environmental rounds have been conducted through the facility. There were no malfunctioning doors. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0374 Subdivision of Building spaces- smoke barriers. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Improper Use of Portable AC in HVAC System
Penalty
Summary
The facility failed to maintain its HVAC systems in compliance with NFPA 101 standards, specifically affecting one of three levels. During an observation, it was noted that a portable air conditioning unit was ducted into the ceiling in the Maintenance and Housekeeping basement corridor, next to Boiler Room #2. This portable AC unit was confirmed by the Facility Administrator and Maintenance Director to be used as a permanent part of the HVAC system, which is not in accordance with the manufacturer's specifications or the required standards.
Plan Of Correction
Portable air conditioning unit removed from boiler rm #2. Maintenance Director conducted rounds in the facility and there were no other air conditioners installed out of compliance. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0521- HVAC. The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Combustible Materials on Heating Units
Penalty
Summary
The facility failed to maintain heating units free of combustible materials, which is a requirement under NFPA 101 for HVAC systems. During an observation conducted on January 22, 2025, between 12:30 p.m. and 1:15 p.m., it was noted that combustible materials were placed on top of heating units in resident rooms 240 and 108. This deficiency affected two of the three levels of the facility. The issue was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
Combustible materials removed from HVACs in 108 and 240. Maintenance Director conducted facility rounds and there were no other HVACs covered with combustible materials. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0522-HVAs- Any Heating Device. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Non-GFCI Outlet Found Near Kitchen Sink
Penalty
Summary
The facility failed to maintain electrical systems in compliance with safety standards, specifically in wet locations. During an observation on January 22, 2025, at 2:05 p.m., it was noted that a non-GFCI outlet was installed within 6 feet of the kitchen hand wash sink. This is a violation of the requirement for ground-fault circuit interrupters (GFCI) in wet areas to ensure safety. The deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The outlet near the kitchen hand wash sink has been replaced with an appropriate GFCI outlet. The Maintenance Director conducted facility rounds and there were no other NON-GFCI outlets located within 6 inches of a sink. The Maintenance Director or Designee will conduct in servicing for maintenance staff on the importance of adherence to: 0912- Electrical Systems - Receptacles. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Oxygen Storage Signage Deficiency
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements on the second floor west nursing station medical room. During an observation on January 22, 2025, it was noted that the entry door to the medical room lacked the required precautionary signage. The sign should have included the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING." This omission indicates a failure to comply with safety protocols for storing oxidizing gases. Additionally, inside the room, there was an absence of signage to differentiate between "Empty" and "Full" oxygen cylinders. This lack of proper labeling could lead to confusion and mishandling of oxygen cylinders. The deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director, who acknowledged the missing signage.
Plan Of Correction
Cautionary, (NO SMOKING), Empty, and Full signs have been placed in 2 west nsg station medical room. Maintenance Director conducted facility rounds and all other oxygen storage areas had appropriate signage. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0923- Storage. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Deficiency in Emergency Preparedness Training Program
Penalty
Summary
Monumental Post-Acute Care at Woodside Park was found to have deficiencies in its Emergency Preparedness Training program during a survey conducted on January 22, 2025. The survey revealed that the facility failed to develop a comprehensive training program based on its emergency plan, risk assessment, policies and procedures, and communication plan. This deficiency affected the entire facility, as it did not include written policies and procedures identifying the training program for all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. The documentation reviewed during the survey indicated that the Emergency Preparedness plan lacked the necessary written policies and procedures for training. This omission was confirmed during an exit interview with the Facility Administrator and Maintenance Director. The absence of a structured training program meant that the facility did not meet the requirements set forth in 42 CFR 483.73, which mandates initial and ongoing training in emergency preparedness for all relevant personnel. The deficiency was identified through a combination of document review and interviews with facility staff. The lack of a documented training program suggests that the facility did not adequately prepare its staff and volunteers for emergency situations, potentially impacting their ability to respond effectively in such events. However, the report does not provide specific details about any incidents or patient outcomes related to this deficiency.
Plan Of Correction
MPAC has an Ep plan which includes education and training of Staff on Hire and annually. Maintenance Director and team will be re-in-serviced BY nha on MPAC Emergency Preparedness' Plan. The Maintenance Director or Designee will conduct random Drills/quizzes monthly to ensure Staff are aware of and follow MPAC EP guidelines during emergencies. Results of Random Drills will be reported in Monthly QAPI.
Building Construction Deficiency Due to Unprotected Structural Elements
Penalty
Summary
The facility failed to maintain building construction requirements, as evidenced by unprotected structural steel columns and beams above the suspended ceiling assemblies and pan-style ceiling diffusers lacking full 'blanket' protection. This resulted in the building being classified as unprotected ordinary construction. The building, classified as two stories, exceeds the maximum height allowed for unprotected ordinary construction by one story. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The facility was evaluated by an engineering firm in 2018. The evaluation determined that the building is permitted to be of Type II (000) construction, which means that the steel in the building is permitted to be non-rated and unprotected. An analysis of the facility structure type was conducted by an engineer. The analysis provided concluded that the "construction type of the two-story, sprinkler protected, existing health care building is permitted to be Type II (000)." Type II (000) is an unprotected non-combustible construction. The facility has been classified as a Type III (200), unprotected ordinary construction. A request for a Time Limited Waiver was submitted to the Director of Safety Inspection on 9/8/21, to last through 1/1/2025. The FSES worksheets will be reviewed and revised by an engineer to identify if alternative corrections will be needed. The FSES worksheets (5.5) from the 2010 edition of the NFPA Guide on Alternative approaches to Life Safety will be included in the analysis.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers in accordance with NFPA 10, affecting the entire facility. During a document review on January 22, 2025, it was found that the facility could not provide an appropriate certificate for the technician responsible for conducting the annual fire extinguisher inspections. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
Information Regarding the qualifications of the Tech/s conducting annual fire extinguisher inspections are available on site in the facility. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0355- Portable Fire Extinguishers. The maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in Monthly QA.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations and interviews. During a tour of the main kitchen, it was noted that a bucket with soapy water and a rag was placed on the preparation table while a cook was assembling sandwiches, which is a breach of sanitary food preparation practices. Additionally, the main refrigerator contained three rolls of 10-pound ground beef, a bag of raw mixed chicken, and a bag of raw chicken thighs that were unlabeled and undated. The Food Service Director confirmed that these items had been removed from the freezer two days prior and should have been labeled with a pull date, as per the facility's policy. Further observations revealed that dishes were drying on the tray line with limited airflow, and prepared hot food was placed nearby, which is not in accordance with proper food safety standards. The drying racks, which should have been used to allow proper draining and airflow, were not utilized. These findings indicate a failure to store, prepare, distribute, and serve food in a manner that meets professional standards for food service safety, as required by the regulations.
Plan Of Correction
The Soapy water and bucket were removed immediately. The dishes were removed from the tray line. The Ground Beef and chicken have since been labeled and used. All other Food items in the kitchen have been inspected by Food Services Director and dated as appropriate. The Food Services Director or Designee will In-service dietary staff on importance of sanitation practices, using the drying rack for dishes, and labeling and dating items when pulled. The Dietary Director or designee will conduct Kitchen inspections weekly for 4 weeks to ensure compliance. Results will be reported in monthly QAPI.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by observations made during a survey of the Food Service Department. On an initial tour, it was noted that the blue dumpster was fully open and overflowing with cardboard boxes, with additional piles of cardboard and boxes scattered on the ground around the dumpster. A follow-up observation confirmed that the situation remained unchanged, with the dumpster still overflowing and surrounded by refuse. An interview with the Food Service Director corroborated these findings, indicating a lack of proper waste management practices in the facility.
Plan Of Correction
The recycling container has since been emptied and no other trash or garbage container on facility property is overflowing. Dietary, housekeeping and maintenance staff will be in-serviced by staff the educator or designee on importance of breaking down boxes prior to dumping in the recycle bin. Dietary Director or Designee will conduct observations weekly times 4 weeks to ensure that the recycle bin not overflowing. Results will be reported in monthly QAPI.
Failure to Notify Ombudsman and Resident's Representative of Emergency Transfers
Penalty
Summary
Monumental Post Acute Care at Woodside Park was found to be non-compliant with the requirements of 42 CFR part 483, Subpart B, specifically regarding the notice requirements before transfer or discharge of residents. The facility failed to notify the Office of the State Long-Term Care Ombudsman about facility-initiated emergency transfers to the hospital for a resident. Additionally, the facility did not inform the resident's representative of the transfer and the reasons for the move in writing and in a language and manner they understand. The deficiency was identified through a review of nursing notes and clinical records for a resident who experienced a seizure and was transferred to a local hospital for evaluation. Further documentation revealed another instance where the resident was admitted to the hospital for altered mental status. Despite these transfers, there was no documentation available to indicate that the Ombudsman was notified, as required. Interviews with staff confirmed the lack of notification to both the Ombudsman and the resident's representative.
Plan Of Correction
State Long Term Care Ombudsmen have been notified of Transfers/discharge for R136. The Social Services team have been educated on the importance of adherence to regulations re: F623. All discharges, transfers, and discharges have been reviewed for the past three months. There were no further discrepancies in notification. State Long Term Care Ombudsmen will be notified of emergency transfers in writing by Social Services or designee monthly. Notification of State Long Term Care Ombudsmen will be reviewed/audited monthly for accuracy by Social Services, and the results will be reported in monthly QAPI.
Failure to Provide Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to provide appropriate bed hold notice to a resident's representative during a facility-initiated transfer to the hospital. This deficiency was identified for one of four residents reviewed for transfers. The resident in question, who had severely impaired cognition, was transferred to a local hospital for evaluation following a seizure. Despite the transfer, there was no documentation in the resident's clinical record indicating that the resident's representative was provided with the required written information about the duration of the state bed-hold policy. An interview with the Social Services Director confirmed the absence of documented evidence that the resident's representative was notified of the bed hold policy at the time of the transfer. The lack of documentation was corroborated by the Social Services Director, who acknowledged that no such records were available for review during the survey. This oversight is a violation of the regulatory requirements for notifying residents or their representatives about bed-hold policies during transfers.
Plan Of Correction
R136 is now aware of MPAC's bed hold policy. The Social Services team have been educated by the NHA on the importance of adherence to regulations re: F625. All discharges, transfers, and discharges have been reviewed by social services staff for the past three months. There were no further discrepancies in notification of bed hold policy. Notification of resident representatives re: facility bed hold policy will be reviewed/audited monthly for accuracy by Social Services. Results will be reported monthly in QAPI.
Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status concerning restraints for two residents. Resident R9, who was admitted with diagnoses of schizophrenia, anxiety, and dementia, was inaccurately documented in the Minimum Data Set (MDS) as having a chair that prevents rising, used less than daily. However, observations revealed that Resident R9 was ambulating freely, and interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility was restraint-free and the MDS was coded inaccurately. Similarly, Resident R38, with diagnoses including anxiety disorder and non-Alzheimer's dementia, was documented in the MDS as using a limb restraint in a chair or out of bed, used less than daily. Observations showed that Resident R38 had no restraints, and there was no physician order for restraints. Interviews with the resident and facility staff confirmed that the resident never had any restraints, and the MDS was inaccurately coded. These inaccuracies in the MDS assessments led to the deficiency findings.
Plan Of Correction
MDS has been corrected for R9 and R38. MDS coordinators or designees will audit all current MDS's to ensure there are no further discrepancies. MDS coordinators will be in-serviced by NHA or designee on importance of assessment accuracy. MDS audits will be conducted by MDS coordinators or designees to ensure assessment accuracy monthly for 3 months, then quarterly thereafter. Results will be reported in QA.
Failure to Update PASRR Following New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to update the Pennsylvania Pre-Admission Screening Resident Review (PASRR) for a resident who was newly diagnosed with a serious mental disorder. The resident, admitted on March 4, 2021, had initial diagnoses including Acute Kidney Failure, Injury of Unspecified Body Region, and Type 2 Diabetes Mellitus. The PASRR Level I Form completed on the admission date indicated a negative screen for Serious Mental Illness, Intellectual Disability/Developmental Disability, or other related conditions, and no further evaluation was deemed necessary at that time. However, on June 4, 2021, the resident received a new diagnosis of Undifferentiated Schizophrenia, a serious mental disorder. Despite this significant change in the resident's mental health status, there was no documented evidence that the facility considered or initiated a referral for a Level II PASARR evaluation and determination. This oversight was confirmed during an interview with the Director of Social Services, indicating a failure to comply with the requirement to update the PASRR following a significant change in the resident's condition.
Plan Of Correction
R103 PASARR has been updated. Social Services staff have been educated regarding the importance of ensuring that residents who have a new schizophrenia are reevaluated for a new or updated PASARR. All residents with PASARRS have been reviewed by social services staff and all are accurate and up to date. All residents with PASARRS will be audited monthly for 3 months by social services or designee to ensure they are up to date. Results will be reported in monthly QAPI.
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 addressing their specific needs. Resident R7, who was admitted with diagnoses including Type 2 Diabetes Mellitus and Dementia, did not have a care plan developed for dementia care. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing. Similarly, Resident R28, who was observed taking smoke breaks, did not have a care plan addressing safety during smoking. The Unit Manager, Nurse Employee E14, was unaware of why a care plan for smoking was not developed. Additionally, Resident R155, who was admitted with prostate cancer and septic pulmonary embolism, was observed to be in pain without a corresponding care plan for pain management. Despite having physician orders for hospice services and pain medications, no care plan was developed to address the resident's pain related to the cancer diagnosis. This oversight was confirmed in an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the expectation that care plans should be developed for all resident care needs.
Plan Of Correction
Care plans for R7, R28, R155 have been updated to reflect dementia, smoking, and pain management as appropriate. All residents' care plans have been reviewed and updated. Unit managers will be educated by staff development or designee on the importance of ensuring up to date and accurate care plans. Care plans will be audited by unit managers or designee monthly x 3 months then quarterly thereafter. Results will be reported in monthly QAPI.
Failure to Update Care Plan for Hospice Status Change
Penalty
Summary
The facility failed to ensure that care plans were updated in a timely manner for a resident who was receiving hospice care. The resident, who had been admitted to the facility with diagnoses including congestive heart failure, ventricular tachycardia, and the presence of a pacemaker, had a physician order on October 10, 2023, to have the pacemaker turned off due to hospice status. The care plan was updated on the same day to reflect this change. However, a subsequent physician order dated December 2, 2024, discontinued hospice care, but the care plan was not updated to reflect this change as of January 10, 2025. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the facility's expectations were for care plans to be reviewed and updated promptly with every major change, such as signing on to or discontinuing hospice care. It was acknowledged that the care plan for this resident had not been updated as required, leading to a deficiency in meeting the regulatory requirements for care plan timing and revision.
Plan Of Correction
The Care plan is revised as appropriate for R31. DON or designee will conduct in-service education on the importance of updated and accurate care plans. Unit managers or designees will update all residents' care plans who have pacemakers, to ensure that they reflect the resident's current pacemaker status. Care plans will be audited by unit managers or designee monthly x 3 months then quarterly thereafter. Results will be reported in monthly QAPI.
Deficiency in Nursing Staff Competency Documentation
Penalty
Summary
The facility was found to be deficient in ensuring that licensed nursing staff had the necessary competencies and skills to provide adequate care to residents. This deficiency was identified during a survey conducted on January 10, 2024, when the surveyor requested evidence of skills competency evaluations for licensed nurses. The requested competencies were related to medication administration, dementia and behavioral care, catheter and tracheostomy care, wound care, and abuse prevention and reporting. During an interview with the facility's educator, identified as Employee E12, it was revealed that the facility was unable to provide the requested documentation of skills competencies for the nurses. Employee E12 admitted that the facility did not have the necessary records to demonstrate that the nursing staff had been evaluated for the required competencies. This lack of documentation indicates a failure to ensure that the nursing staff possessed the specific skills needed to meet the residents' care needs as outlined in their individual care plans.
Plan Of Correction
Staff Educator conducted competency assessments for licensed nurses. Licensed Nurses who currently work in the facility now have skills competency evaluations for: Medication Administration, Dementia and Behaviors, Urinary Catheters, Tracheostomy care, wound Care and Abuse prevention and reporting. Staff Educator or Designee will conduct Skills competency evaluations for all licensed nurses at least annually. Staff Educator or Designee will conduct Skills competency evaluation audits Quarterly. Results will be kept on file and reported on Monthly QAPI.
Delayed Disposal of Controlled Medications
Penalty
Summary
The facility failed to ensure the timely disposal of controlled medications for a resident, identified as Resident R162, who was admitted on September 23, 2024, and discharged against medical advice on October 24, 2024. During her stay, she had prescriptions for Morphine Sulfate, a Schedule 2 controlled medication, and Lorazepam, a Schedule 4 controlled substance. These medications are known for their potential for misuse and dependence. Upon review, it was found that the controlled medications were not disposed of until January 9, 2025, which was 11 weeks after the resident's discharge. The delay in the disposal of these medications was confirmed through an interview with the Director of Nursing, Employee E2, who acknowledged that the disposal was not conducted in a timely manner. The nursing note from January 9, 2025, indicated that all medications, including the controlled substances, were counted and destroyed on that date. However, the facility's failure to dispose of these medications promptly after the resident's discharge constitutes a deficiency in their pharmacy services, as it did not comply with the requirement for timely reconciliation and disposal of controlled drugs.
Plan Of Correction
All medication for R162 have been destroyed. The Staff educator or designee will in-service all Licensed nurses on the importance of timely disposal of medications after discharge. All Medication Carts and Medication rooms were inspected by unit managers and there are no further incidents of untimely disposal of medication. Unit managers or designees will conduct audits on discharge residents weekly for 4 weeks to ensure timely disposal of medications. Results will be reported in monthly QAPI.
Infection Control Deficiency: Failure to Use PPE
Penalty
Summary
The facility failed to maintain an effective infection control program concerning Transmission Based Precautions for Resident R113. The deficiency was identified during an observation on January 10, 2025, when a Licensed Nurse, Employee E17, was seen cleansing Resident R113's G-tube site without wearing the required personal protective equipment (PPE). This was despite the fact that Resident R113 was on Enhanced Barrier Precautions, as indicated by a guiding description on the door of the resident's room. Resident R113 had a physician's order dated July 11, 2024, to cleanse the G-tube site daily with soap and water during the day shift. The failure to use PPE during this procedure was confirmed with Employee E17 at the time of the observation. Enhanced Barrier Precautions are infection control measures designed to reduce the transmission of novel or Multi-Drug Resistant Organisms, requiring the use of targeted PPE during high-contact activities.
Plan Of Correction
PPE is now worn for high contact activities with R113. All residents who are on Enhanced Barrier precautions have been reviewed by DON/ educator. PPE is available on the unit for all residents who require use during high contact activities. Licensed nurses will be in-serviced by the educator or designee on the importance of wearing PPE for high contact activities with residents who are on Enhanced Barrier Precautions. Staff educators or designee will conduct random audits during resident care weekly times 4 weeks to ensure PPE is being used appropriately. Results will be reported in monthly QAPI.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day on four specific days in January 2025. A review of nursing staffing hours revealed that on January 3, 2025, the facility provided 509 care hours for 164 residents, resulting in 3.1 hours per patient day (PPD). On January 4, 2025, 502 care hours were provided for 165 residents, totaling 3.04 PPD. On January 5, 2025, 524.5 care hours were provided for 165 residents, resulting in 3.18 PPD. On January 6, 2025, 507.5 care hours were provided for 161 residents, totaling 3.15 PPD. These staffing levels were confirmed by the Nursing Home Administrator, Employee E1, as not meeting the required minimums.
Plan Of Correction
The multidisciplinary team has reviewed the dates: January 3rd, 4th, 5th, and 6th. There were no resident negative outcomes as a result of substandard staffing on those days. DON or designee will calculate PPD daily for accuracy prior to the start of the day. Daily PPD will be documented and kept on file for ongoing review and reporting. DON or designee will review all PPDs for the past 3 months to ensure none were below the current required minimum of 3.2. Results will be reported in Monthly QAPI.
Failure to Implement Lice Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan to prevent reinfestation of lice for a resident diagnosed with bipolar disorder. The resident, who was admitted to the facility with this diagnosis, experienced two separate incidents of lice infestation after visits with his sister. On both occasions, the resident returned to the facility with lice, necessitating treatment for himself, his roommate, and their room and clothing. Despite these incidents, the resident's care plan did not include measures to prevent further lice infestations related to family visits or infested items being brought into the facility. Interviews with the LNAC and the Director of Nursing confirmed the absence of such a care plan, highlighting a deficiency in addressing the resident's specific needs.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple structural and housekeeping deficiencies. Observations revealed that the double doors adjacent to the main kitchen were not sealed, allowing easy access for pests and rodents. Additionally, a plumbing issue in the janitor closet resulted in ongoing sewage backup and water damage. The ceiling tiles above the hot food preparation area were covered with oil and grease, and the commercial deep fat fryer contained cooking oils and food debris, providing food sources for pests. The trash receptacles outside the food and nutrition department were not covered, and the surrounding area was littered with discarded trash, further attracting pests and rodents. Interviews with the Director of Dietary Services and the administrator confirmed the presence of pests and rodents throughout the facility, as well as structural deficits and lack of housekeeping contributing to the problem. The pest control operator's service reports for February and March 2024 identified multiple voids, holes, and gaps in resident rooms and common areas that required sealing. Mice activity was noted in various locations, including the main kitchen, resident rooms, and the administrator's office. The pest control operator repeatedly requested structural repairs to eradicate the pests, but these repairs were not completed. Residents also reported issues with mice in their rooms. One resident had a container of grapes at their bedside that was not stored in an airtight container, and another resident had a piece of rotting fruit on the windowsill. These observations were confirmed by a registered nurse. The facility's failure to address structural and housekeeping issues, as well as the lack of effective pest control measures, led to the ongoing presence of pests and rodents, compromising the health and safety of the residents.
Failure to Prepare Pureed Food to Proper Consistency
Penalty
Summary
The facility failed to ensure that food was prepared appropriately for nine residents on a pureed diet. Facility documentation indicated that pureed foods should be smooth and thick enough to mound on the plate, similar to pudding. However, observations revealed that the pureed chicken and vegetables served to the residents had a watery appearance and were runny on the plate. This was confirmed during an interview with the Food Service Director, who acknowledged that the pureed items were not prepared to the proper consistency. The deficiency was observed during lunch service and on the tray line steam table in the main kitchen.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, antibiotic usage, and isolation precautions for four residents. The facility's policies on infection control, standard precautions, contact precautions, and droplet precautions were not properly implemented. For instance, Resident R45 was incorrectly placed under Special Droplet/Contact Precautions instead of the required Contact Precautions for MRSA, leading to confusion and improper use of PPE. Additionally, the facility did not have a policy related to Enhanced Barrier Precautions, further complicating the situation for Resident R45. The facility also failed to maintain accurate and up-to-date infection surveillance data and antibiotic tracking for the residents. No infection surveillance data was available for review for the months of February, March, and April 2024. This lack of data made it impossible to determine if any of the infections were facility-acquired or reportable to the Pennsylvania Patient Safety Reporting System (PA-PSRS). The Infection Preventionist was unable to provide any infection analysis or relevant policies, indicating a significant gap in the facility's infection control practices. Furthermore, the facility's infection committee was found to be ineffective. The last infection committee meeting was held in December 2023, and the minutes from that meeting revealed that only basic infection data was reviewed. There was no participation from laboratory or pharmacy personnel, and no data analysis from these departments was included. The committee did not review any infection control practices, antibiotic stewardship, staff education programs, or pertinent health advisories, highlighting a systemic failure in the facility's infection prevention and control program.
Failure to Maintain Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of antibiotic use protocols and systems for monitoring antibiotic use for four residents. During the survey, it was found that the facility did not have any recent data or documentation related to their antibiotic stewardship program. The Infection Preventionist and the Director of Nursing were unable to provide any information or documentation regarding the facility's antibiotic stewardship plans, policies, or procedures. The only data available was outdated, from 2019 and 2020, and did not include any recent information on antibiotic usage or infection control measures. The deficiency was highlighted through the review of clinical records for four residents who were prescribed antibiotics for various infections. These residents included one with a right foot infection and MRSA, another with a right foot infection treated with clindamycin, a third with bilateral leg wounds treated with gentamicin cream, and a fourth with a urinary tract infection requiring intravenous antibiotics. Despite these cases, the facility had no tracking or monitoring system in place for antibiotic use, and no documentation was available to demonstrate compliance with an antibiotic stewardship program. This lack of oversight and documentation indicates a significant gap in the facility's infection control and antibiotic management practices.
Failure to Provide Proper Wheelchair Size for Resident
Penalty
Summary
The facility failed to ensure proper accommodation of needs for a resident regarding the appropriate wheelchair size. Resident R47, who has chronic kidney disease, unspecified dementia, type 2 diabetes, pain in unspecified joints, and muscle weakness, was admitted to the facility and assessed by physical therapy on December 5, 2023, and provided a wheelchair. However, a re-assessment on February 20, 2024, determined that the resident's wheelchair was too small and required a larger one. Despite this, the resident continued to use the improperly fitted wheelchair until March 3, 2023, when the surveyor observed the issue and brought it to the attention of the physical therapist, who then located a larger wheelchair for the resident. The resident's discomfort in the wheelchair was confirmed through observations and interviews. On March 2 and March 3, 2023, the resident was observed in the hallway outside his room, seated in a noticeably improper fitted wheelchair. During an interview on March 3, 2023, the resident expressed discomfort and a desire for a larger wheelchair. The physical therapist, Employee E23, confirmed the wheelchair was too small and only took action to find a larger wheelchair after the surveyor's observation. This failure to promptly address the resident's needs and preferences constitutes a deficiency in accommodating the resident's needs appropriately.
Discrepancy in Advanced Directives for a Resident
Penalty
Summary
The facility failed to ensure that advanced directives were accurately reflected in the records of Resident R45. The resident, who was admitted with severe cognitive impairment and multiple serious medical conditions, had a POLST form indicating a DNR status. However, the active physician orders for the resident indicated a Full Code status, which is contradictory to the DNR directive. This discrepancy was not explained in the progress notes reviewed from March 6, 2024, through April 4, 2024. During an interview, the unit manager confirmed the inconsistency between the physician orders and the POLST form but was unable to provide an explanation for the discrepancy. This failure to align the resident's advanced directives with the physician orders constitutes a deficiency in honoring the resident's right to request, refuse, and/or discontinue treatment as per their advance directive.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment on one of its nursing units. Observations revealed multiple deficiencies, including an open window without a screen, a falling front panel of the heating/air conditioning system, and a large hole in the wall above the baseboard by the bathroom in one room. A resident expressed that the hole in the wall was bothersome and wished for it to be repaired. Further observations identified additional issues such as holes in walls, broken drawers, and missing baseboard panels in several rooms. These findings were confirmed by the Maintenance Director during a tour of the unit.
Incomplete Investigation of Incontinence Care Incident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an incident involving a resident's incontinence care. Resident R442, who has intact cognition and was admitted for continued medical management and therapy after repeated falls, reported that she was left wet and soiled for hours from March 23 to March 24, 2024. The family reported this grievance to the social worker on March 25, 2024. The investigation conducted by the facility included a statement from only one nurse aide, Employee E30, who worked the night shift and claimed to have checked on the resident multiple times during the night. However, there was no statement from the resident herself or from the nurse aide on the morning shift, making the investigation incomplete. Interviews with the social worker, the Director of Social Worker, and the Assistant Nursing Home Administrator confirmed that the investigation was incomplete. The report lacked a statement from Resident R442 and did not include input from the morning shift nurse aide. This failure to gather comprehensive information and statements from all relevant parties led to the determination that the facility did not adequately respond to the alleged violation of incontinence care for Resident R442.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for two residents, R45 and R70, who were unable to perform this task themselves. Resident R45, who has right-sided hand and arm weakness due to a cerebrovascular accident, was observed with long, overgrown, and dirty fingernails. Despite the resident's expressed discomfort and inability to manage his own nail care, and the facility's policy requiring staff to provide such care, his nails remained untrimmed and dirty over multiple days. Interviews with staff confirmed that nail care was the responsibility of the nursing staff, yet it was not provided as needed. Similarly, Resident R70, who has bilateral hand contractures and requires assistance with activities of daily living, was observed with significantly long and dirty fingernails. The resident's care plan indicated that nail care should be provided on shower days, but this was not done. Staff interviews confirmed the resident's need for nail care, yet it was not addressed. These observations and interviews indicate a failure by the facility to adhere to its own grooming policy and to meet the residents' needs for personal hygiene.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for two nurse aides, Employee E28 and Employee E29, as required by regulations. Employee E28 was hired on July 12, 2022, and Employee E29 was hired on August 3, 2009. During an interview on April 4, 2024, the Nursing Home Administrator confirmed that the annual performance reviews for these employees had not been completed. This deficiency was identified based on a review of facility documentation and staff interviews.
Unlocked Medication Cart on Secured Nursing Unit
Penalty
Summary
The facility failed to ensure that one of two medication carts observed remained locked on a secured nursing unit. During an observation on the second floor secured nursing unit, an unlocked medication cart was found in the hall with no employee in sight. A resident was observed sitting in a wheelchair next to the open cart. The facility's policy, last revised on June 1, 2020, requires that medication carts be kept locked unless in immediate attendance. An interview with a licensed nurse confirmed that the medication cart was unlocked and that the nurse had stepped away to assist a resident in another room.
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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