Parkhouse Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Royersford, Pennsylvania.
- Location
- 1600 Black Rock Road, Royersford, Pennsylvania 19468
- CMS Provider Number
- 395454
- Inspections on file
- 31
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Parkhouse Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that one unit had a sticky floor in front of the nursing station and in the hallway, visible spills in the lounge and a room doorway, and scattered debris including paper scraps, a sugar packet, a plastic lid, a straw, and a plastic glove on floors. A dried, brown substance was observed on the floor and in the bathroom of a room, including on the toilet, and dried food substances were present on the floors of multiple rooms. In addition, a room thermostat lacked a cover, leaving exposed wires visible. These conditions resulted in a deficiency under resident rights for not maintaining a safe, clean, comfortable, and homelike environment.
A resident who uses a wheelchair and requires supervision or touching assistance for showering and transfers did not receive scheduled showers on two consecutive days. The resident reported that staff told him/her there were not enough staff on the unit to provide the shower and requested that staff be informed of the desire to shower. Facility policy requires person-centered ADL care, including bathing, but during an interview the NHA and DON, while stating that some residents refuse showers or are care planned for bed baths, did not confirm that this resident preferred or was care planned for bed baths only.
A resident with multiple comorbidities, including metabolic encephalopathy, HTN, hyperlipidemia, paroxysmal A-fib, and a neurocognitive disorder, was mistakenly given Humalog insulin instead of a tuberculin solution. Facility policy required verification of the right medication, dose, time, and route before administration and consultation with a physician if a medication or dose seemed inappropriate. The nurse administered Humalog despite no physician order for insulin, and subsequent documentation and a medication error report confirmed that the wrong medication had been given. The DON later verified that the resident received Humalog in error instead of the ordered tuberculin solution.
Surveyors identified unsanitary and unsafe environmental conditions on the North Building 7th and 8th floors, including a bathroom on N8 with used briefs on the trash can, paper towels, used gloves, and empty body wash and shampoo bottles left in the sinks. The N8 trash chute closet had an overflowing trash bin with papers, used gloves, paper towels, and food on the floor, and used gloves were found on the stairwell landing between N7 and N8. Additional observations of trash chute rooms on the North Building floors showed food, used gloves, papers, and paper towels on the floor on N8.
Surveyors identified that the facility did not ensure a safe, clean, and homelike environment for residents. One resident room had a wall with bubbled and peeling paint, cracked drywall, and pieces of drywall on the windowsill. On another floor, fraying fall mats were observed in several resident rooms, indicating inadequate maintenance of resident care areas and safety equipment.
Surveyors identified unsanitary conditions in the 8th floor pantry, including rust and brown stains on cabinet interiors and exteriors, stained countertops, and red and brown stains inside the refrigerator and freezer. A coffee carafe with dried coffee, a water-stained ice bucket and ice scoop on the counter, rust on the coffee and ice machines, and calcium build-up on the ice machine, sink fixtures, and inside the sink were also observed. During an interview, the NHA reported that both dietary and housekeeping staff were responsible for cleaning the pantry. The deficiency was cited under Food and Nutrition Services 483.60(i)(1)(2) for failure to maintain sanitary food storage conditions.
A nursing unit failed to maintain a clean and homelike environment, with multiple residents affected by unclean and sticky floors, unmade or soiled beds, refuse such as food, gloves, and empty containers left in rooms, and broken or missing furnishings. Staff confirmed the presence of unsanitary items, including feces, and the facility's policy for cleanliness and comfort was not followed.
Multiple residents were not provided necessary assistance with activities of daily living, as evidenced by observations of soiled clothing, unkempt appearance, wet bed linens, and missed meals. Documentation and resident grievances further revealed infrequent showers, delayed care, and unmet needs for snacks, water, and toileting. The facility administrator confirmed these failures following review.
A deficiency was identified when a unit serving residents with Alzheimer's and other dementias did not provide an ongoing program of activities to support their physical, mental, and psychosocial well-being. Observations showed only a single activity—folding towels—was offered, with the activities calendar containing many blank or vague entries and staff confirming the lack of structured programming.
Staff did not ensure that residents, including those with dementia, had access to drinking water, with observations showing empty or missing cups and beverages in multiple rooms. Nurse aides relied on residents to request water and were unaware that some may not be able to do so due to cognitive impairment. The deficiency was confirmed by the administrator.
The facility did not timely assess or document pressure ulcers and failed to follow wound care orders for three residents. One resident with quadriplegia developed a Stage 3 sacral ulcer that was not identified or treated until it had progressed, with no prior documentation of a blister. Another resident's Stage 3 ulcer was not comprehensively assessed for six days after admission, and a third resident's Stage 4 ulcer treatment was delayed by four days due to late order entry. These actions resulted in noncompliance with wound care policies and regulations.
Three residents with conditions including severe protein-calorie malnutrition experienced significant weight loss that was not promptly identified or addressed, and timely re-weights were not obtained as required by facility policy. Staff interviews confirmed that proper monitoring and intervention did not occur, resulting in inaccurate assessments and a failure to ensure adequate nutrition and hydration.
During a kitchen inspection, surveyors observed opened and undated bags of frozen burgers and chicken patties in the freezer, contrary to facility policy requiring all food items to be labeled and dated. A staff member confirmed that labeling and dating were expected but not followed for these items.
A resident's quarterly MDS assessment inaccurately documented significant weight loss, despite weight records and a reweigh by the RD showing otherwise. A licensed employee confirmed the inaccuracy in the assessment.
A facility failed to meet professional standards for medication administration when an LPN left a resident's medications mixed in an Ensure drink without ensuring full consumption. The resident, with severe cognitive impairment, was not assessed for safe self-medication, leading to incomplete administration of prescribed medications.
A facility failed to change the feeding bag for a resident with a feeding tube every 24 hours as required by their policy. The resident, who had multiple medical conditions, was on a specific feeding regimen. Observations showed the feed bag was not changed within the required timeframe, which was confirmed as a deficient practice by the Nursing Home Administrator.
Two residents experienced medication administration errors, resulting in a 17.24% error rate. A nurse crushed and mixed medications into a drink for one resident, which was not fully consumed, and improperly crushed Morphine ER for another resident, contrary to guidelines.
Failure to Maintain Clean, Safe, and Homelike Environment on One Unit
Penalty
Summary
Surveyors identified a failure to provide a safe, clean, comfortable, and homelike environment on the North building 8th floor (N8). During observations conducted between 10:00 and 10:30 a.m., the floor in front of the nursing station and in the hallway was found to be sticky, and visible spills were present in the lounge area and in the doorway of a resident room. Multiple scraps of paper were scattered on the floor in the lounge and hallways, and additional debris, including a sugar packet, a plastic lid, and a straw, were observed on the floors of resident rooms. A plastic glove was seen on the hallway floor. A dried, brown substance was present on the floor and in the bathroom of a resident room, including on the toilet, and dried food substances were observed on the floors of multiple other resident rooms. In one room, a thermostat was noted to be missing its cover, leaving exposed wires visible. These conditions were reported to the Nursing Home Administrator and the Director of Nursing at 12:30 p.m. the same day. The deficiency was cited under 42 CFR 483.10 (Resident rights) and 28 Pa. Code 201.18(e)(1), and was noted as previously cited on 1/30/26 and 7/28/25.
Failure to Provide Scheduled Assisted Showers for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with activities of daily living (ADLs), specifically bathing, to one resident. Facility policy on ADLs, last reviewed in December 2024, states that care and services for hygiene, including bathing, dressing, grooming, and oral care, will be person-centered and honor each resident’s preferences, choices, values, and beliefs. Review of the resident’s admission MDS dated February 20, 2026, showed the resident uses a wheelchair and requires supervision or touching assistance with showering/bathing and with tub/shower transfers. During an interview on March 3, 2026, the resident reported not receiving scheduled showers on March 2 and March 3, 2026, and stated staff told him/her there were not enough staff scheduled on the unit to provide the care. The resident expressed a desire to have a shower and requested that staff be made aware. In a subsequent interview on March 4, 2026, when this information was presented to the Nursing Home Administrator (NHA) and Director of Nursing (DON), they stated that residents often refuse showers, prefer bed baths, and some are care planned for bed baths only; however, they did not confirm that this resident preferred or was care planned for bed baths only. The deficiency was cited under Quality of Care 483.24(b)(1) and related Pennsylvania nursing services and clinical records regulations.
Medication Error: Insulin Administered Instead of Tuberculin Solution
Penalty
Summary
The facility failed to administer medications safely and as prescribed for one resident when a nurse gave Humalog, a fast-acting insulin, instead of tuberculin solution. Facility policy on administering medications, revised April 17, 2024, requires that medications be administered in a safe and timely manner as prescribed, that staff verify the right medication, dose, time, and method before administration, and that the nurse contact the physician or medical director if a dosage is believed to be inappropriate or a medication has potential adverse consequences. For this resident, the nurse did not follow these verification steps and administered Humalog insulin despite there being no physician order for Humalog in the resident’s record. The resident involved had multiple medical diagnoses, including metabolic encephalopathy, hypertension, hyperlipidemia, paroxysmal atrial fibrillation, and neurocognitive disorder with Lewy bodies, and had been admitted on December 31, 2025. Progress notes documented that in the early morning of January 1, 2026, a nurse notified the RN supervisor that the resident had received insulin, and new orders were received to monitor blood sugars. A medication error report documented that the resident was given Humalog instead of tuberculin solution, and review of the physician’s orders confirmed there was no order for Humalog. In an interview, the DON confirmed that the resident received Humalog insulin in error instead of tuberculin solution on that date.
Unsanitary Environmental Conditions on North Building 7th and 8th Floors
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment on two of eight units, specifically the North Building 7th and 8th floors. On the North Building 8th floor (N8), surveyors observed a bathroom with used briefs placed on the trash can, paper towels, used gloves, and empty bottles of body wash and shampoo left in the sinks. The N8 trash chute closet contained an overflowing trash bin with papers, used gloves, paper towels, and food scattered on the floor. In the North Building stairwell, used gloves were observed on the landing between the 7th (N7) and 8th (N8) floors. Additional observations of trash chute rooms on all North Building floors showed food, used gloves, papers, and paper towels on the floor on N8. When these findings were presented to the Nursing Home Administrator and DON, they acknowledged the information and stated they would investigate. No specific residents, medical histories, or clinical conditions were described in relation to these environmental sanitation deficiencies.
Environmental Deficiencies in Resident Rooms and Fall Mats
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents as required under Resident Rights 483.10(i)(1)-(7). During observations of 27 rooms on the 8th floor, one room was found to have a wall with bubbled and peeling paint, along with cracked drywall and pieces of drywall sitting on the windowsill. Additional observations on the 6th floor identified fraying fall mats in multiple rooms, specifically rooms 601, 615, 616, 625, and 627. These environmental deficiencies were identified during surveyor observations, and when the findings were presented to the Nursing Home Administrator and DON, the NHA stated she would investigate the matter.
Unsanitary 8th Floor Pantry and Food Storage Conditions
Penalty
Summary
The facility failed to ensure that food was stored in a clean, sanitary environment in the pantry on the 8th floor. Surveyor observations of this pantry showed rust and brown stains on the outside and inside of the cabinets, as well as brown stains on the countertop. Additional observations revealed red and brown stains inside the refrigerator and freezer, a coffee carafe with dried coffee at the bottom, and a water-stained ice bucket and ice scoop on the counter. Further review identified rust on the coffee and ice machines, along with calcium build-up on the ice machine, sink fixtures, and inside the sink. During an interview, the NHA stated that both dietary and housekeeping staff were responsible for cleaning the pantry and indicated that she would investigate the matter. The deficiency was cited under Food and Nutrition Services 483.60(i)(1)(2) for failure to maintain sanitary conditions for food storage and related equipment on one of three floors observed.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment on one of its nursing units, affecting 12 out of 17 residents. Observations included unclean and sticky floors in common areas and resident rooms, unmade beds, and the presence of refuse such as empty cups, food, and soiled gloves in various locations. Specific rooms were found with winter holiday decorations and excessive tape on the walls, missing outlet cover plates, broken furniture, and personal items in disarray. In several instances, soiled items such as gloves, incontinence brief pieces, and what appeared to be feces were found on floors, beds, and linens. Some residents were observed lying in beds without linens or with soiled linens, and in one case, a resident was in a bed not assigned to them. Staff interviews confirmed the presence of these unsanitary conditions, with a nurse aide identifying a brown object under a bed as feces. The facility's own policy requires maintaining a clean, comfortable, and homelike environment, including regular housekeeping and maintenance services, but these standards were not met. The Nursing Home Administrator acknowledged the failure to provide the required environment for the affected residents.
Failure to Provide Adequate ADL Assistance to Multiple Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for 11 of 17 residents, as evidenced by multiple observations, document reviews, and interviews. Residents were observed with soiled clothing, untrimmed fingernails with debris, greasy and unbrushed hair, and in some cases, without bed linens. Several residents were found in wet clothing and bed linens, and documentation did not reflect timely toileting or incontinence care. One resident was not provided lunch until prompted by staff, and another was found in a bed not assigned to them, surrounded by pieces of an incontinence brief. Grievance records and Resident Council minutes further documented concerns about lack of assistance with showers, delayed care from nurse aides, and unmet needs for snacks, water, and catheter care. Facility records indicated that some residents had not received showers as frequently as expected, and grievances confirmed delays in care and lack of staff responsiveness. Resident Council minutes from several months highlighted ongoing issues with staff not providing care, not passing snacks or water, long call light response times, and not completing rounds. The Nursing Home Administrator confirmed the failure to provide necessary ADL assistance for the affected residents.
Failure to Provide Ongoing Activities Program for Residents with Memory Impairments
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of residents on one of four nursing units, specifically 8 North, which is a secure unit for residents with memory impairments such as Alzheimer's disease and non-Alzheimer's dementia. Review of the facility's assessment indicated a commitment to providing therapeutic recreation for this population. However, observations on the unit revealed that the only activity provided was folding towels in the morning, with no further recreational or structured activities observed throughout the day. The posted activities calendar for the month contained multiple blank days and vague entries such as 'TBA' (to be announced), with limited scheduled activities and many days lacking any planned events. Interviews with staff confirmed the lack of structured activities, with one activities employee stating that the calendar had been hastily prepared and acknowledging the absence of a comprehensive program. Further, there was no evidence of nursing staff engaging with residents in a non-clinical manner during the observed period. The Nursing Home Administrator confirmed that the facility did not provide an ongoing program of activities to meet the needs of residents on the affected unit, as required by facility policy and state regulations.
Failure to Provide Drinking Water Consistent with Resident Needs
Penalty
Summary
The facility failed to provide drinking water consistent with resident needs and preferences on the 8 North nursing unit. Observations revealed that multiple residents, including those with memory impairment and dementia, did not have access to drinking cups or beverages in their rooms. Some residents had only empty or outdated cups, and in several cases, no cups or beverages were present at all. Staff interviews confirmed that nurse aides relied on residents to request water, and did not routinely provide fresh water, particularly for those unable to verbalize their needs due to cognitive impairment. Additionally, staff were unaware that individuals with dementia may not recognize thirst or be able to request fluids. Further observations later in the day confirmed that water was still not made available to residents. The facility's policy required that residents be offered sufficient fluid intake to maintain hydration, but this was not followed. The deficiency was acknowledged by the Nursing Home Administrator, who confirmed the lack of available drinking water consistent with resident needs and preferences on the unit.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to timely and comprehensively assess and document pressure ulcers, as well as to follow physician wound treatment orders for multiple residents. For one resident with quadriplegia, epilepsy, protein-calorie malnutrition, and psychiatric disorders, the care plan required frequent repositioning and skin monitoring due to high risk for skin breakdown. Despite weekly skin checks indicating no new issues, a nurse later discovered a significant sacral wound, which was ultimately identified as a Stage 3 pressure ulcer. There was no clinical documentation of a preceding blister or prior sacral wound, and treatment by the wound consultant was delayed due to the resident's unavailability. The pressure ulcer was not identified until it had progressed to Stage 3, and no treatments were in place for a blister prior to this discovery. Another resident was admitted with a history of acute respiratory failure and was found to have a Stage 3 pressure ulcer on the left buttock. Although the wound was identified upon admission, a comprehensive assessment of the wound's size and condition was not completed until six days later. The Director of Nursing confirmed this delay in assessment, indicating a lapse in timely wound evaluation and documentation as required by facility policy. A third resident was admitted with a Stage 4 sacral pressure ulcer, and a wound care order was issued by the wound physician. However, the order was not implemented until four days after it was written, due to a delay in entering the order into the electronic medical record. The responsible nurse acknowledged the delay was due to not entering the order promptly. These failures resulted in noncompliance with facility policies and state regulations regarding timely assessment, documentation, and implementation of wound care for residents at risk for or experiencing pressure ulcers.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that residents' weights were properly monitored and that significant weight changes were promptly addressed for three out of fifteen residents reviewed. According to the facility's policy, any weight change greater or less than 5 pounds within 30 days should be retaken for confirmation, and the dietitian is responsible for reviewing monthly weights and addressing negative trends. For one resident with diagnoses including depression and severe protein-calorie malnutrition, a 7.3% weight loss was recorded over a month, but there was no evidence that this significant weight loss was identified or that any intervention was implemented. Similarly, another resident experienced a rapid weight drop, but a timely re-weight was not obtained, resulting in an inaccurate MDS assessment. A third resident, also with severe protein-calorie malnutrition, lost 8.39% of body weight in a month, with no documentation of the weight loss being identified or addressed. Staff interviews confirmed that re-weights should have been obtained sooner and that the facility did not follow its own policy for monitoring and responding to significant weight changes. The lack of timely identification and intervention for significant weight loss in these residents, some of whom had critical conditions such as severe protein-calorie malnutrition, represents a failure to provide adequate food and fluids to maintain residents' health as required by facility policy and regulatory standards.
Failure to Properly Label and Date Frozen Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in the freezer area. During an observation in the freezer, a bag of frozen burgers and frozen chicken patties were found opened and undated. Facility policy requires that leftover food be stored in covered containers or wrapped securely, with each item clearly labeled and dated before refrigeration. An interview with a staff member confirmed that all items should be labeled and dated, but this was not done for the items observed.
Inaccurate MDS Assessment of Resident Weight
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident. Clinical record review showed that the resident's quarterly MDS assessment indicated a significant weight loss. However, a review of the resident's weight summary revealed fluctuating weights, with a reweigh by the registered dietitian showing a current body weight that did not support the significant weight loss documented in the MDS. An interview with a licensed employee confirmed that the MDS inaccurately reflected a significant weight loss for the resident.
Failure in Medication Administration Standards
Penalty
Summary
The facility failed to ensure that staff met professional standards for medication administration for a resident with severe cognitive impairment. During an observation, a licensed nurse, supervised by another nurse, crushed and mixed several medications into an Ensure drink for the resident. The nurse then left the room after marking the medications as administered in the electronic medical record, without confirming that the resident consumed the entire drink. Later, it was observed that the Ensure drink, containing the medications, was discarded with some liquid remaining, indicating that the medications were not fully administered. The supervising nurse confirmed this observation. An interview with the nurse revealed that the resident had a history of not taking medications, and the staff left the drink for the resident to finish on their own. However, there was no documentation in the resident's clinical record indicating an assessment for safe self-medication administration.
Failure to Change Feeding Bag for Resident with Enteral Nutrition
Penalty
Summary
The facility failed to ensure proper care for a resident with a feeding tube, specifically Resident 269, by not adhering to the established procedure for enteral nutrition via pump. The facility's policy required that the tubing connected to a feeding bag be changed every 24 hours when using canned formula. However, observations revealed that the feed bag for Resident 269 had not been changed within the required timeframe, as it was dated two days prior to the observation. Resident 269 had several medical conditions, including hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage, diabetes mellitus type II with nephropathy, and gastroesophageal reflux disease without esophagitis. The resident's clinical record indicated a specific feeding regimen using Nutren 1.0 with fiber via a feeding pump. Despite these detailed orders, the facility did not comply with the necessary protocol to prevent complications from enteral feeding, as confirmed by the Nursing Home Administrator during an interview.
Medication Administration Errors
Penalty
Summary
The facility failed to correctly administer medications to two residents, resulting in a medication error rate of 17.24%. The facility's policy requires medications to be administered safely and as prescribed. However, during an observation, a licensed nurse, Employee E3, supervised by Employee E4, crushed and mixed several medications, including Aspirin, Amlodipine, Olanzapine, and Oxycodone, into an Ensure drink for a resident. The nurse then left the room without ensuring the resident consumed the entire mixture. Later, it was observed that the drink, with some medication still in it, was discarded, indicating incomplete administration. In another instance, Employee E3 crushed Morphine ER, which should not be crushed according to the manufacturer's guidelines, and administered it to another resident. The nurse admitted that the resident does not take medications whole and acknowledged that the physician should have been notified to change the medication form. These actions led to the residents not being free from medication errors, violating the facility's policies and state regulations.
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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