Park Lane Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in West Chester, Pennsylvania.
- Location
- 1619 East Boot Road East Goshen, West Chester, Pennsylvania 19380
- CMS Provider Number
- 396082
- Inspections on file
- 19
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Park Lane Post Acute Llc during CMS and state inspections, most recent first.
A resident with a spinal fracture did not receive multiple scheduled doses of Lyrica and Hydrocodone-Acetaminophen due to pharmacy delays and medication unavailability. Nursing documentation confirmed the missed and delayed doses, and there was no evidence that the physician was notified about the missed medications. The DON verified that the medications were not administered as ordered because they were not available.
The facility failed to follow physician orders for obtaining and documenting weights and did not adequately monitor significant weight changes for three residents. One resident experienced a falsely elevated weight due to failure to subtract wheelchair weight, while two others were not weighed as ordered, resulting in missed identification of significant weight changes. These deficiencies were confirmed by staff interviews and record reviews.
Two residents with psychiatric diagnoses were prescribed antipsychotic medications, but their clinical records did not show any monitoring of behaviors or medication side effects as required by facility policy. The DON confirmed that this monitoring was not conducted while the residents were receiving these medications.
A resident with spinal stenosis and lumbar disc degeneration, who required assistance with mobility and transfers, reported that two CNAs were rough during care. The facility did not thoroughly investigate this allegation, as required by policy, and failed to obtain statements from the involved staff or interview potential witnesses until prompted by a surveyor.
A resident admitted with a right heel pressure injury did not receive a comprehensive wound assessment upon admission, and the wound physician's updated orders for daily wound care were not followed, resulting in missed treatments for an unstageable pressure ulcer.
A resident with a tracheostomy and PEG tube, diagnosed with protein-calorie malnutrition and chronic respiratory failure, did not receive enteral nutrition as ordered by the physician. Documentation showed significant discrepancies in the volume of tube feeding administered on several days, and an LPN confirmed that the feeding order was not being documented correctly.
A resident with chronic respiratory failure and hypoxia was not provided with the physician-ordered tracheostomy collar and 28% humidified oxygen at 2L/min. Observation and staff interviews confirmed that the resident was not receiving the prescribed oxygen therapy, despite staff awareness of the order.
A resident with a history of bipolar disorder, major depression, and sleep apnea did not receive a prescribed medication for several days because it was not available from the pharmacy. Nursing documentation showed the medication remained on order and was not administered, and the physician was not consistently notified of the missed doses. The DON confirmed the medication was not given due to unavailability.
A large accumulation of ice was observed on the fans and ceiling of the walk-in freezer, extending down to food boxes on the top shelf. The issue persisted over two days, with both the Dietary Director and the Nursing Home Administrator confirming the ongoing ice buildup.
The facility failed to timely certify the completion of MDS assessments for nine residents. These residents were either discharged home, admitted to the hospital, or had expired in the facility, but their respective MDS assessments were not finalized as required by the guidelines.
The facility failed to implement enhanced barrier precautions (EBP) for three residents requiring such measures. Observations revealed a lack of EBP signage and PPE in the rooms of residents with indwelling catheters, MRSA, and colostomies. Additionally, the first-floor nursing unit lacked EBP signage and PPE, and staff were observed not using PPE when entering and exiting rooms requiring EBP.
The facility failed to complete comprehensive MDS assessments within the required time frame for five residents. Admission MDS assessments for four residents were either not completed or listed as in progress, and one resident's annual assessment was also not completed. This deficiency was previously cited under relevant state codes.
The facility failed to complete quarterly MDS assessments within the required 92-day timeframe for four residents. The assessments for these residents were either not completed or listed as in progress, based on a review of clinical records and staff interviews.
The facility failed to notify the State LTC Ombudsman's office of resident transfers or discharges for three residents. One resident was sent to the hospital for bilateral lower extremity pain, another for a right knee infection, and a third for a urinary tract infection. The Nursing Home Administrator confirmed the lack of notification.
The facility failed to ensure MDS assessments accurately reflected the residents' status for two residents. One resident was admitted with a venous stasis ulcer that was not documented in the MDS, and another resident's MRSA diagnosis was omitted from the MDS. These discrepancies were confirmed by the Director of Nursing and the Nursing Home Administrator.
The facility failed to develop baseline care plans for three residents upon admission. One resident had a PICC line and IV anti-fungal medication, another had MRSA of the left foot, and the third had a colostomy. These omissions were confirmed by the DON and Nursing Home Administrator.
The facility failed to develop a comprehensive care plan for a resident with multiple medical needs, including anticoagulant medication and various wounds. The resident had no care plan or interventions for these conditions, which was confirmed by the DON.
The facility failed to follow physician's weight monitoring orders for two residents. One resident's weights were not recorded due to a broken Hoyer lift, and another resident's hospital weight was incorrectly used as a baseline. The facility's policy mandates weight monitoring as directed by physicians, but this was not adhered to.
The facility failed to follow a physician's order and wound specialist's recommendation for a resident with a Stage 4 pressure ulcer. The resident's wound treatment was not updated as recommended, and the resident was not assisted out of bed as ordered. This was confirmed through observations and interviews with staff and the resident.
The facility failed to provide treatment and services to maintain or restore bladder continence for a resident who became frequently incontinent after being readmitted from the hospital. The facility did not follow its policy on continence care, and no comprehensive assessment or treatment was documented.
A facility failed to ensure timely availability of Verapamil for a resident with hypertension and Atherosclerotic Heart Disease. The medication, ordered on April 12, 2024, was not administered until four days later due to delays in delivery from the pharmacy. The facility's emergency medication list did not include Verapamil.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to ensure that prescribed medications were made available and administered as ordered for a resident with a T11-T12 compression fracture. Clinical and pharmacy records showed that the resident was prescribed Lyrica 25 mg to be given three times daily, but three consecutive doses were missed because the medication was not delivered from the pharmacy in time. Nursing progress notes documented the unavailability of Lyrica throughout the day, and pharmacy delivery records confirmed the medication was not delivered until the following day. Additionally, there was no evidence in the clinical records that the physician was notified about the missed doses. Further review revealed that the resident was also prescribed Hydrocodone-Acetaminophen for back pain, but a scheduled dose was not administered on time due to unavailability, resulting in a delayed administration. The DON confirmed that both medications were not given as ordered because they were not available from the pharmacy. These findings demonstrate that the facility did not meet the requirement to provide pharmaceutical services to meet the needs of each resident, as required by state regulations.
Failure to Follow Physician Orders and Monitor Significant Weight Changes
Penalty
Summary
The facility failed to follow physician orders and adequately monitor significant weight changes for three residents reviewed for nutrition. For one resident with diagnoses including congestive heart failure and chronic kidney disease, daily weights were ordered with instructions to subtract the wheelchair weight. However, a significant weight gain of over 40 pounds was recorded within four days due to failure to subtract the wheelchair weight, as confirmed by the dietitian and staff interviews. The Director of Nursing was unable to provide a valid explanation for this discrepancy, and the resident's weight was not appropriately monitored or addressed. Another resident with progressive bulbar palsy, severe protein calorie malnutrition, ALS, and other complex conditions was ordered to have weekly weights for four weeks. The clinical record showed that the resident was not weighed on one of the scheduled dates, and there was no documented explanation for the missed weight. The dietitian confirmed that nursing staff were responsible for obtaining weights and that the missed weight was reported to the nursing supervisor the following day, but the physician's orders for weekly weights were not followed. A third resident with dementia, anxiety disorder, muscle weakness, and depression was also ordered to have weekly weights. The clinical record revealed a significant weight loss of 12.2 pounds between two documented weights, and there was no evidence that a weight was obtained on one of the scheduled dates as ordered. These findings demonstrate that the facility did not ensure physician orders for weights were followed and failed to adequately monitor and address significant weight changes for these residents.
Failure to Monitor Behaviors and Side Effects for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to monitor behaviors and potential side effects for residents who were prescribed antipsychotic medications. According to the facility's policy, psychotropic drugs should only be administered when necessary to treat a specific, documented condition, and the resident's response to the medication must be monitored and documented. Additionally, residents receiving antipsychotic medications are required to have an Abnormal Involuntary Movement Scale (AIMS) test performed as per facility policy. A review of clinical records for two residents with diagnoses including bipolar disorder, major depression, and generalized anxiety disorder revealed that both were prescribed antipsychotic medications (Abilify and Chlorpromazine). However, there was no documentation that behaviors or medication side effects were monitored during the periods the medications were administered. The DON confirmed that this monitoring was not performed for these residents while they were receiving antipsychotic medications.
Failure to Investigate Allegation of Rough Care by Staff
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff being rough with a resident during care. According to the facility's policy, any suspicion or report of abuse, neglect, or exploitation requires a comprehensive investigation, including identifying and interviewing all involved parties and documenting the findings. In this case, a resident with spinal stenosis and lumbar disc degeneration, who required assistance with bed mobility and transfers, reported that two CNAs were rough while providing care. The facility's documentation addressed the resident's concern about not receiving medication but did not include a thorough investigation into the allegation of rough care. Specifically, the investigation report lacked statements from the two staff members accused of being rough and did not include interviews with other potential witnesses. It was only after the surveyor's inquiry that statements from the alleged staff were obtained, well after the initial report. This failure to promptly and thoroughly investigate the allegation of rough care constituted a deficiency under the relevant state codes.
Failure to Assess and Treat Pressure Ulcer per Physician Orders
Penalty
Summary
The facility failed to ensure comprehensive assessment and appropriate wound care for a resident admitted with a right heel pressure injury. Upon admission, the skin assessment identified a right heel pressure area but did not document the wound's stage, size, appearance, drainage, odor, or the condition of the surrounding skin. The admitting nurse did not perform a thorough assessment as required by facility policy, and a comprehensive evaluation was not completed until the wound physician's consult two days later, which identified the wound as an unstageable pressure ulcer with significant slough. Additionally, the facility did not follow the wound physician's updated treatment recommendations. The physician ordered daily wound care with saline, medical grade honey, and foam dressing, but the Treatment Administration Record showed that the prescribed treatment was not performed on two consecutive days. The Assistant Director of Nursing confirmed that the physician's orders were not followed, resulting in missed wound care for the resident's unstageable pressure ulcer.
Failure to Follow Physician Orders for Enteral Nutrition
Penalty
Summary
The facility failed to follow physician orders regarding the administration of enteral nutrition for a resident diagnosed with unspecified protein-calorie malnutrition and chronic respiratory failure. The resident was admitted with a tracheostomy and a PEG tube, with a physician's order specifying continuous tube feeding of Nutren 1.5 at 60 mL/hour for 20 hours per day, totaling 1200 mL. Review of the medication administration record showed significant discrepancies in the actual volumes administered on multiple days, with amounts ranging from 60 mL to 3405 mL, deviating from the prescribed total. A licensed nurse confirmed that the tube feeding order was not being documented correctly, indicating a failure to ensure the physician's order was followed.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for respiratory care for a resident with chronic respiratory failure and hypoxia. According to the clinical record, the resident had a physician order for a tracheostomy collar with 28% humidified oxygen delivered via a concentrator set at 2L/min. During an observation, the resident was found not to be receiving the ordered two liters of oxygen. Staff interviews confirmed that the tracheostomy setup had not been changed since the last check earlier that morning, and the nurse was able to recite the correct order but did not ensure it was being followed. This failure resulted in the resident not receiving the prescribed oxygen therapy as ordered by the physician.
Failure to Provide Timely Medication Due to Pharmacy Delay
Penalty
Summary
The facility failed to ensure that a prescribed medication, Armodafinil 250 mg, was made available and administered to a resident diagnosed with bipolar disorder, major depression, and sleep apnea. The physician's order for Armodafinil was dated April 23, 2025, to be given once daily for a sleep disorder. However, the medication was not administered on five consecutive days as documented in the Medication Administration Record. Nursing progress notes indicated that the medication was still on order from the pharmacy and not available during this period. Additionally, while the physician was notified of the missed medication on the first day, there was no documentation that the physician was notified of the missed doses on the subsequent days. The Director of Nursing confirmed that the medication was not administered due to its unavailability from the pharmacy. This resulted in the resident not receiving the ordered medication as required.
Unsanitary Food Storage Due to Ice Accumulation in Freezer
Penalty
Summary
The facility failed to store food in a sanitary manner as evidenced by observations in the walk-in freezer, where a large accumulation of ice was found on the fans and ceiling, extending down to the food boxes on the top shelf. This condition was observed on two consecutive days, with the ice buildup still present during the second observation. The Dietary Director confirmed the presence of the ice and stated that it is typically cleaned after lunch. The Nursing Home Administrator also confirmed the ongoing issue during an interview. No information about residents or their medical conditions was provided in relation to this deficiency. The deficiency was cited under 28 Pa. Code: 201.18(b)(3) Management and 28 Pa. Code 211.6(f) Dietary services.
Failure to Timely Certify MDS Assessments
Penalty
Summary
The facility failed to timely certify the completion of the Minimum Data Set (MDS) assessments for nine sampled residents. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual mandates that the MDS Completion Date must be no later than 14 days after the Assessment Reference Date. However, the review of clinical records and progress notes revealed that discharge MDS assessments for Residents 6, 40, 42, 50, 57, 65, 76, 77, and 99 were not completed and were listed as in progress. These residents were either discharged home, admitted to the hospital, or had expired in the facility, but their respective MDS assessments were not finalized as required by the guidelines. Specifically, Resident 6 was discharged home, but the discharge MDS assessment was still in progress. Similarly, Residents 40, 42, 57, and 77 were discharged home, and their discharge MDS assessments were also incomplete. Resident 50 and Resident 76 were admitted to the hospital, but their discharge MDS assessments were not completed. Resident 65 was discharged to the community, and the discharge MDS was still in progress. Lastly, Resident 99 expired in the facility, and the Death in Facility MDS was listed as in progress. This failure to complete the MDS assessments in a timely manner is a violation of the regulatory requirements for nursing services as cited in 28 Pa. Code: 211.12 (d)(1)(5).
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were in place for residents requiring such precautions. The facility's policy, revised March 26, 2024, mandates the use of gowns and gloves during high-contact resident care activities for residents with multidrug-resistant organisms (MDROs), chronic wounds, or indwelling medical devices. However, observations during the survey revealed that no EBP signage or personal protective equipment (PPE) was present in the rooms of three residents who required these precautions. Specifically, Resident 50 had an indwelling catheter, Resident 212 had osteomyelitis of the left foot with MRSA, and Resident 213 had a colostomy, yet none of their rooms displayed the required EBP signage or PPE. Additionally, the surveyors observed that the first-floor nursing unit lacked EBP signage on any resident rooms that required it, and no PPE was present in resident rooms or hallways. Multiple observations of staff entering and exiting rooms requiring EBP showed no evidence of PPE use. This failure to implement the facility's EBP policy was noted as a deficiency, as it did not comply with the required infection prevention and control measures for residents with specific medical conditions and devices.
Failure to Complete MDS Assessments in Required Time Frame
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed within the required time frame for five of the twelve residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a comprehensive admission MDS assessment must be completed no later than 14 days following admission, and an annual assessment must be completed at least once every 12 months. The clinical records revealed that the admission MDS assessments for Residents 27, 166, 212, and 214 were either not completed or listed as in progress, with ARDs ranging from April 11, 2024, to April 17, 2023. Additionally, Resident 262's annual assessment with an ARD of November 3, 2023, was also not completed and listed as in progress. This deficiency was previously cited on June 23, 2023, under 28 Pa Code 201.18(b)(1) Management and 28 Pa. Code 211.5(f) Clinical records.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 92-day timeframe for four residents. Resident 5 had an assessment reference date (ARD) of March 15, 2024, which was not completed and listed as in progress. Resident 22 had an ARD of March 6, 2024, and the assessment was not completed. Resident 50 had an ARD of March 22, 2024, and the assessment was also not completed and listed as in progress. Resident 211 had an ARD of November 14, 2023, which was not completed and listed as in progress. These findings were based on a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of residents transferred or discharged for three residents. Resident 50 was sent to the hospital for evaluation due to bilateral lower extremity pain, but there was no documented evidence of notification to the Ombudsman's office. Resident 64 was sent back to the hospital for further treatment of a right knee infection, and again, there was no notification to the Ombudsman's office. Resident 76 was admitted to the hospital due to a urinary tract infection, and similarly, there was no evidence of notification to the Ombudsman's office. The Nursing Home Administrator confirmed that the facility did not notify the State Ombudsman's office when residents were transferred or discharged.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure MDS assessments accurately reflected the residents' status for two residents. Resident 50 was admitted with a left medial ankle venous stasis ulcer, as indicated in the hospital readmission skin assessment, but the admission MDS assessment did not document this condition. The Director of Nursing confirmed this discrepancy. Similarly, Resident 212 was admitted with a diagnosis of a left foot infection caused by MRSA, as noted in the clinical progress note, but this diagnosis was not included in the Admission/5 day MDS. Both the Director of Nursing and the Nursing Home Administrator confirmed that Resident 212's MDS did not accurately reflect the resident's status.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure baseline care plans were completed upon admission for three residents. Resident 93 was admitted with a PICC line and an order for Micafungin Sodium IV solution for post-abdominal surgery. However, a care plan for the PICC line and IV anti-fungal medication was not developed. This was confirmed by the Director of Nursing during an interview on April 19, 2024. Resident 212 was admitted with a diagnosis of MRSA of the left foot, but the baseline care plan did not include this condition. Similarly, Resident 213 was admitted with a colostomy, and the baseline care plan failed to document this. Both the Nursing Home Administrator and the Director of Nursing confirmed the absence of baseline care plans for these conditions during an interview on April 19, 2024.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 50, who had multiple medical needs. The resident had a physician's order for Heparin Sodium Injection 5000 units subcutaneously every 12 hours, dated December 22, 2023, but there was no care plan or interventions addressing the anticoagulant medication. Additionally, Resident 50 had arterial wounds on both ankles, the left first MTP, right medial foot, right lateral ankle, and both heels, as well as a venous ulcer on the left calf and pressure ulcers on the right and left buttocks. Despite these conditions, there was no care plan or interventions addressing the wounds. The Director of Nursing confirmed on April 19, 2024, that Resident 50 did not have a care plan for the anticoagulant or wounds. This deficiency was previously cited on June 23, 2023, under 28 Pa. Code 211.5(f) Clinical records and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Follow Physician's Weight Monitoring Orders
Penalty
Summary
The facility failed to follow the physician's weight monitoring orders for two residents, Resident 64 and Resident 263. Resident 64, who was readmitted with diagnoses including lymphedema and a right knee infection, had a physician's order for daily weights for three days. However, the Treatment Administration Record (TAR) showed that weights were not recorded on two of the required days. Nursing progress notes indicated that the Hoyer lift was broken, preventing the weight measurements. Similarly, Resident 263, admitted with a feeding tube due to a cerebrovascular accident, had a physician's order for daily weights for three days. The TAR revealed that only the hospital weight was recorded, and no weight was taken on the second day as required. The dietitian confirmed that the hospital weight should not have been used as a baseline and could not explain why the physician's order was not followed. The facility's policy, dated August 1, 2023, mandates that residents be weighed as directed by the physician, federal/state regulations, or standards of practice. Despite this policy, the facility did not ensure that the physician's orders for weight monitoring were followed for both residents. This failure was confirmed through clinical records review and staff interviews, indicating a lapse in adherence to prescribed medical orders and facility policy.
Failure to Follow Physician's Orders and Wound Specialist Recommendations
Penalty
Summary
The facility failed to follow a physician's order and the wound specialist's recommendation for a resident with a Stage 4 pressure ulcer. The resident was admitted with a severe sacral wound, and the physician's order dated January 19, 2024, specified a treatment regimen involving an acetic wash and Medihoney with calcium alginate. However, a wound consult on March 12, 2024, recommended changing the acetic wash to a saline solution. This recommendation was not followed, as evidenced by observations on April 19, 2024, where the wound was still being cleaned with an acetic solution. The clinical record did not show that the primary physician was notified of the wound specialist's new recommendation, and the facility could not provide documentation explaining why the recommendation was not followed. Additionally, the facility failed to adhere to a physician's order for the resident to be out of bed for two hours during lunch. Observations on April 17 and 18, 2024, revealed that the resident remained in bed during the specified times. The resident reported that staff did not offer to assist them out of bed and expressed a desire to be out of bed for a few hours, as recommended by the wound doctor. An interview with an agency nursing assistant confirmed that the resident was not offered to be out of bed based on a report that the resident does not get out of bed. This information was conveyed to the Director of Nursing, who acknowledged the failure to follow the physician's orders and wound specialist's recommendations.
Failure to Maintain or Restore Bladder Continence
Penalty
Summary
The facility failed to provide treatment and services to maintain or restore bladder continence for one resident. The facility's policy on bowel and bladder continence care includes a structured voiding schedule and consultation with therapy and nursing for any changes or concerns. However, the facility did not follow this policy for Resident 64, who was initially assessed as always continent but later became frequently incontinent after being readmitted from the hospital. The clinical records did not show any comprehensive bladder continence assessment or any treatment or services provided to address the change in the resident's urinary status. An interview with the Director of Nursing confirmed that the facility did not comprehensively assess the resident's urinary continence upon identifying the change and failed to implement any treatment or services to restore or maintain the resident's urinary status. This deficiency was cited under multiple Pennsylvania codes, indicating a failure in management, clinical records, and nursing services.
Failure to Ensure Timely Availability of Medication
Penalty
Summary
The facility failed to ensure that medications were made available for a resident diagnosed with hypertension and Atherosclerotic Heart Disease. A physician's order for Verapamil HCL ER 240 mg, to be administered daily at bedtime, was issued on April 12, 2024. However, the medication was not administered until April 16, 2024, four days after the order was placed. Nursing progress notes indicated that the medication was en route from the pharmacy on April 12, 2024, and subsequent notes on April 14 and April 15, 2024, showed that the facility was still waiting for the pharmacy to deliver the medication. The pharmacy records confirmed that the medication was not delivered until late on April 15, 2024. Additionally, the facility's emergency medication list did not include Verapamil. This information was discussed with the Director of Nursing on April 19, 2024.
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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