Norriton Square Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norristown, Pennsylvania.
- Location
- 1700 Pine Street, Norristown, Pennsylvania 19401
- CMS Provider Number
- 396009
- Inspections on file
- 26
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Norriton Square Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A nurse aide improperly emptied and cleaned a bedside commode by carrying an unlabeled bag dripping reddish liquid to a resident’s bathroom, placing the bag in the resident’s trash, dumping the liquid into the toilet, and rinsing the urine collection basin in the resident’s hand sink before returning it to the commode without a new liner. The aide then removed gloves, dropped one on the floor, initially attempted to leave it there, and later picked it up with bare hands and discarded it. The Unit Manager, Infection Preventionist, and Nursing Home Administrator all confirmed these actions did not follow the facility’s infection control procedures for handling bedside commode waste and equipment.
A resident with chronic pain and cancer diagnoses was affected when 30 tablets of prescribed oxycodone went missing due to failures in controlled drug procedures. Inventory count sheets and staff interviews revealed discrepancies during shift changes, including missing signatures and improper documentation by an agency nurse. The DON confirmed the medication was not found and had to be replaced, resulting in noncompliance with management, pharmacy, and nursing service regulations.
The facility did not maintain accurate and orderly records for controlled substances, resulting in discrepancies between medication containers and record sheets during shift changes for two residents receiving oxycodone. There were also mismatches between the Medication Administration Records and Controlled Drug Record sheets, with staff unable to explain the inconsistencies.
Two agency nurses did not have documented training on abuse, neglect, exploitation, or misappropriation of resident property as required by facility policy. The DON was unable to provide verification of completed training for these nurses, including one involved in an incident where a resident's oxycodone was unaccounted for.
Essential dining equipment, including multiple refrigerators and an ice machine, was found to be non-operational on two floors. Staff were unaware of proper procedures for addressing equipment issues, and a resident's dietary needs were not immediately met due to the lack of functioning refrigeration in the dining area.
Surveyors found that multiple food items in the kitchen's walk-in refrigerator were not labeled or dated according to facility policy, with some items past their use-by dates and others missing required 'Use By' labels. The Director of Dining Services confirmed these items were improperly stored and labeled, in violation of professional food safety standards.
A resident with severe cognitive impairment and a complex medical history, including a hip fracture and pressure ulcer, was neglected in their incontinence care at Norriton Square. The resident was found soiled with urine, and their wound dressing was also soiled, due to the oversight of a nursing assistant overwhelmed with the care of eighteen patients. The facility's policies on abuse and neglect were not followed, leading to a substantiated report of neglect.
A facility failed to provide adequate nursing staff on the 2nd floor, resulting in neglect of a resident with severe cognitive impairment and complex medical needs. The resident was found soiled with urine and a soiled wound dressing, indicating neglect. The nursing assistant responsible admitted to overlooking the resident due to being assigned eighteen patients and insufficient help. The facility's staffing was below state requirements, confirmed by the DON.
Two residents experienced inadequate accommodations in the facility. One resident, with multiple health conditions, was not provided a bariatric bed upon admission, causing discomfort and requiring extensive assistance. Another resident faced issues with a malfunctioning heater, leaving them cold in their room. The facility had the necessary equipment but failed to implement it in a timely manner.
A facility failed to follow physician orders for a resident with diabetes by not notifying the physician of multiple instances where the resident's blood glucose levels exceeded 400. Despite elevated readings recorded over several months, there was no documentation of physician notification, as confirmed by the unit manager.
The facility failed to monitor weights for two residents with a history of weight loss, leading to gaps and inconsistencies in weight records. One resident with Huntington's Disease had missing and disputed weights without re-weigh attempts, while another resident with dementia had missing weights, hindering nutritional assessments. A third resident experienced significant weight loss over six months, with no documentation of daily weights as ordered, despite multiple hospitalizations.
The facility did not maintain respiratory equipment according to professional standards for two residents. One resident was using an oxygen concentrator at an incorrect flow rate, and their oxygen tubing was not dated. Another resident's humidifier bottle and oxygen tubing were also not dated, despite facility policy requiring weekly changes.
The facility failed to keep medication carts locked and medications properly stored. Medication Cart A was found unlocked and unsupervised with aspirin on top, while Medication Cart B had a mucus relief expectorant bottle improperly used to support a computer. Both incidents involved licensed nurses who confirmed the inappropriate handling of the carts.
The facility failed to provide meals according to the dietary preferences of three residents, all of whom follow vegetarian diets. One resident received a fish sandwich instead of a vegetarian burger, while two others did not receive their requested vegetarian meal items. The food service director could not explain the oversight, indicating a possible communication issue among staff.
The facility failed to maintain food safety standards by not properly labeling and storing food items. Observations revealed mislabeled or unlabeled bins of food substances, and improperly labeled items in the freezer, refrigerator, and dry storage. Staff interviews confirmed these deficiencies, indicating a breach of the facility's food handling policy.
The facility failed to ensure proper licensing and registration of staff, with a registered nurse working on an expired license and two nurse aides not registered in the state registry. This was discovered during an audit following the identification of the expired license.
A facility failed to maintain an effective infection control program for a resident with MDRO risk. An employee provided care without proper PPE, believing precautions were only for the resident's roommate. The resident, with Type 2 diabetes and a diabetic foot ulcer, required assistance for all ADLs. The care plan noted a risk for skin breakdown, but the Kardex lacked enhanced barrier precaution instructions.
The facility did not meet the required 12 hours of annual in-service training for a nurse aide, Employee E9, who only completed courses on hand hygiene and personal protective equipment. This was confirmed by personnel records and an interview with the Nursing Home Administrator.
The facility failed to meet required nurse aide staffing ratios on two consecutive days, with significant shortfalls in care hours during the day and evening shifts. Despite a census of 93-94 residents, the facility did not provide the necessary hours of care, and no higher-level staff were available to compensate for the deficiency.
The facility consistently failed to meet the required nurse aide staffing ratios over several months, as evidenced by staff schedules and punch reports. Despite a regulation requiring specific staffing levels based on resident census, the facility fell short on 17 out of 19 days reviewed, with no additional staff available to compensate for the deficiencies.
The facility failed to meet the required LPN staffing ratios on six occasions, with insufficient LPN hours provided during evening shifts. The census data showed that the required LPN hours were not met, and no additional higher-level staff were available to compensate for the shortfall. The Nursing Home Administrator confirmed these deficiencies during a review.
The facility did not meet the required minimum of 2.87 hours of direct nursing care per resident on two consecutive days. With a census of 94 and 93 residents, the facility provided only 2.53 and 2.33 hours of care per resident, respectively. This was confirmed through a review of nursing schedules and punch reports, and acknowledged by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct nursing care per resident on 15 out of 19 days reviewed. The census ranged from 88 to 95 residents, with care hours per resident varying from 2.65 to 3.18, consistently below the mandated level. The Nursing Home Administrator confirmed the shortfall in staffing ratios.
A pharmacy error led to a resident receiving 21 doses of Lithium instead of the prescribed Lisinopril. Facility staff discovered the error, but the pharmacy had not confirmed the medication identity. The facility failed to ensure accurate dispensing of medication.
The facility failed to provide fresh air breaks for residents, despite their expressed desire and the availability of a secure courtyard. Interviews and documentation reviews confirmed that no outdoor activities were scheduled, impacting the residents' quality of life.
The facility failed to maintain sufficient nursing staff levels, leading to significant delays in care for residents. Observations and interviews revealed issues such as residents not receiving timely assistance, family members performing care duties, and extended wait times for call bell responses. The administrator confirmed the facility's staffing shortages, impacting the quality of care.
A registered nurse left a medication cart unattended with the computer screen open, revealing a resident's identifiable information. This incident violated the facility's HIPAA compliance policy, which requires securing patient records to prevent unauthorized access.
A licensed nurse was observed borrowing Eliquis 5 mg from one resident to administer to another without consent, which was confirmed as misappropriation of medication by the Unit Manager. This action violated the facility's policy on Abuse Prohibition.
The facility failed to evaluate and obtain consent for the use of an abdominal binder as a restraint for a resident with multiple medical conditions. The binder was used to secure the resident's enteral feed, but the facility did not recognize it as a restraint and did not conduct the required reassessments or obtain consent.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. One resident's care plan lacked an intervention for an abdominal binder, another's did not reflect a new diagnosis of suicidal attempts or required checks, and a third resident's care plan did not include oxygen usage despite an active order.
The facility failed to follow a physician order to obtain weekly weights for a resident with severe protein-calorie malnutrition and abnormal weight loss. Despite a significant unplanned weight loss, no weekly weight measurements were documented for two weeks, as confirmed by the Registered Dietician.
A facility failed to maintain a hazard-free environment by leaving a medication cart unattended and unlocked with unsecured medications. A nurse left the cart in the hallway with Furosemide and Ampicillin on top, and later left it unlocked again while attending to a resident.
The facility failed to provide oxygen as ordered for two residents. One resident received incorrect oxygen levels, causing discomfort, while another had outdated oxygen equipment despite not using supplemental oxygen for months. The Director of Nursing acknowledged the discrepancies.
The facility failed to ensure food was served according to professional standards. A dietary aide used picnic-style paper plates and reheated mashed potatoes in the microwave without covering them. A nursing aide then checked the food temperature with her finger before feeding it to a resident with severe cognitive impairment, contrary to facility policy.
A resident with a history of anxiety, dementia, and major depressive disorder attempted self-harm and expressed suicidal ideation. The incident was not reported to the Department of Health within the required time frames, as confirmed by the Director of Nursing and the Administrator.
Improper Handling and Cleaning of Bedside Commode and Waste
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control procedures for care and maintenance of a bedside commode on the second floor. During an observation in a resident room, a nurse aide (Employee E4) emptied a bedside commode by lifting out the urine collection basin and removing an unlabeled grey plastic bag that was dripping a reddish-colored liquid. The aide placed the bag into the urine collection basin, carried it into the resident’s bathroom, removed the bag from the basin, placed the bag into the resident’s bathroom trash can, and dumped the liquid into the toilet. The aide then filled the urine collection basin about halfway with water from the resident’s hand sink, dumped this water into the toilet, flushed, and returned the basin to the commode without a bag, stating she would need to get another bag. After removing her gloves and washing her hands, the aide took the plastic can liner out of the resident’s bathroom trash can, dropped a glove on the floor, and initially attempted to leave the room. When questioned about the glove on the floor, she returned, picked up the soiled glove with bare hands, placed it into the trash bag, and then took the bag to the soiled utility room, disposed of it in a large trash can, and washed her hands. The Unit Manager (Employee E3) and the Infection Preventionist (Employee E2) both stated that the aide’s actions did not follow facility infection control procedures, explaining that the soiled contents of the bedside commode, including the basin, should have been placed in a red biohazard bag, transported to the soiled utility room, emptied into the wall-mounted service sink, and cleaned with soap and water using the spray hose before being returned in a clean biohazard bag. The Nursing Home Administrator confirmed that the aide did not follow facility infection control procedures.
Failure to Prevent Misappropriation of Resident Medication
Penalty
Summary
The facility failed to ensure that a resident was free from misappropriation of property, specifically related to missing medication. According to the facility's abuse prohibition policy, misappropriation includes the wrongful use of a resident's belongings without consent. In this case, a resident with diagnoses including cancer and chronic pain, who was prescribed oxycodone for pain management, was affected when 30 tablets of oxycodone were found to be missing from the narcotic drawer. Review of documentation showed that the medication was delivered to the facility and was present in the narcotic drawer, as confirmed by inventory count sheets and pharmacy shipping records. During a series of shift changes, discrepancies in the narcotic count were noted. Employee E7, a licensed nurse, and Employee E8, an agency licensed nurse, were responsible for the medication cart during the relevant shifts. The count sheets indicated inconsistencies, including missing signatures and a lack of proper documentation at the end of Employee E8's shift. Employee E7 discovered the missing medication during her shift and reported it immediately to her supervisor. Interviews confirmed that the controlled drug procedures were not followed, leading to the loss of the medication. The Director of Nursing verified that the medication was not found in the facility and had to be replaced. Employee E8, who was identified as the alleged perpetrator, did not respond to requests for an interview. The incident was reported to the Pennsylvania Department of Health, and the facility was found to be noncompliant with regulations regarding management, pharmacy services, and nursing services.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to maintain accurate and orderly drug records and did not ensure that all controlled drugs were properly accounted for and periodically reconciled, as required by policy and state regulations. Specifically, for two residents receiving oxycodone for pain management, there were discrepancies between the number of medication containers and controlled drug record sheets during shift changes, with missing signatures and unexplained differences in counts. On several occasions, the number of medication containers did not match the number of record sheets, and staff were unable to explain these inconsistencies during interviews. Additionally, there were mismatches between the Medication Administration Records (MARs) and the Controlled Drug Record sheets for both residents. Doses of oxycodone were documented as administered on the Controlled Drug Record sheets but were not reflected on the MARs, and vice versa. The Director of Nursing was unable to provide explanations for these discrepancies. These findings indicate that the facility did not follow its own policy for controlled substance management and failed to maintain an accurate account of controlled drugs for the residents involved.
Failure to Ensure Agency Nurses Received Required Abuse and Neglect Training
Penalty
Summary
The facility failed to ensure that nursing staff, specifically two agency licensed nurses, received required training on abuse, neglect, exploitation, and misappropriation of resident property. Facility policy mandates that all employees receive such training during orientation, through code of conduct training, and at least annually. However, review of personnel files and interviews revealed that one agency nurse, on her first day, could not specify the topics covered in her pre-employment online training, and the facility was unable to provide documentation verifying completion of the required training for either of the two agency nurses reviewed. Additionally, an incident occurred in which a licensed nurse discovered that 30 tablets of oxycodone for a resident were missing from the narcotic drawer, and one of the agency nurses was identified as the alleged perpetrator. The Director of Nursing stated that agency staff are expected to complete required trainings through their agencies but was unable to obtain or provide records confirming that the two agency nurses had completed training specific to abuse, neglect, exploitation, and misappropriation of resident property. The facility was therefore unable to verify compliance with its own policies and state regulations regarding staff development and personnel procedures.
Failure to Maintain Safe and Functional Dining Equipment
Penalty
Summary
Essential equipment in the dining service areas on both the second and third floors was not maintained in safe and operating condition. On the third floor, an ice machine was observed to be leaking, with a saturated towel and visible water present on the floor. Dietary staff confirmed the leak but were unaware of the appropriate response, indicating it was the responsibility of another department. Additionally, two refrigerators in the third floor dining area were not operational; one had a 'Do Not Use' sign and visible condensation, while the other was a clear display refrigerator that staff stated had not been working. On the second floor, three refrigerators in the dining service area were also found to be inoperable, with staff reporting they had not worked for at least a few months. During lunch service, dietary staff noted that a resident required a turkey and cheese sandwich due to dietary preferences, but the broken refrigerator meant no cold sandwiches were available on hand. The sandwich was eventually provided after a request to the Director of Dining, who delivered it from the dietary department.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple items in the walk-in refrigerator that were either undated or improperly labeled. During a kitchen tour, surveyors observed containers of prepared shredded carrots, deli ham, chopped ham and cheese, deli cheese, thawed raw ground beef, chopped fruit, prepared peas, raviolis, and finely chopped herbs that were missing required 'Use By' dates. Some items, such as the shredded carrots, appeared dry with residue, and the herbs and hard-boiled eggs were past their use-by dates and should have been discarded according to facility policy. The Director of Dining Services confirmed that the labeling and storage practices did not align with the facility's policy, which requires all foods to be wrapped or covered, labeled, dated, and arranged to prevent cross-contamination. The policy also mandates adherence to FDA Food Code guidelines for storing time/temperature control for safety (TCS) foods. The observed deficiencies were based on direct observation, staff interviews, and a review of facility policy, with no mention of specific residents or their conditions.
Neglect in Incontinence Care for a Resident
Penalty
Summary
Norriton Square was found to be non-compliant with the requirement to ensure residents are free from neglect, as outlined in 42 CFR Part 483.12(a)(1). The deficiency was identified during an abbreviated survey following complaints, where it was determined that a resident, identified as R12, did not receive adequate incontinence care. The facility's policy on abuse and neglect, which prohibits mistreatment and mandates effective communication and training, was not adhered to in this instance. The resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene due to a left hip fracture, was found soiled with urine, and their wound dressing was also soiled. This neglect was attributed to a nursing assistant, Employee E3, who admitted to overlooking the resident due to being overwhelmed with the care of eighteen patients. Resident R12 had a complex medical history, including a non-displaced intertrochanteric fracture of the left femur, chronic embolism and thrombosis of the vein, diabetes with neuropathy, and a personal history of transient ischemic attack. The resident's care plan highlighted the need for regular monitoring for skin irritation and repositioning every two hours to prevent skin breakdown, as the resident had a stage three pressure ulcer on the sacrum. Despite these documented needs, the facility failed to provide the necessary care, resulting in the substantiated report of neglect. The nursing home administrator confirmed the neglect after an investigation and noted that Employee E3 had prior disciplinary actions related to care concerns.
Plan Of Correction
1. R12 has discharged from the facility. 2. NPE or designee will re-educate staff on OPS300 Abuse Prohibition policy with review of the definition of Neglect. 3. The Director of Nursing or designee will conduct an initial audit of incontinent residents to ensure incontinence care was provided. 4. The Director of Nursing or designee will conduct random weekly audits x 12 weeks of 10 incontinent residents to ensure incontinence care was provided. 5. NHA or designee to review the results of these audits will be reviewed at the monthly QAPI meeting x 3 months.
Inadequate Staffing Leads to Neglect of Resident Care
Penalty
Summary
The facility failed to ensure an adequate number of nurse aides to meet the needs of residents on the 2nd floor, as evidenced by the case of Resident R12. Resident R12 had a complex medical history, including a non-displaced intertrochanteric fracture of the left femur, chronic embolism and thrombosis of the vein, diabetes with neuropathy, and a history of transient ischemic attack. The resident was assessed with severe cognitive impairment and was dependent on staff for toileting hygiene due to the left hip fracture. The care plan included interventions for skin care and repositioning every two hours due to a stage three pressure ulcer on the sacrum. On February 12, 2025, Resident R12 was found soiled with urine, and the wound dressing was also soiled, indicating neglect in care. The charge nurse discovered the issue while performing wound care. The nursing assistant, Employee E3, who was responsible for Resident R12, admitted to overlooking the resident due to being assigned eighteen patients and a lack of sufficient help. The facility's staffing sheet confirmed that the number of nurse aides scheduled was below the required state regulation, with only eight nurse aides for a census of 95 residents. The Director of Nursing confirmed the staffing inadequacy on the day of the incident.
Plan Of Correction
1. R12 has discharged from the facility. 2. The Director of Nursing or designee will educate nursing staff to review CNA assignments to divide assignments related to acuity of residents care needs. 3. The Director of Nursing or designee will conduct an initial audit of CNA assignments to ensure the assignments are divided related to acuity of residents care needs. 4. The Director of Nursing or designee will conduct weekly audits X 12 weeks of CNA assignments to review that assignments are divided related to acuity of residents care needs. 5. NHA or designee to review the results of these audits will be reviewed at the monthly QAPI meeting x 3 months.
Failure to Provide Adequate Accommodations for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, leading to deficiencies in care. Resident R251, who was admitted with conditions including respiratory failure, chronic congestive heart failure, type 2 diabetes, and morbid obesity, was not provided with a bariatric bed upon admission. Despite the facility having the necessary equipment, the resident was observed lying in a regular-sized hospital bed, which was too small and caused discomfort. It took three days after admission for the bed to be adjusted to a bariatric setting, during which time the resident required extensive assistance for repositioning. Resident R248 experienced issues with the heating system in their room. The resident was observed sitting in a chair with a sheet wrapped around them due to feeling cold. The heater was initially thought to be functioning correctly, but further inspection by the Regional Maintenance Director revealed that it was not working properly. The heater's safety mechanism was supposed to prevent overheating, but it was confirmed that the unit was malfunctioning, failing to provide adequate warmth for the resident.
Plan Of Correction
1. Resident 251 has been issued a Bariatric bed and mattress to accommodate his needs. Resident 248 heater has been replaced and is functioning. 2. Maintenance Director or designee to conduct an initial audit of residents requiring a bariatric bed to ensure appropriate bed and mattress in place. Maintenance Director or designee to conduct an initial audit of all resident room heaters to ensure proper functioning. 3. NPE or designee to educate maintenance and nursing staff regarding identification of bariatric bed equipment needs and when resident room heaters are not functioning to notify maintenance utilizing TELS platform. 4. The Maintenance Director or Designee will audit weekly for 12 weeks for both PTech units and bariatric mattresses to ensure compliance. 5. NHA or designee to review the results of these audits at the monthly QAPI meeting for 3 months.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to adhere to physician orders regarding diabetes management for a resident, identified as Resident R24. The resident, who was admitted to the facility in March 2021, had a diagnosis of diabetes, which requires careful monitoring of blood glucose levels. According to the physician's order dated May 23, 2023, the facility was required to check the resident's blood glucose levels and notify the physician if the levels exceeded 400. However, the facility did not comply with this order. The clinical records revealed multiple instances where Resident R24's blood glucose levels exceeded 400, specifically on several dates between November 2025 and January 2025, with levels ranging from 407 to 427. Despite these elevated readings, there was no documentation indicating that the physician was notified as required. This deficiency was confirmed during an interview with Employee E13, the unit manager, who acknowledged the findings.
Plan Of Correction
1. Physician reviewed resident R24 blood glucose levels for last 7 days with no changes to orders. 2. The Director of Nursing or designee will conduct an initial audit of current residents with physician orders for blood glucose levels with parameters for the last 7 days to ensure out of range parameters are reported to the physician. 3. NPE or designee will educate current licensed nurses on diabetes management and ensure physician is notified when blood glucose parameters are out of range. 4. The DON or designee will conduct weekly random audits of 5 residents per week x 12 weeks of residents with accu-checks to ensure that blood sugars out of range were reported to the physician. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Failure to Monitor Resident Weights
Penalty
Summary
The facility failed to ensure that weekly weights were obtained for two residents with a history of weight loss. Resident R39, who has Huntington's Disease, dysarthria, and dysphagia, had a physician's order for monthly weights, but there were significant gaps and inconsistencies in the weight records. Notably, there were no weights recorded for July 2024, and the resident refused to be weighed in August 2024 without any documented re-weigh attempts. Additionally, a disputed weight in December 2024 was not rechecked, as confirmed by the Regional Nurse. Resident R74, with a history of alcohol abuse and dementia, also experienced lapses in weight monitoring. The resident's care plan indicated a potential nutritional risk, yet weights for May and July 2024 were missing. This lack of documentation hindered the ability to assess weight changes, as noted in a nutrition assessment from August 2024. Resident R240 experienced a significant weight loss of 57.8 pounds over six months, with multiple hospitalizations during this period. Despite physician orders for daily weights, there was no documentation of these weights being obtained. The resident's nutritional assessments indicated regular diet intake, but the weight loss was attributed to hospitalizations. The Registered Dietitian noted the significant weight loss and recommended interventions, but the cause of continued weight loss post-hospitalization remained unclear.
Plan Of Correction
1. Resident R39 and R74 had not suffered any adverse effects. Resident 240 signed onto hospice services with admitting diagnosis of Failure to Thrive. 2. The Director of Nursing or designee will conduct an initial audit of current residents with a physician order for weekly weights obtained as ordered and comply with the Genesis Weight policy for the last 7 days. 3. NPE/IP or designee will educate current licensed nurses to ensure residents with weekly weights are obtained per physician orders and comply with the Genesis Weight policy. 4. The DON or designee will conduct weekly random audits of 5 residents per week x 12 weeks of residents with orders for weekly weights, to ensure compliance with the Genesis Weight policy. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Failure to Maintain Respiratory Equipment Standards
Penalty
Summary
The facility failed to maintain respiratory equipment according to professional standards of practice for two residents. Resident R17, who has a history of chronic diastolic congestive heart failure and atrial fibrillation, was observed using an oxygen concentrator at 3 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. Additionally, the oxygen tubing for Resident R17 was not dated, which was confirmed by a licensed nurse during the observation. Resident R56, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure, was observed using an oxygen concentrator at 6 liters per minute via nasal cannula. The humidifier bottle and oxygen tubing for Resident R56 were also not dated, as confirmed by the same licensed nurse. The facility's policy requires oxygen tubing to be changed weekly, but the lack of dating on the equipment indicates non-compliance with this policy.
Plan Of Correction
1. Resident R17 and R56 had not suffered any adverse reactions and oxygen tubing was changed/dated. 2. The Director of Nursing or designee will complete an initial audit of all residents receiving oxygen therapy to ensure oxygen tubing changed per Physician order for the last 7 days. 3. NPE/IP or designee will re-educate licensed nurses on Oxygen Therapy Management to ensure oxygen tubing changed per physician order. 4. DON or designee will conduct weekly audits x 12 weeks on 5 random residents to ensure Oxygen tubing was changed per physician order to ensure compliance. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Medication Cart Security and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medication carts were kept locked when not in use and that medications were properly stored, as observed with two medication carts. On February 9, 2025, at 8:35 a.m., Medication Cart A was found unlocked and unsupervised in the hall of the second floor, with a bottle of over-the-counter aspirin placed on top. Employee E7, a licensed nurse, confirmed that the cart was her responsibility and admitted to leaving it unattended to assist a resident. Similarly, Medication Cart B was observed during a medication pass at 8:49 a.m. on the same day. The cart was found with a bottle of over-the-counter mucus relief expectorant being used to support the medication cart computer. Employee E23, another licensed nurse, confirmed that the medication bottle was not being used appropriately. These observations indicate a failure to adhere to the facility's medication storage policy, which requires medication carts to be locked when not in use and attended by authorized personnel.
Plan Of Correction
1. No resident was adversely impacted due to unsecured medications in an unattended, unlocked medication cart. Employee E7 and E23 were re-educated by NPE on Medication Cart Safety/Management to ensure medications are secured and not left unattended on top of the med cart and med carts are locked while unattended. 2. NPE or designee to conduct an initial house audit to ensure all medication carts are locked and free from unsecured medications. 3. NPE or designee will re-educate all licensed nurses on Medication Cart Safety/Management to ensure medications are secured and not left unattended on top of the med cart and med carts are locked while unattended. 4. DON or designee will conduct 5 random weekly audits x 12 weeks to ensure medications are secured and not left unattended on top of the med cart and med carts are locked while unattended. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Failure to Honor Dietary Preferences
Penalty
Summary
The facility failed to provide meals in accordance with the dietary preferences and needs of three residents, leading to a deficiency in meeting the requirements for accommodating resident allergies, intolerances, and preferences. Resident R43, who is on a lacto-ovo vegetarian diet and is at nutritional risk due to being underweight, received a fish sandwich instead of the ordered vegetarian burger. This error was confirmed by a medical supply coordinator and a dietary employee, who acknowledged the mistake and corrected it immediately. Similarly, Resident R42, who follows a vegetarian diet, did not receive the requested vegetarian meal items, as confirmed by a nurse aide and the resident's family member. Resident R19, also on a vegetarian diet, did not receive the vegetarian burger patty or any protein source with her meal, despite the availability of these items in the kitchen. The food service director could not explain why the residents' preferences were not honored, suggesting a lack of communication or awareness among the weekend kitchen staff.
Plan Of Correction
1. Resident R43 was provided with the appropriate diet for lunch. Resident R42 was provided with the appropriate diet for lunch. Resident R19 was provided with the appropriate diet for lunch. 2. Food Service Director or designee to complete an initial audit of all residents with food preferences and substitutes to ensure compliance. 3. Food Service Director or designee to re-educate all kitchen staff to ensure residents are receiving the appropriate diet and food preferences. NPE or designee to educate all nursing staff on verifying meal ticket with food tray prior to delivery. 4. Food Service Director or designee to conduct 5 random weekly audits to ensure appropriate diet and food preferences are accurate. 5. Director of Dietary or Designee to review findings monthly during the Quality Improvement Committee x 3 months.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper labeling and storage of food items. During a kitchen inspection, it was observed that several plastic bins containing various food substances such as corn starch, sugar, flour, and panko were either mislabeled or not labeled at all. Additionally, items in the freezer and refrigerator, including mixed pasta, sandwiches, a loaf of bread, and plates of salad, were not labeled. In the dry storage room, cereal, uncooked spaghetti, fettuccini, rice crispies, and cornflakes were found without proper labeling, with some items exposed to air due to improper sealing. Interviews with dietary staff confirmed the mislabeling and lack of labeling for these food items. The facility's policy on safe food handling, which requires all food items to be appropriately labeled and dated, was not followed. This oversight in food storage and labeling practices was confirmed during a follow-up tour with the District Manager and kitchen supervisor, highlighting a significant lapse in maintaining food safety standards.
Plan Of Correction
1. All food items not labeled or dated were removed and discarded. 2. Food Service Manager to conduct an initial audit to ensure all food is stored, labeled and dated as per regulations. 3. Food Service Manager or designee to re-educate dietary staff to ensure food is stored, labeled and dated as per policy. 4. Food Service Manager or Designee to complete random weekly audits X 12 to ensure food is labeled, stored and dated. 5. NHA or Designee to review findings monthly during the Quality Improvement Committee x 3 months.
Staff Licensing and Registration Deficiency
Penalty
Summary
The facility failed to ensure that staff were licensed and registered in accordance with State laws for three of the eleven personnel files reviewed. Employee E21, a registered nurse, was found to be working with an expired nursing license, which had expired on October 31, 2024. The facility discovered this lapse on December 18, 2024, and subsequently provided education to Employee E21 regarding the policy that mandates maintaining an active nursing license at all times. Employee E21 reactivated her nursing license on December 20, 2024. Additionally, the facility conducted an audit of all employees with nursing licenses and nurse aide registries, which revealed that Employees E17 and E16, both nurse aides, were not included in the audit. Further review showed that neither employee was enrolled in the Pennsylvania nurse aide registry, a requirement for employment in a nursing care facility receiving Medicare or Medicaid reimbursement. Employee E17 was hired on October 22, 2024, and Employee E16 on November 19, 2024, both having completed a nurse aide training course prior to their hiring. However, they were not registered to work as nurse aides in Pennsylvania, as confirmed by the Nursing Home Administrator.
Plan Of Correction
1. Employee E21 provided no direct care and caused no harm to residents. Employee E17 and E16 are no longer employed at the facility. 2. Employee E21 was educated on his responsibility to ensure his license is renewed timely and active. 3. NPE or designee to educate licensed nursing staff on the importance of timely license renewal. 4. NPE or designee will conduct an initial audit of licensed nursing staff then monthly audits x 3 months to ensure compliance. 5. NHA or designee to review results of these audits at the monthly QAPI meeting x 3 months.
Inadequate Infection Control for Resident with MDRO Risk
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a resident identified as R35. The deficiency was observed when Employee E16 provided incontinence care to Resident R35 without wearing the appropriate personal protective equipment (PPE), specifically a gown, despite the resident being at risk for multi-drug resistant organism (MDRO) transmission. The facility's policy on Enhanced Barrier Precautions (EBP) requires the use of targeted PPE during high-contact resident activities to reduce the transmission of MDROs. However, the employee was only wearing gloves and was unaware that PPE was required for Resident R35, mistakenly believing that the enhanced barrier precaution sign on the door was only for the resident's roommate. Resident R35 entered the facility with a diagnosis of Type 2 diabetes and was assessed as having a diabetic foot ulcer. The resident required assistance and was dependent on staff for all activities of daily living due to paralysis and weakness on the left side. The resident's care plan indicated a risk for skin breakdown related to an actual pressure ulcer, and the clinical record included instructions to monitor for skin breakdown. However, the Kardex did not indicate that Resident R35 was on enhanced barrier precautions, contributing to the oversight in infection control measures.
Plan Of Correction
1. Resident R35 was placed on Enhanced Barrier Precautions. 2. IP or designee to conduct initial house audit to ensure all residents are identified for enhanced barrier precautions. 3. Infection Preventionist or designee will educate all staff on Enhanced Barrier Precautions. 4. Infection Preventionist or designee will conduct 5 random weekly audits x 12 weeks to ensure staff are compliant with EBP. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Deficiency in Required In-Service Training for Nurse Aide
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service education per year, as mandated by regulations. Specifically, Employee E9, a nurse aide hired on June 20, 2019, did not complete the necessary annual in-service training hours between February 11, 2024, and February 10, 2025. During this period, Employee E9 only completed two courses related to hand hygiene and personal protective equipment. This deficiency was confirmed through a review of personnel records and an interview with the Nursing Home Administrator, who acknowledged the shortfall in meeting the training requirements.
Plan Of Correction
1. Employee E9 completed their 12 hours annual inservice education. 2. NPE or designee to conduct an initial audit of all CNA's to ensure 12 hour annual in-servicing is in compliance. 3. NPE will be re-educated by the DON on the importance of ensuring all Nurse Aides completed at least 12 hours of inservice education annually. 4. NPE will conduct random monthly audits to ensure all Nurse Aides completed at least 12 hours of inservice education annually X 3 months. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides during the day, evening, and overnight shifts on June 29 and 30, 2024. On June 29, the facility had a census of 94 residents, necessitating 58.75 hours of nurse aide care during the evening shift. However, only 43.00 hours of care were provided, with no additional higher-level staff available to compensate for the shortfall. Similarly, on June 30, the facility had a census of 93 residents, requiring 58.13 hours of nurse aide care during both the day and evening shifts. The facility only provided 37.50 hours of care for each of these shifts, again without any higher-level staff to make up for the deficiency. The deficiency was confirmed during a review of staffing calculations, nursing staff schedules, and punch reports with the Nursing Home Administrator on February 11, 2024. The administrator acknowledged that the required staffing ratios were not met on the specified dates. The report does not mention any corrective actions or follow-up measures taken to address the staffing shortfall.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on 17 out of 19 days reviewed. The regulation mandates a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. However, the facility consistently fell short of these requirements across multiple shifts and dates, as evidenced by the review of nursing staff schedules, punch reports, and interviews with staff. On July 1, 2024, the facility had a census of 92 residents, necessitating 69 hours of nurse aide care during the day shift, 62.73 hours during the evening shift, and 46 hours overnight. The facility only provided 60, 42, and 37.5 hours of care, respectively, with no additional higher-level staff available to compensate for the deficiency. Similar shortfalls were observed on subsequent days, with the facility repeatedly failing to meet the required hours of nurse aide care based on the census data. The deficiency persisted over several months, with specific instances noted on September 28 and 29, October 1 to 4, and February 3 to 9, 2025. Each of these dates showed a consistent pattern of understaffing, with the facility unable to provide the necessary hours of nurse aide care required by the resident census. The Nursing Home Administrator confirmed the failure to meet staffing ratios during a review on February 11, 2024.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on six specific dates. The regulation mandates a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. However, on June 29, July 2, 4, and 5, 2024, and February 4 and 6, 2025, the facility did not meet these staffing requirements during the evening shifts. The census data indicated that the number of LPN hours required was not met, and there were no additional higher-level staff available to compensate for the deficiency. On June 29, 2024, the facility had a census of 94 residents, requiring 25.07 hours of LPN care, but only 24.00 hours were provided. Similar deficiencies were noted on July 2, 4, and 5, 2024, and February 4 and 6, 2025, where the required LPN hours were not met, with the most significant shortfall occurring on July 5, 2024, when only 16.00 hours of LPN care were provided against a requirement of 24.27 hours. The Nursing Home Administrator confirmed these deficiencies during a review of staffing calculations, nursing staff schedules, and punch reports on February 11, 2024.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
Deficiency in Direct Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 2.87 hours of direct nursing care per resident on two consecutive days, June 29 and 30, 2024. On June 29, with a census of 94 residents, only 237.50 direct nursing staff hours were provided, resulting in 2.53 hours of care per resident. On June 30, with a census of 93 residents, 217.00 direct nursing staff hours were provided, equating to 2.33 hours of care per resident. These deficiencies were confirmed through a review of nursing time schedules, punch reports, and staff interviews, and were acknowledged by the Nursing Home Administrator during a review session on February 11, 2024.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
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 15 out of 19 days reviewed. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. Specific dates where the facility did not meet the required staffing ratios include July 1-5, 2024; September 28-30, 2024; October 1-4, 2024; and February 7-9, 2025. On these dates, the facility's census ranged from 88 to 95 residents, and the direct nursing care hours provided per resident varied from 2.65 to 3.18 hours, consistently falling short of the mandated 3.2 hours on most days. The Nursing Home Administrator confirmed the shortfall in staffing ratios during a review of staffing calculations, nursing staff schedules, and staff punch reports on February 11, 2024. The deficiency was evident as the facility consistently failed to provide the required level of direct nursing care, impacting the quality of care provided to the residents. The report does not mention any corrective actions or plans to address this deficiency, focusing solely on the failure to meet the required staffing levels on the specified dates.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
Pharmacy Dispensing Error and Delayed Response
Penalty
Summary
The pharmacy failed to timely respond to an inquiry regarding a possible medication dispensing error for a resident. The facility's policy required the pharmacy to accurately dispense medications based on authorized prescriber orders. However, a licensed nurse discovered that the medication card for a resident's prescribed Lisinopril did not match the description of the medication actually packaged. Upon further investigation by the nurse and the unit manager, it was determined that the medication card contained 450 milligrams of Lithium instead of the prescribed 40 milligrams of Lisinopril. This error resulted in the resident receiving 21 doses of Lithium over three weeks, which was not prescribed to them. Interviews with facility staff revealed that the pharmacy was notified of the error, but the pharmacy had not yet confirmed the identity of the medication dispensed. The Nursing Home Administrator and the Director of Nursing acknowledged that the true verification of the medication administered needed to be determined by the pharmacy. The facility failed to ensure that pharmacy services accurately dispensed medication for the resident, as required by state regulations.
Lack of Fresh Air Breaks for Residents
Penalty
Summary
The facility did not ensure that residents were treated with dignity and care in a manner that promotes the enhancement of their quality of life, specifically related to providing fresh air breaks. During a resident council meeting, twelve alert and oriented residents expressed a strong desire for fresh air breaks during the day and could not recall the last time they were allowed outside, except for approved leave of absence visits. A review of three months of Resident Council minutes and four months of activity calendars revealed that residents had requested fresh air time, but no outside activities were scheduled. The activity director confirmed that there were no fresh air activities on the calendar and mentioned plans to implement them once a week in the future. Recreation assessments for several residents indicated that outdoor time was important to them for activities such as sitting, relaxing, and bird watching. Despite the facility having a gated courtyard that provides a secure space for residents to enjoy fresh air, it was observed that this area was not being utilized for the residents' benefit. The deficiency was confirmed through interviews with residents and staff, as well as a review of facility documentation and observations.
Insufficient Nursing Staff Levels
Penalty
Summary
The facility failed to maintain sufficient nursing staff levels to provide adequate care and services for five of the 19 residents reviewed. Observations and interviews revealed that residents experienced significant delays in receiving necessary care. For instance, Resident R80 was found in bed with a strong odor of feces, indicating a lack of timely assistance. Resident R78's family member had to perform morning care due to insufficient staffing, and there was an expectation from the staff for the family member to assist regularly. Resident R90 reported a general shortage of staff, while Resident R73 did not receive a shower for a week and a half, missing a shower before an Easter celebration. The assigned nurse aide, Employee E4, confirmed that high resident-to-staff ratios often prevent timely care, with priorities shifting to meal service over morning care. Resident R198, a new admission, reported unresponsive call bell service and a delay in receiving a bedpan during the night shift. A resident council meeting with 12 alert and oriented residents further confirmed the facility's staffing issues, leading to extended wait times for call bell responses. A unit manager, Employee E7, verified that the second-floor unit was understaffed, with only three nurse aides scheduled for 41 residents, and one aide arriving late. The administrator, Employee E1, confirmed that the facility lacked a sufficient number of certified nursing aides and licensed nursing employees, as evidenced by a review of three weeks of schedules. These findings indicate a systemic issue with staffing levels, directly impacting the quality of care provided to residents.
Confidentiality Breach of Resident's Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the third floor. During a medication administration, a registered nurse left the medication cart unattended with the computer screen open, revealing identifiable information of a resident. This incident was observed and confirmed by the nurse, violating the facility's HIPAA compliance policy, which mandates securing patient records to prevent unauthorized access. The deficiency was noted during an observation on April 4, 2024, at 9:10 a.m., and confirmed through an interview with the involved employee shortly after.
Misappropriation of Medication
Penalty
Summary
The facility failed to ensure that one resident was free from misappropriation of medication. Specifically, a licensed nurse, Employee E10, was observed preparing medication for Resident R23 and found that there was no Eliquis 5 mg available in the resident's drawer. Employee E10 then decided to borrow Eliquis from another resident, Resident R74, without consent. This action was confirmed as misappropriation of Resident R74's medication by Employee E7, the Unit Manager. The facility's policy on Abuse Prohibition, which prohibits misappropriation of resident property, was not followed in this instance.
Failure to Evaluate and Obtain Consent for Restraint Use
Penalty
Summary
The facility failed to ensure ongoing evaluation of a resident's need and use of restraints, specifically an abdominal binder, for one resident. The resident, who had multiple medical conditions including chronic obstructive pulmonary disease, chronic kidney disease, and parkinsonism, was observed with an abdominal binder to secure his enteral feed. The facility's policy required reassessment of restraints monthly for three months, then quarterly, and with any significant change in condition, but no such assessments were conducted for this resident. Additionally, the facility did not obtain consent for the use of the abdominal binder, as they did not recognize it as a restraint. The resident's clinical records and nursing documentation confirmed that the abdominal binder remained in place and that the resident consistently complied with and tolerated the intervention. However, there was no documentation indicating that the resident had attempted to remove the binder, nor was there any indication of upper extremity limitations that would prevent the resident from doing so. The facility's failure to recognize the abdominal binder as a restraint and to follow their own policy for reassessment and consent led to this deficiency.
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 their care. Resident R6, admitted with multiple serious conditions including acute respiratory failure and chronic kidney disease, had a physician order for an abdominal binder to be worn at all times. However, the care plan initiated on March 9, 2023, did not include this intervention. This omission was confirmed by a unit manager on April 4, 2024, despite the resident being observed with the abdominal binder in place. Similarly, Resident R83, who had a history of severe mental health issues and a recent suicide attempt, was placed on 15-minute checks per a physician's order. However, the care plan dated September 9, 2023, did not reflect this new diagnosis or the required checks, a fact confirmed by the Director of Nursing and the Administrator on April 5, 2024. Resident R86, who had a diagnosis of lung cancer and a blood clot, was observed with an unused portable oxygen cylinder on her wheelchair. Despite an active physician order for continuous oxygen at 2 L/min, no care plan had been developed for her oxygen usage. This was confirmed by the Director of Nursing on April 2, 2024, who acknowledged that a care plan should have been in place. These deficiencies indicate a failure to develop and implement comprehensive care plans that meet the residents' needs, as required by regulatory standards.
Failure to Follow Physician Order for Monitoring Weight Loss
Penalty
Summary
The facility did not ensure that a physician order was followed related to unplanned weight loss for one of 19 residents reviewed. Resident R6, who was admitted with multiple diagnoses including severe protein-calorie malnutrition and abnormal weight loss, experienced a significant unplanned weight loss of 5.76% over two weeks. A physician order was initiated to obtain weekly weights for four weeks starting on March 8, 2024. However, clinical records indicated that there were no weekly weight measurements documented between March 21, 2024, and April 4, 2024. This was confirmed by an interview with the Registered Dietician, Employee E8, who acknowledged the absence of the required weekly weights during this period.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to maintain an environment free from hazards related to an unlocked medication cart and unsecured medications on the cart for one of two nursing units. During an observation of medication administration, a licensed nurse left the medication cart unattended and unlocked in the second-floor hallway. The cart had two medications, Furosemide and Ampicillin, left on top of it. The nurse confirmed this observation upon returning to the cart. Additionally, the nurse was observed preparing medication for a resident and left the cart unlocked with medications on top and unsecured inside the cart while attending to the resident. This was confirmed again when the nurse returned to the cart.
Failure to Provide Oxygen as Ordered
Penalty
Summary
The facility failed to provide oxygen as ordered for two residents. Resident R43, who was admitted with chronic obstructive pulmonary disease and acute and chronic respiratory failure, had a physician's order for three liters of oxygen via nasal cannula continuously. However, observations on two separate days revealed that the resident was receiving either 3.5 liters or 2.5 liters of oxygen instead of the prescribed amount. During an interview, the resident expressed discomfort due to inadequate oxygen, and a licensed nurse confirmed the discrepancy and adjusted the oxygen level to the correct amount. Resident R86, admitted with diagnoses including malignant neoplasm of the lung and acute deep vein embolism, had an active order for two liters of oxygen via nasal cannula continuously and for weekly oxygen tubing changes. Despite this, the resident had not used supplemental oxygen for months and still had a portable oxygen cylinder attached to her wheelchair with outdated tubing. The Director of Nursing acknowledged that the order should have been modified or discontinued and that the tubing should have been changed weekly as per the physician's order.
Improper Food Handling and Serving Practices
Penalty
Summary
The facility did not ensure that food was served in accordance with professional standards for food service safety for one resident. During lunch dining, a dietary aide ran out of plates and began using white picnic-style paper plates. The aide reheated mashed potatoes on a paper plate in the microwave without covering them, contrary to the facility's policy. The reheated food was then placed on the counter without checking its temperature with a dial thermometer as required by the policy. A nursing aide subsequently touched the mashed potatoes with her pinky finger to check the temperature before feeding them to the resident. This action was also against the facility's policy, which mandates the use of a thermometer to ensure food safety. The resident involved had multiple severe medical conditions, including hemiplegia, hemiparesis, aphasia, hydrocephalus, Parkinson's Disease, apraxia, dysphagia, vascular dementia, and cognitive communication deficit, with a BIMS score of 00 indicating severe cognitive impairment. Interviews with the dietary aide and nursing aide confirmed the improper handling and reheating of food. The Food Service Director acknowledged that there were adequate supplies of plates and that the staff failed to follow the proper procedures for reheating and serving food.
Failure to Report Resident's Self-Harm Incident
Penalty
Summary
The facility failed to report a reportable incident involving a resident to the local Department of Health within the required and appropriate time frames. Resident R83, who had a history of anxiety disorder, dementia, major depressive disorder, and adjustment disorder, attempted self-harm by trying to wrap a bed remote cord around his neck and expressed suicidal ideation. The incident occurred on December 23, 2023, and the resident was subsequently sent to the nearest emergency room. Upon returning to the facility on December 29, 2023, the resident was placed on 15-minute checks every shift. However, it was confirmed on April 5, 2024, by the Director of Nursing and the Administrator that the incident was not reported to the Department of Health as required.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
