Onyx Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norristown, Pennsylvania.
- Location
- 205 East Johnson Highway, Norristown, Pennsylvania 19401
- CMS Provider Number
- 395346
- Inspections on file
- 26
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Onyx Wellness Center during CMS and state inspections, most recent first.
Surveyors found that the ice machine's inner lining was stained, the adjacent baseboard was peeling and dirty, and the floor around the machine had significant dirt and debris buildup, with several fruit flies present. These conditions demonstrated a failure to maintain essential kitchen equipment in a clean and sanitary manner.
Staff posted signs in resident rooms and dining areas that publicly displayed sensitive dietary and medical information, such as NPO and thickened liquid requirements, for multiple residents. Residents were also served meals on plastic trays in the dining areas, and interviews confirmed these practices, resulting in a failure to maintain resident dignity.
Surveyors found multiple deficiencies including unclean resident rooms with peeling tiles, broken furniture, and caked dirt, as well as a non-functioning hand sanitizer in the dining area. Additionally, agency staff were unfamiliar with residents and their diets, leading to inconsistent support during meal service.
A resident with advanced cognitive decline and COPD had a physician order for DNR, DNH, and DNI, but the POLST form incorrectly indicated CPR/Attempt Resuscitation. The DON confirmed the POLST did not match the physician's order, resulting in a deficiency for failing to ensure accurate documentation of code status.
A resident with diabetes, heart failure, and hypertension experienced ongoing foot problems, including an ingrown toenail and ruptured blisters. Despite repeated physician orders and nursing notes indicating the need for an urgent podiatry consult, the facility did not document timely arrangement of the consult. The resident was only assessed by podiatry when the specialist was later present in the building, as confirmed by the DON.
Agency nursing staff, including two nurses and a nurse aide, worked without receiving facility-specific training or competency evaluations. Multiple residents and a family member reported inadequate care and lack of familiarity with care needs. The DON confirmed that no skills competency assessments were conducted for these agency staff.
A resident with a diagnosis of dementia did not have an individualized, person-centered care plan with measurable goals and interventions to address their dementia care needs. The DON confirmed the absence of a dementia-specific care plan during staff interview.
Surveyors found that required Department of Health contact information was not posted or accessible on either nursing floor. The only visible posting in the lobby had an outdated phone number, and the only other posting was in Spanish. Several residents reported not knowing where to find this information, and staff confirmed the postings were missing due to recent renovations.
A resident with anxiety disorder, bipolar disorder, PTSD, and spinal stenosis did not have a comprehensive care plan addressing their behavioral health and pain management needs. Despite documented mental health diagnoses, pain issues, and substance use, the care plan lacked specific interventions for anxiety, PTSD, grief, and pain. Staff confirmed that no person-centered interventions were implemented to meet the resident's medical, mental, and psychosocial needs.
A resident with severe cognitive impairment and mobility issues fell out of bed and sustained fractures due to inadequate supervision during incontinence care. The facility failed to provide the required two-plus person assistance for bed mobility, as outlined in the resident's care plan, resulting in actual harm.
The facility failed to maintain a safe and comfortable environment for residents due to unresolved maintenance issues. Problems such as malfunctioning toilets, beds, and call bells were reported but not addressed in a timely manner, affecting residents' safety and comfort. The Maintenance Director confirmed the delays in resolving these issues.
The facility failed to provide palatable and properly temperature-controlled food and drink to residents. A test tray evaluation showed milk served at 57 degrees, above the acceptable 41 degrees, and poorly prepared meals. Resident interviews revealed dissatisfaction with meal content, temperature, and adherence to dietary needs, with reports of missing items and inappropriate food for dietary restrictions.
A facility failed to accurately complete a resident assessment for a resident. The resident's quarterly MDS indicated a discharge to a hospital, but the physician discharge summary showed the resident was discharged home with family. This discrepancy was confirmed by the RN Assessment Coordinator, who acknowledged the MDS was coded inaccurately.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with Parkinson's Disease was not wearing prescribed hand splints due to the absence of a care plan. Another resident with a urinary catheter reported it had not been changed since admission, and no care plan was in place. Additionally, a resident receiving hospice care lacked a care plan for hospice services. The DON and NHA confirmed these deficiencies.
A resident with Parkinson's Disease was not provided with restorative nursing programs as required. Despite physician orders for bilateral upper extremity resting hand splints to be worn after breakfast and removed before lunch, the resident was observed multiple times without the splints. Staff interviews revealed a lack of awareness and training regarding the resident's care plan, leading to the deficiency.
The facility failed to employ a qualified Food Service Director (FSD), as the current FSD lacked necessary certifications and qualifications. Despite being responsible for food service operations, the FSD did not hold a Certified Dietary Manager (CDM) or Certified Food Manager (CFM) certification, nor did he have a relevant degree or receive regular consultations from a qualified dietitian. The Administrator confirmed the FSD's unqualified status during a review of his credentials.
Unsanitary Conditions Observed in Kitchen Ice Machine Area
Penalty
Summary
During a tour of the main kitchen with the Food Service Director, surveyors observed that the facility failed to maintain essential kitchen equipment in a clean and sanitary condition. Specifically, the inner lining of the ice machine had a blackish/brown stain along the bottom half perimeter. Additionally, the plastic baseboard adjacent to the ice machine was peeling off and had a significant build-up of dirt and debris. The floor underneath and surrounding the ice machine was also dirty, with a substantial accumulation of dirt and debris, and several fruit flies were seen hovering in the area. These findings indicate that the facility did not adhere to professional standards for the storage, preparation, and distribution of food as required.
Failure to Protect Resident Dignity Through Public Posting of Medical Information
Penalty
Summary
The facility failed to maintain and enhance resident dignity on both the first and second floor nursing units. During observations, a sign listing nine residents' dietary restrictions, including NPO (nothing by mouth), thickened liquid requirements, and other specific instructions, was posted at the head of a resident's bed, making private medical information visible. Additionally, in both the first and second floor dining areas, signs indicating thickened liquid diets were publicly posted on the wall. Residents were observed being served meals on plastic trays in the dining rooms. Interviews with residents and staff confirmed the presence of these postings and the use of plastic trays for meal service. These actions resulted in the public display of sensitive resident information and did not promote an environment that supports the dignity of each resident.
Failure to Maintain Clean, Homelike Environment and Consistent Staff Support
Penalty
Summary
Surveyors observed multiple deficiencies related to the maintenance of a safe, clean, and homelike environment across both nursing units. Specific findings included a wall with red paint markings, peeling baseboards, a bathroom leak with a saturated towel on the floor, and a broken glove box that could not hold gloves. Additional issues included a broken closet drawer, air conditioning vents with heavy dust accumulation, and a non-functioning hand sanitizer dispenser in the dining room. In another room, several bathroom floor tiles were peeling, and there was visible residue from dried tube feeding formula and caked dirt under and around the bed, as well as on a fall mat. During meal service observations, staff issues were also noted. One resident reported that an aide refused to pass out meal trays, stating she was agency staff and unfamiliar with residents' names. Another aide admitted to not knowing all the residents in the dining area. These findings indicate that the facility did not ensure a clean, well-maintained environment or a consistent, knowledgeable staff presence during resident dining experiences.
Inaccurate POLST Form Fails to Reflect Resident's Code Status
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's Physician Orders for Life Sustaining Treatment (POLST) form accurately reflected the resident's code status as documented in the physician's order. The resident, who had diagnoses of senile degeneration of the brain and chronic obstructive pulmonary disease, was admitted with specific physician orders indicating Do Not Resuscitate (DNR), Do Not Hospitalize (DNH), and Do Not Intubate (DNI) status. However, upon review, the POLST form for this resident was found to indicate CPR/Attempt Resuscitation, which was inconsistent with the physician's documented orders in the electronic medical record. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the POLST form did not match the resident's code status as ordered by the physician. The failure to ensure consistency between the physician's orders and the POLST form constituted a violation of resident care policies and nursing services regulations.
Failure to Timely Arrange Podiatry Consult for Resident with Foot Issues
Penalty
Summary
A deficiency was identified when the facility failed to timely arrange a podiatry appointment for a resident with significant risk factors, including congestive heart failure, type 2 diabetes mellitus, and hypertension. The resident's care plan included an intervention to consult podiatry as ordered. Multiple nursing and medication administration notes documented the need for an urgent podiatry consult due to an ingrown toenail and subsequent physician orders, but there was no documented evidence that the consult was arranged in a timely manner as required. The resident continued to experience foot issues, including pain and ruptured blisters, and only received a podiatry assessment when the podiatrist was present in the facility at a later date. The Director of Nursing confirmed that there was no documentation showing that the podiatry consult was ordered as per physician instructions. This failure was found to be noncompliant with resident care policies and nursing services regulations.
Failure to Ensure Agency Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that agency nursing staff, including two licensed nurses and one nurse aide, demonstrated the necessary competencies and skill sets to meet residents' needs. Multiple residents reported that agency staff did not provide adequate care, with specific complaints that agency staff did not assist them, did not give showers at night, and were not attentive to their needs. A family member also stated that agency staff were unfamiliar with residents' care requirements and did not appropriately reapproach residents who declined care. Review of facility staffing schedules confirmed that the agency staff in question worked on the specified date. Observations showed that both agency nurses administered medications on their first day at the facility without having received any training or skills competency evaluations from the facility. Personnel file reviews for all three agency staff revealed no documentation of training or competency assessments. The Director of Nursing confirmed that no skills competency evaluations had been conducted for these agency staff members.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address the dementia care needs of a resident diagnosed with dementia. Clinical record review showed that the resident was admitted with a diagnosis of dementia, but the interdisciplinary plan of care did not include measurable goals or interventions specific to dementia care. During an interview, the DON confirmed that the care plan lacked this information and no additional documentation was provided to address the resident's dementia-related needs. This deficiency was identified for one of 32 residents reviewed, based on both clinical record review and staff interview.
Failure to Post Required Department of Health Contact Information
Penalty
Summary
The facility failed to ensure that the required Department of Health contact information was posted and readily accessible on both nursing floors. During observations, it was found that there were no postings for the Department of Health contact information on the first floor nursing unit, and the only posting in the lobby area contained an outdated phone number. On the second floor, the only visible posting was in Spanish, with no English version available. Clear plastic coverings intended for these notices were empty on both floors. The Director of Social Services confirmed the absence of the required postings and explained that one resident sometimes removed the paper, but at the time of the survey, no current postings were present. Resident interviews during a council meeting revealed that several residents were unaware of where to find information on how to contact the State Department of Health within the building. The Nursing Home Administrator confirmed that the postings had been removed during recent bathroom renovations and had not been replaced. The lack of accessible and accurate postings for the Department of Health contact information was observed and confirmed by both staff and residents.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Behavioral Health and Medical Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the behavioral health and medical needs of a resident diagnosed with anxiety disorder, bipolar disorder, PTSD, and spinal stenosis. Despite multiple clinical assessments and documentation by the physician's assistant and psychologist noting the resident's mental health diagnoses, pain issues, and recent trauma from the loss of a family member, there were no care plan interventions created or revised to address these specific needs. The resident was prescribed medications for anxiety, depression, and pain, but the care plan did not reflect interventions for managing anxiety related to outside stressors, PTSD, grief, or paranoid and anxious behaviors. Further review revealed that the resident experienced episodes of lethargy, unsteadiness, and was found to have used marijuana via a vape pen, which was against facility policy. The resident's medications for anxiety and pain were held due to concerns about the effects of combining them with marijuana use. Despite the psychologist discussing relaxation techniques with the resident, there was no documentation of what these techniques were or their inclusion in the care plan. Interviews with staff confirmed that no person-centered care plan interventions were implemented to address the resident's medical, mental, and psychosocial needs.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
Towne Manor West was found to be non-compliant with federal and state regulations due to a failure in providing adequate supervision during incontinence care for a resident, resulting in actual harm. The facility's policy required assistance from more than one staff member for residents needing two-plus person physical assistance for bed mobility. However, during an incident, a single staff member attempted to provide care, leading to the resident falling out of bed and sustaining fractures to the left arm and hip. The resident, who had severe cognitive impairment and required significant assistance for bed mobility, was not adequately supervised according to their care plan. The resident involved had a history of chronic obstructive pulmonary disease, lack of coordination, abnormalities of gait and mobility, and dementia. The incident occurred when a nurse aide, while providing care, asked the resident to roll over, resulting in the resident falling from the bed. The facility's documentation and staff interviews confirmed that the resident required two-plus person assistance for bed mobility, which was not provided at the time of the incident. This lack of adherence to the care plan and facility policy led to the resident's injuries, highlighting a significant lapse in supervision and care.
Plan Of Correction
All residents have the potential to be affected by this deficient practice. 1) The Director of Nursing (DON) immediately updated the care plan of the resident with 2 assists for turning and repositioning. 2) The Facility educator and/or designee will in-service all the nurses, Minimum Data Set (MDS) Coordinator, and Certified Nursing Assistants (CNA) on Federal Guidelines F 689 related incident and accidents. 3) The Facility Educator and/or designee will in-service all the nurses and Certified Nursing Assistants (CNA) on accuracy of documentation in the Point of Care Service (POC) task. 4) The DON and/or designee will in-service the MDS Coordinator on accuracy of MDS assessment and documentation of CNA in the POC. 5) The DON and/or designee will audit 5 residents' ADL care plan to ensure that resident's bed mobility/turning and repositioning are documented according to the Point of Care Task/Kardex weekly x 4 weeks and monthly x 3 months. The DON will submit the audit reports to the Quality Assurance Committee.
Facility Fails to Address Maintenance Issues Promptly
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for nine residents, as evidenced by multiple unresolved maintenance issues. The facility's policy, "Environment of Care," requires that work orders be prioritized and addressed in a timely manner, but this was not adhered to. Several work orders, including those for malfunctioning toilets, beds, and call bells, were left open and unresolved for extended periods, impacting the residents' ability to receive care and services safely. Resident R1 and R2 experienced issues with a non-flushing and overflowing toilet in their room, which was reported on November 16, 2024, but remained unresolved as of December 9, 2024. Resident R1 also reported a malfunctioning bed that was not addressed promptly, leading to a room change. Similarly, Resident R9 had a mattress issue reported on December 3, 2024, which was only resolved six days later. Residents R7 and R8 had a non-functioning call bell, and they were only provided with hand-held bells on the day of the survey. Additional unresolved issues included a leaking ceiling in Resident R5's room, reported on September 16, 2024, and a broken call light in the room of Residents R3 and R4, reported on November 15, 2024. The Maintenance Director confirmed that these work orders were not addressed in a timely manner, indicating a systemic failure in the facility's maintenance processes, which compromised the residents' safety and comfort.
Plan Of Correction
1. The toilets in room 128 and in the 2nd floor north side shower room have been repaired. Rooms 018 and 024 call bell has been repaired. Missing ceiling tile in room 003 has been replaced. 2. Maintenance director/designee will audit all current open work order requests to ensure they are addressed timely. 3. Administrator/designee will reeducate Maintenance director on ensuring work order requests are addressed timely. 4. Maintenance director/designee will conduct audits of all new work order request to ensure timely completion, weekly X4 monthly X 3. Finding will be presented to QAPI Quarterly X 2.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at the proper temperature for all 18 residents interviewed. A test tray evaluation conducted during a lunch meal revealed that the milk was served at 57 degrees, which is above the acceptable standard of 41 degrees. Additionally, the baked ziti was not properly baked, the noodles were overcooked, and the meat sauce had an off sweet flavor. The mixed vegetables were also overcooked, with the squash being so soft that it could not be picked up with a fork. These findings were confirmed by the Food Service Director. Resident interviews revealed widespread dissatisfaction with the food service. Residents reported not receiving items listed on their meal tickets, such as breakfast meats and coffee, and expressed concerns about the nutritional content of their meals, particularly for those with dietary restrictions like diabetes or lactose intolerance. Some residents reported receiving food items they should avoid, such as pork and dairy, while others noted that the food was often too spicy or had too much gravy. A group meeting with alert and oriented residents further confirmed dissatisfaction with the taste and temperature of the food, describing it as dry, overcooked, and unappetizing.
Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to accurately complete a resident assessment for one of the residents reviewed, identified as Resident R102. A review of Resident R102's quarterly Minimum Data Set (MDS), which is an assessment of resident needs, dated May 15, 2024, indicated that the resident was discharged to a hospital. However, a review of the resident's physician discharge summary revealed that the resident was actually discharged home with family. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator, Employee E8, on August 1, 2024, who acknowledged that Resident R102's MDS was coded inaccurately.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident R56, diagnosed with Parkinson's Disease, had an order for bilateral upper extremity resting hand splints to be worn after breakfast and removed before lunch. However, observations revealed that the resident was not wearing the splints, and there was no care plan in place for their use. The Director of Nursing confirmed the absence of a care plan for the hand splints, despite the physician's order. Resident R97, admitted with Fournier's gangrene, had a urinary catheter with orders for daily care and drainage every shift. The resident reported that the catheter had not been changed since admission, and there was no care plan for its use and care. Similarly, Resident R71, who was receiving hospice care for end-stage senile dementia, did not have a care plan developed for hospice services. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the lack of care plans for these residents, which is against the facility's expectations.
Failure to Provide Restorative Nursing Programs for Resident with Parkinson's Disease
Penalty
Summary
The facility failed to provide restorative nursing programs for a resident diagnosed with Parkinson's Disease, which affects the nervous system and causes difficulty in movement. The resident was admitted with impairments in both upper extremities, as noted in the Minimum Data Set assessment. Observations revealed that the resident's hands and wrists were flexed and contracted, and she was not wearing her prescribed bilateral upper extremity resting hand splints. These splints were ordered to be worn after breakfast and removed before lunch daily, but they were consistently found on the nightstand instead of being worn by the resident. Interviews with staff, including a nurse aide and the Director of Nursing, confirmed that the resident was not wearing the hand splints as ordered. The nurse aide was unaware of the requirement to place the hand splints on the resident, as it was not part of her usual assignment. Additionally, another CNA, who worked a different shift, was also unaware of the order despite it being noted on the resident's care card. The Director of Nursing acknowledged the oversight and mentioned that the facility was in the process of training CNA staff to perform these restorative nursing orders.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as evidenced by the findings from staff interviews and a review of employee credentials. Employee E4, the Food Service Director (FSD), was responsible for overseeing the ordering, receiving, storing, preparation, and service of food. However, during an interview, the FSD confirmed that he did not hold a certification as a Certified Dietary Manager (CDM) or Certified Food Manager (CFM), nor did he have a national certification for food service management and safety from a national certifying body. Additionally, he lacked an associate's or higher degree in food service management or hospitality from an accredited institution and had not received regularly scheduled consultations from a qualified dietitian. A review of Employee E4's credentials further revealed that he did not meet the statutory qualifications required for the position. During a subsequent interview with the Administrator, it was confirmed that the FSD had not completed the necessary program or taken the exam for the required certifications. The Administrator was unable to provide evidence of the FSD's certification, confirming his unqualified status to direct the dietary department.
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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