Newport Meadows Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Christiana, Pennsylvania.
- Location
- 41 Newport Avenue, Christiana, Pennsylvania 17509
- CMS Provider Number
- 395403
- Inspections on file
- 29
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Newport Meadows Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and chronic pain had PRN Oxycodone orders that were adjusted around a surgical procedure, but the facility failed to maintain complete and accurate MAR documentation. On numerous occasions, doses of Oxycodone recorded on the controlled substance administration record were either missing from the EMR MAR or documented at different times than shown on the controlled substance record. Facility policy required full documentation of pain assessments, medication, dose, route, and results in the medical record, yet the DON acknowledged that EMR entries did not match the controlled substance record, resulting in incomplete clinical records.
A resident who was frequently incontinent and dependent on staff for toileting was found with a soaked incontinence brief late in the morning, indicating that timely incontinent care had not been provided. Documentation showed the last care was recorded during the night shift, and staff interviews confirmed that morning care was delayed due to competing duties. The DON verified that care was not provided as needed, in violation of facility policy.
A resident with multiple medical conditions experienced increased slurred speech, which was observed by an LPN but not reported to the physician or documented, contrary to facility policy. Family concerns later prompted assessment and hospital transfer, where the resident was diagnosed with Dilantin toxicity. The facility failed to ensure timely physician notification of the resident's change in condition.
The facility did not meet the required nurse aide staffing ratios during specific shifts over a period, failing to provide one nurse aide per 10 residents during the day on four days, one per 11 residents during the evening on one day, and one per 15 residents during the night on one day. These deficiencies were identified through staffing data review and communicated to the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per day on seven occasions, with PPDs ranging from 2.83 to 3.19. This was identified through staffing data review and communicated to the Nursing Home Administrator.
The facility failed to maintain required nurse aide staffing ratios over several shifts in December 2024, with deficiencies confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient day for nine days, with PPD ranging from 2.76 to 3.09. This deficiency was identified through staffing data review and communicated to the Nursing Home Administrator.
A resident in an LTC facility was mistakenly given their roommate's medications by an LPN, who failed to properly verify the resident's identity. This error led to the resident experiencing bradycardia and hypotension, requiring emergency medical treatment and hospitalization. The incident was identified as past non-compliance due to the LPN not following the facility's medication administration policy.
A resident suffered second-degree burns after a nursing employee failed to ensure a reheated beverage was at a safe temperature before serving. The resident, who was cognitively intact, requested their coffee to be reheated, but the facility did not document temperature checks as required by policy, leading to the injury.
The facility failed to monitor and assess side effects of antipsychotic medications for three residents. Two residents on Abilify lacked side effect monitoring in their MARs, while another resident on Risperidone had improper documentation of side effect monitoring. These issues were confirmed with the DON.
The facility failed to follow COVID-19 infection control measures on the 1st Floor Chestnut Unit. An employee did not change PPE or perform hand hygiene between resident tests, and the facility did not notify visitors of COVID-19 presence. The DON confirmed the need for proper PPE use and visitor screening.
The facility failed to develop and implement comprehensive care plans for two residents. One resident receiving oxygen therapy lacked a care plan for this intervention, while another with a wrist contracture had no care plan addressing the condition or the recommended intervention of using a rolled-up washcloth. These deficiencies were confirmed by the DON, indicating a lack of proper documentation and planning for the residents' needs.
A facility failed to follow physician orders for a resident's fluid restriction, with records showing the resident consistently consumed more fluids than prescribed. The nursing staff did not document fluid intake, and the DON confirmed the dietary fluid restriction was not followed.
A deficiency was found in the pharmacy services when a physician disagreed with a Consultant Pharmacist's recommendation for a GDR for a resident but failed to provide a clinical rationale. This was confirmed by the DON, indicating non-compliance with regulatory requirements.
A resident experienced a delay in receiving an x-ray for a foot injury after a fall, as recommended by a podiatrist. The x-ray, which was ordered on the day of the podiatry consult, was not performed until several days later, revealing a fracture. This delay was confirmed by the DON.
A facility failed to accurately follow physician medication orders for a resident with Epilepsy and IBS. Prednisone was incorrectly transcribed in the MAR, leading to improper administration. Additionally, Mesalamine was not administered due to unavailability, and the physician was not consistently notified of the missed doses.
The facility failed to implement Enhanced Barrier Precautions for three residents with wounds, as required by their policy. Observations showed no signage or PPE at the room entrances, and a nurse confirmed that staff had to request PPE from housekeeping. This deficiency was noted during a review of the facility's infection control practices.
The facility failed to obtain physician's orders for immediate care at the time of admission for a resident requiring dialysis. Despite documentation indicating the need for dialysis three times a week, the physician's admission orders did not include these instructions. This was confirmed through an interview with the NHA and Assistant NHA.
Incomplete and Inaccurate Documentation of Controlled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medication administration records for a cognitively intact resident with multiple chronic conditions, including bladder cancer, diabetes mellitus, depression, chronic pain syndrome, and a right below-knee amputation. Facility policy on administering pain medications requires documentation of the pain assessment, medication, dose, route, and results of the medication in the resident’s medical record. The resident had an order for Oxycodone HCL 15 mg by mouth every 8 hours as needed for moderate to severe chronic pain, later changed to every 6 hours for a post-surgical period and then changed back to every 8 hours. Review of the February and early March 2026 MARs and the Individual Patient Controlled Substance Administration Record showed multiple discrepancies between doses documented on the controlled substance record and those recorded in the electronic medical record (EMR). On multiple dates in February and March 2026, doses of Oxycodone were recorded as administered on the Patient Controlled Substance Administration Record but were either missing or documented at different times in the EMR. Specifically, on several dates in February, one or more doses given at documented times (e.g., midnight, morning, afternoon, or late evening) on the controlled substance record were not recorded at all on the EMR MAR. On other dates, the times of administration differed between the two records, such as doses documented at 8:00 AM and 2:00 PM on the controlled substance record but at 9:11 AM and 3:00 PM in the EMR. Additional missing EMR entries occurred after the order reverted to every 8 hours, with several doses documented on the controlled substance record not appearing in the EMR. During an interview, the DON acknowledged that the EMR documentation was incomplete and did not reflect the controlled substance administration record, indicating noncompliance with the requirement to maintain clinical records in accordance with accepted professional standards.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident who was frequently incontinent of bladder and dependent on staff for toileting. According to the resident's Minimum Data Set (MDS), the resident required assistance with toileting and was frequently incontinent. On the morning of the observation, the resident was found in bed with a soaked incontinence brief containing dark yellow/light brown urine, and their hair was disheveled. The staff member assigned as the resident's morning aide confirmed that incontinent care had not been provided since the aide's arrival at 7:00 a.m., as other duties such as passing breakfast trays and preparing residents for the hair salon took precedence. The aide was unsure when the night shift last provided care. A review of the resident's care documentation indicated that the last recorded incontinent episode was at 1:08 a.m., with toileting hygiene marked as not applicable at that time. The Director of Nursing confirmed that the resident did not receive timely incontinent care. The facility's policy requires staff to appropriately manage urinary incontinence and provide services to prevent urinary tract infections, but these procedures were not followed for this resident.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify the physician of a change in a resident's condition as required by facility policy. A resident with diagnoses including severe protein calorie malnutrition, epilepsy, and dysarthria was observed by an LPN to have increased slurred speech, but the LPN did not notify the physician or document the observation, attributing the change to a previous respiratory illness. There was no documentation in the clinical record regarding slurred speech or its worsening during the relevant period. The facility's policy requires staff to notify the physician of significant changes in a resident's physical or mental condition, but this was not followed in this instance. Further review of the resident's record showed that a family member expressed concern about a dramatic negative change in the resident's vocal ability, prompting a nursing supervisor to assess the resident and arrange for hospital transfer. Hospital records indicated the resident presented with worsening dysarthria, confusion, bilateral lower extremity weakness, and was diagnosed with Dilantin toxicity. The failure to notify the physician in a timely manner about the resident's change in condition led to a delay in appropriate medical intervention.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during specific shifts over a period from April 12 through April 21, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift on four separate days, one nurse aide per 11 residents during the evening shift on one day, and one nurse aide per 15 residents during the night shift on one day. These deficiencies were identified through a review of the facility's staffing data and were communicated to the Nursing Home Administrator during a telephone interview on April 23, 2025.
Plan Of Correction
NHA/designee reviewed the CNA day shift ratios for 4/12/25, 4/17/25, 4/20/25, and 4/21/25. The CNA evening shift ratio for 4/21/25 and the CNA night shift for 4/21/25. No grievance or residents care were affected due to staffing. To prevent this from happening again, NHA/designee will re-educate staffing coordinators on correct ratios: one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on the night shift. To monitor and maintain ongoing compliance, NHA/designee will audit nursing schedules weekly x4, then monthly x1, to ensure correct nurse aid ratios. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations as needed.
Failure to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required Per Patient Day (PPD) of 3.2 hours of direct resident care for each resident on seven days between April 12 and April 23, 2025. The specific days and their respective PPDs were as follows: April 12 (3.01), April 13 (3.14), April 14 (3.13), April 17 (3.19), April 19 (3.09), April 20 (3.12), and April 21 (2.83). This deficiency was identified through a review of the facility's staffing data and was communicated to the Nursing Home Administrator during a telephone interview on April 23, 2025.
Plan Of Correction
NHA/designee reviewed the following dates as they were below the required PPD minimum of 3.20: 4/12/25, 4/13/25, 4/14/25, 4/17/25, 4/19/25, 4/20/25, 4/21/25. No grievance or residents care were affected. To prevent this from happening again, NHA/designee will re-educate staffing coordinators on the need for PPD to be at 3.20 or above. To monitor and maintain ongoing compliance, NHA/designee will audit nursing schedules weekly x4, then monthly x1, to ensure correct PPD. The results of the audit will be forwarded to the facility QAPI committee for further review and recommendations as needed.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides across multiple shifts over a period from December 10 through December 19, 2024. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift on five occasions, one nurse aide per 11 residents during the evening shift on two occasions, and one nurse aide per 15 residents during the night shift on four occasions. These deficiencies were identified through a review of the facility's staffing data and were confirmed by the Nursing Home Administrator during a telephone interview on January 6, 2025.
Plan Of Correction
The Cna Day shift Ratio were reviewed for 12/10/2024, 12/11/2024, 12/14/2024, 12/16/2024 and 12/18/2024. The Cna Evening shift ratio were reviewed for 12/16/2024 and 12/17/2024. The Cna Night shift ratio was reviewed for 12/12/2024, 12/16/2024, 12/17/2024 and 12/18/2024. No grievance or residents care were affected due to the staffing. Other Days were reviewed. No residents care were affected due to staffing. Staffing coordinators will be re-educated on correct ratios - one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents on the evening shift and one nurse aide per 15 residents on the night shift. Random Weekly audits will be done by the NHA for 4 weeks. Results will be reviewed in QAPI to see if further action is needed.
Facility Fails to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per patient day (PPD) for nine days between December 10 and December 19, 2024. A review of the facility's staffing data revealed that on these days, the PPD ranged from 2.76 to 3.09, all below the mandated threshold. This deficiency was identified through an analysis of staffing records and was communicated to the Nursing Home Administrator during a telephone interview on January 6, 2025.
Plan Of Correction
The following dates were reviewed as their HPPD were below the required minimum of 3.20: 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/18/2024. No grievance or residents care were affected. Other dates were reviewed to see the HPPD. Residents care was not affected. Staffing coordinator to be re-educated on need for an HPPD at 3.2 or above. Random weekly audits will be done by the NHA to ensure HPPD is correct. Weekly times 4. Results will be reviewed by QAPI to see if further action is needed.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving Resident R1. The Licensed Practical Nurse (LPN) mistakenly administered medications intended for Resident R1's roommate, Resident R2, to Resident R1. This error occurred because the LPN asked Resident R1 if their name was the same as Resident R2's, and Resident R1 incorrectly confirmed. The LPN did not follow the facility's policy of verifying the resident's identity through multiple methods before administering medication. As a result of receiving the wrong medications, Resident R1 experienced a significant drop in blood pressure and heart rate, leading to a medical emergency. The resident was found to have a blood pressure of 72/40 and a heart rate of 42, prompting the on-call physician to direct that the resident be sent to the hospital. Resident R1 was admitted to the Intensive Care Unit (ICU) for monitoring and required inotropic and vasopressor support due to bradycardia and hypotension. The incident was identified as past non-compliance, and the facility's investigation revealed that the LPN did not adhere to the medication administration policy. The error was discovered when the LPN realized that Resident R1 was sitting in the hallway and not in their assigned bed, leading to the recognition that the wrong medications had been given. The facility's documentation confirmed that the LPN failed to follow the proper procedures for verifying resident identity, resulting in the significant medication error and subsequent hospitalization of Resident R1.
Failure to Safely Reheat Beverage Results in Resident Injury
Penalty
Summary
The facility failed to safely reheat a beverage for a resident, resulting in actual harm. The incident involved a resident who requested their coffee to be reheated. The nursing employee reheated the coffee in the microwave for approximately 30 seconds, three times, testing the temperature between each heating. However, there was no documentation or evidence that the beverage's temperature was checked to ensure it was safe before serving. The resident subsequently spilled the coffee on themselves, resulting in second-degree burns on both buttocks. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had requested the coffee to be reheated before bed. The nursing employee left the reheated coffee on the bedside table at the end of their shift. The facility's policy on microwave use required that beverages be checked for a maximum temperature of less than 165 degrees Fahrenheit and allowed to sit for three minutes before serving. The lack of adherence to this policy and the absence of temperature logs contributed to the incident, leading to the resident's injury.
Failure to Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to accurately monitor and assess residents for side effects of antipsychotic medications for three residents. Resident 2 had an order for Abilify 5 mg once daily, but their clinical record did not show evidence of side effect monitoring. Similarly, Resident 84 had an order for Abilify 10 mg once daily, and their clinical record also lacked evidence of side effect monitoring. An interview with a licensed nurse revealed that side effect monitoring should be documented in the residents' Medication Administration Record (MAR), but this was not found for Residents 2 and 84. Resident 93 had an order for Risperidone 0.5 mg twice daily and a specific order to monitor for side effects every shift, with instructions to document 'N' if no side effects were observed and 'Y' if side effects were observed. However, the September 2024 Treatment Administration Record for Resident 93 showed that staff were not documenting 'N' or 'Y' as required, instead using a checkmark and initials. These findings were confirmed with the Director of Nursing.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to adhere to infection prevention measures for COVID-19 on the 1st Floor Chestnut Unit. The facility's policy required staff to use full PPE, including an N95 respirator, gown, gloves, and eye protection, when entering the room of a resident in isolation. However, observations revealed that Licensed Employee E5 did not change PPE between resident rooms while conducting COVID-19 tests. The employee was seen wearing a cover gown, N95, and gloves, and did not change these items or perform hand hygiene between testing different residents. Additionally, the employee placed a second pair of gloves over the first pair without removing or changing the initial pair, further violating infection control protocols. The facility also failed to notify family members or visitors of the presence of COVID-19 in the building. Observations at the entrance and reception area on multiple days showed no evidence of notification or screening procedures for visitors. The Director of Nursing confirmed that all staff should have been wearing face masks and that additional screening should have been conducted at the entrance following the detection of a positive COVID-19 case. This lack of communication and adherence to infection control measures contributed to the deficiency.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident 26 was observed receiving oxygen therapy at 2 liters per minute through a nasal cannula, as per physician's orders for PRN use. However, the resident's active care plan did not include any interventions or a care plan for oxygen therapy. This oversight was confirmed by the Director of Nursing during an interview, indicating a lack of proper documentation and planning for the resident's respiratory needs. Similarly, Resident 93 was found to have a left wrist contracture, with clinical records noting the condition and a recommendation from a hospice nurse to use a rolled-up washcloth to slow its progression. Despite this, the resident's care plan did not address the contracture or the recommended intervention. Observations revealed that the intervention was not implemented, and the Director of Nursing confirmed the absence of an active care plan for the contracture. These deficiencies highlight the facility's failure to ensure that care plans are comprehensive and reflective of residents' current needs.
Failure to Adhere to Fluid Restriction Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding fluid restriction for a resident, identified as Resident 11. The physician's order, dated August 13, 2024, specified a fluid restriction of 1500 ml per day, with 900 ml to be provided by nursing and 600 ml by dietary services. However, a review of the clinical records revealed a lack of documentation regarding the fluid amounts administered by nursing. Additionally, the dietary records showed that the resident consistently consumed more than the prescribed 600 ml from dietary sources on multiple occasions between August 13, 2024, and September 24, 2024. The Director of Nursing confirmed the absence of nursing documentation for the resident's fluid intake and acknowledged that the dietary fluid restriction was not adhered to as ordered by the physician. This deficiency was identified during a survey, and it was noted that similar issues had been previously cited on October 20, 2023, and June 13, 2024, under the Pennsylvania Code 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services.
Lack of Clinical Rationale for Declining Pharmacist's Recommendation
Penalty
Summary
A deficiency was identified in the facility's pharmacy services, specifically related to the drug regimen review process for Resident 102. The Consultant Pharmacy Medication Review conducted on March 27, 2024, included a recommendation for a Gradual Dose Reduction (GDR) which the physician disagreed with. However, the physician failed to provide a clinical rationale for declining the Consultant Pharmacist's recommendation. This lack of documentation was confirmed during an interview with the Director of Nursing on September 25, 2024, indicating non-compliance with the facility's policy and the regulatory requirement under 28 Pa. Code 211.9(a) Pharmacy Services.
Delay in Obtaining X-ray for Resident's Foot Injury
Penalty
Summary
The facility failed to ensure timely radiological diagnostic studies for a resident, leading to a deficiency. A podiatry consult on April 15, 2024, indicated that the resident had fallen a week or two prior and was experiencing pain in the left foot. The podiatrist recommended an x-ray of the left foot. However, the nurse's note from the same day stated that no new orders were received. The x-ray was not obtained until April 23, 2024, revealing a fracture of the distal fifth metatarsal bone. This delay in obtaining the x-ray was confirmed by the Director of Nursing on September 25, 2024.
Failure to Accurately Follow Physician Medication Orders
Penalty
Summary
The facility failed to ensure that physician medication orders were accurately entered and followed for a resident diagnosed with Epilepsy and Irritable Bowel Syndrome (IBS). Upon admission, the resident's hospital discharge summary included a medication order for Prednisone, which was to be taken in a tapering dose starting with four tablets daily for five days. However, the facility's Medication Administration Record (MAR) incorrectly transcribed this order as every five days instead of daily, resulting in the medication being administered only once before the resident left the facility. The licensed nurse involved could not explain why the order was entered incorrectly, and there was no documentation indicating that the physician had altered the hospital's original order. Additionally, the facility failed to administer Mesalamine, prescribed for the resident's IBS, due to the medication's unavailability. Although the physician was initially notified of the missed doses, there was no further notification when the medication continued to be unavailable, leading to additional missed doses. This lack of communication and failure to follow the physician's orders contributed to the deficiency identified by the surveyors.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who required them due to having wounds. The facility's policy, dated April 2024, mandates EBP for residents with wounds or indwelling medical devices, regardless of their Multiple Drug Resistant Organism (MDRO) status. This includes placing appropriate signage at room entrances and ensuring Personal Protective Equipment (PPE) is available for staff before entering the resident's room. However, observations on June 13, 2024, revealed that there was no signage or PPE available at the room entrances of the three residents with wounds. Resident R1 was observed in bed with a dressing on the left foot, and their clinical record confirmed a left heel ulcer. Resident R2's clinical record indicated a sacral pressure ulcer, and Resident R3 had a left lateral foot wound. An interview with a licensed nurse, Employee E5, confirmed the presence of wounds in all three residents and revealed that staff had to request housekeeping to provide PPE when needed. This lack of immediate availability of PPE and absence of signage at the room entrances led to the deficiency in implementing the EBP process for these residents.
Failure to Obtain Physician's Orders for Immediate Care at Admission
Penalty
Summary
The facility failed to ensure that physician's orders for immediate care were obtained at the time of admission for a resident. The resident's hospital discharge documentation indicated the need for follow-up appointments with Nephrology and continuation of dialysis on specific days. The resident's clinical records, including an admission MDS and a care plan, documented the need for dialysis treatments three times a week due to renal insufficiency and end-stage disease. However, the physician's admission orders did not include orders for dialysis. This deficiency was confirmed through an interview with the Nursing Home Administrator (NHA) and Assistant NHA.
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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