Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkhouse Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Unlocked Trash Chute Door on Memory Care Unit: The facility failed to keep the door leading to the trash chute on the memory care unit locked at all times. Observations found the door unlocked and out of view of the nurses’ station, with a laundry cart placed in front of the chute but still allowing access once moved. The NHA and ANHA confirmed the door was required to remain locked at all times.
Failure to implement enhanced barrier precautions was identified for residents with wounds and indwelling devices. On Unit 2 West, surveyors observed missing EBP signs on room doors and no PPE bins in hallways for multiple rooms, including a resident with a urinary drainage bag and a resident with a contained RLE wound whose care plan included EBP. Staff interviews confirmed gaps in EBP knowledge and that some PPE bins were not available.
A resident with Parkinson's disease, gait impairment, and significant toileting assistance needs was found wet in a wheelchair with liquid on the floor and stated no staff provided continence care during the night shift. When the resident used the call bell, an NA entered, turned it off, and told the resident to wait for help, then did not return; the resident later reported the same lack of overnight continence care again, and the toileting task form had no overnight documentation.
Late NOMNC Delivery. A resident’s NOMNC for ending Medicare-covered skilled services was signed only 1 day before services ended, and the NHA confirmed it was not provided within the required 48-hour advance timeframe.
Failure to Monitor Psychotropic Medication Effects: The facility failed to monitor behaviors and medication side effects for three residents receiving psychotropic medications. One resident received quetiapine for anxiety, another received risperidone for psychotic disorder with delusions, and a third received Seroquel with directions to monitor for sedation and increased falls; MARs and progress notes showed the required monitoring was not documented, and the DON confirmed the findings.
MDS assessments did not accurately reflect falls with major injury for three residents. One resident had a witnessed fall with head strike and hip impact, later found to have an acute femur fracture and sent to the hospital, while two other residents had falls followed by x-ray-confirmed fractures of the foot and nasal bone. The Quarterly MDS for each resident did not indicate a fall with major injury, and an LPN confirmed the discrepancies.
Failure to provide assistance with ADLs and continence care. A resident with Parkinson's disease, mobility impairment, and a care plan requiring 1 staff for personal hygiene, transfers, and toilet use was found wet in a wheelchair with liquid on the floor and reported no overnight continence care. An aide entered the room, turned off the call bell, told the resident to wait for assistance, and did not return; there was also no documentation of overnight toileting care on the task form.
Failure to follow physician orders affected residents with COPD, ESRD, hypertension, and a colostomy. One resident receiving O2 via NC did not have ordered ear mates attached to the tubing, while residents on HD had medications withheld on dialysis days or given outside ordered BP parameters. Another resident with a colostomy had orders for colostomy care every shift, but the record showed EBP documentation without documentation that colostomy care was actually provided.
Failure to Follow Wound Treatment Orders: A resident at risk for skin impairment developed a sacral DTI that progressed to Stage II and then Stage III. Wound specialist recommendations for Triade Hydrophilic dressing were not entered or followed, and a later honey hydrogel treatment was started late. The ADON confirmed the wound treatment orders were not followed correctly and in a timely manner.
Failure to Monitor Fluid Restrictions and Weight Loss: The facility failed to accurately monitor fluid restriction intake for one resident with ESRD, CKD, HF, and fluid overload, where documented intake either exceeded the ordered limit or was missing. The facility also failed to consistently obtain weights and timely address significant weight loss for another resident, whose weight dropped more than 10% over four months and was not promptly communicated to the physician.
Enteral feeding was not provided and documented as ordered for a resident with a PEG tube, dysphagia, TBI, and protein malnutrition. MAR review showed multiple days with missing or inconsistent total volume documentation, and an observation found the feeding pump inactive with formula still remaining in the bag. The UM RN and DON confirmed the enteral feed orders were not being followed and/or documented properly.
A facility failed to properly store and label insulin on two med carts, with multiple opened insulin vials and pens left undated, and also left a treatment cart unlocked in a hallway. In addition, a cognitively intact resident who wished to self-medicate with homeopathic remedies had multiple dropper bottles stored on a shelf in a shared room rather than locked in a bedside table, and nursing staff did not track what remedies she had, what they were for, or when they were taken.
A resident with dementia, left shoulder pain, and a significant left-hand contracture had an OT plan with short- and long-term goals to achieve normal finger alignment using a left hand roll. Initial OT sessions showed the resident tolerated several hours of splint use with intact skin, but on subsequent days no left-hand treatment was provided, and documentation later noted cognitive decline, difficulty with ADLs, and refusal of the left hand splint and hygiene. OT goals for the left hand were discharged, and there was no further evidence of left-hand treatment before discharge, while leadership confirmed that therapy sessions on key days did not address the hand, resulting in a failure to provide the ordered specialized rehabilitative services.
A resident with intact cognition and a history of schizoaffective disorder, bipolar type, was observed sitting on the bedside without any call bell available to summon staff. Surveyors found no call bell cord plugged into the wall and no call bell present in the room, despite facility records from recent nonclinical rounds indicating that a call bell had previously been in place. A staff member and the Nursing Home Administrator confirmed that the resident did not have access to a call bell at the time of the survey.
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.
Unlocked Trash Chute Door on Memory Care Unit
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible by not keeping the door leading to the trash chute on the memory care unit locked at all times. On June 9, 2026, observations on the 8th floor memory care unit found a sign on the door stating, “TRASH CHUTE - This door must be kept locked at all times. THANK YOU,” yet the door was unlocked and located out of view of the nurses’ station. A laundry cart had been placed in front of the trash chute, requiring it to be moved to access the chute. Follow-up observations on June 10 and June 11, 2026, showed the door remained unlocked, and the laundry cart continued to be positioned in front of the chute, although the chute was still accessible once the cart was moved. During an interview on June 11, 2026, the NHA and ANHA confirmed that the door to the trash chute is required to remain locked at all times.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for residents with open wounds and/or indwelling medical devices, as required by its policy titled, "Isolation Steps: Categories of Transmission-Based Precautions." The policy, reviewed in August 2025, stated that residents with open wounds or devices such as a urinary catheter, feeding tube, or tracheostomy should use enhanced barrier precautions, including wearing a gown and gloves for interactions that may involve contact with the resident or the resident's environment. On Unit 2 West, observation of a room on June 9, 2026, revealed a urinary drainage bag hanging from the bed frame and no enhanced barrier precautions sign on the door. Additional observations showed that one room had an enhanced barrier precautions sign for residents in bed 2 and bed 4, but there was no PPE bin in the hallway for two of the three rooms where enhanced barrier precautions were in place. Later observations on June 10 and June 11 found no enhanced barrier precautions sign on the door of another room and no PPE bin for that hallway. Observation of rooms 211, 214, 215, and 217 on the 2 [NAME] hallway on June 11, 2026, revealed enhanced barrier precautions signs, but no PPE bin for any room on that hallway. Resident 9's care plan included enhanced barrier precautions related to a contained RLE wound, yet observations of Resident 9's room on June 10, June 11, and June 12 showed no enhanced barrier precautions sign on the door and no PPE outside the door. Interviews confirmed staff were aware of missing signs and PPE bins, and one nursing employee stated they did not know what enhanced barrier precautions were.
Failure to Provide Timely Continence Care and Respectful Response to Call Bell
Penalty
Summary
Resident 99, who was admitted with Parkinson's disease, difficulty walking, unsteadiness on feet, abnormal gait, and a need for assistance with personal care, was assessed as using a wheelchair and requiring partial to moderate assistance with toileting hygiene and substantial to maximum assistance with sit-to-stand and toilet transfers. The care plan identified toileting deficits and an ADL self-care performance deficit related to depression, Parkinson's disease, and asthma, with interventions stating the resident required one staff member for personal hygiene, transfers, and toilet use. During observations, Resident 99 was found sitting in the room in a wheelchair with clear liquid pooling on the floor and the resident's clothes and wheelchair wet. The resident stated he/she needed assistance with continence care and that no staff came during the entire night shift. When the resident activated the call bell, Nurse Aide Employee E9 entered the room, observed that continence care was needed, turned off the call bell, and told the resident to wait for assistance. Employee E9 stated he/she could not leave Resident 93 because that resident was a fall risk, and Employee E10 was observed sitting behind the nurses' station with Employee E9. Resident 99 stated Employee E9 did not return and continence care was not provided until day shift, and later stated the same issue occurred again the next night. The 30-day toileting task form contained no documentation of overnight toileting care for the dates reviewed.
Late Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) within the required 2-day advance timeframe for one resident. Review of the resident’s medical record showed a NOMNC stating that Medicare-covered skilled services were ending on May 14, 2026, and the notice was signed and dated by the resident on May 13, 2026 at 9:00 a.m., which was only 1 day before the end of Medicare-covered services. During an interview on June 12, 2025 at 12:05 p.m., the Nursing Home Administrator confirmed that the NOMNC was not provided within the required 48-hour timeframe.
Failure to Monitor Behaviors and Side Effects for Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to monitor the behaviors and medication side effects of residents receiving psychotropic medications for three residents reviewed. The facility's policy on Antipsychotic/Anxiolytic Utilization stated that documentation is necessary to help assess whether a resident's behavioral symptoms need intervention and whether the symptoms are transitory or permanent. For Resident 15, a physician order for Quetiapine Fumarate 25 mg at bedtime for anxiety was reviewed, and the resident's MARs and progress notes showed that side effects were not monitored after the medication started. For Resident 17, a physician order for Risperdal 1 mg at bedtime for psychotic disorder with delusions due to a known physiological condition was reviewed, and the MARs and progress notes showed that side effects were not monitored after the medication started. For Resident 327, a physician order for Seroquel 25 mg twice daily for psychotic disorder with delusion included instructions to monitor for sedation and increased falls, but the resident's MARs and progress notes showed that behaviors and medication side effects were not monitored after the medication started. The DON confirmed these findings during interview, including that Resident 327's behavior and medication side effects were not monitored. The facility failed to ensure that Residents 15, 17, and 327's behaviors and medication side effects were monitored.
MDS assessments did not reflect falls with major injury
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for three residents reviewed. For Resident 2, the clinical record documented a witnessed fall after breakfast with head strike and left hip impact, followed by x-ray results showing an acute left subcapital femur fracture with impaction and transfer to the hospital; however, the Quarterly MDS did not indicate that the resident had a fall with major injury. Employee E6 confirmed this discrepancy during interview. For Resident 3, nursing notes documented that the resident was found on the floor next to the bed, later had an x-ray of the left foot after a fall, and the x-ray showed an acute fracture at the base of the 1st metatarsal; the Quarterly MDS did not indicate a fall with major injury. For Resident 283, nursing notes documented an unwitnessed fall followed by x-ray results showing a nondisplaced fracture of the nasal bone, with the physician and guardian notified; the Quarterly MDS also did not indicate a fall with major injury. Employee E6 confirmed that Resident 3 and Resident 283's falls with major injury were not accurately reflected on their MDS assessments.
Failure to Provide Assistance With ADLs and Continence Care
Penalty
Summary
The facility failed to provide assistance with activities of daily living for Resident 99, who was admitted with diagnoses including Parkinson's disease, difficulty walking, need for assistance with personal care, unsteadiness on feet, and abnormality of gait. The resident's quarterly MDS dated May 14, 2026, showed use of a wheelchair and a need for partial to moderate assistance with toileting hygiene, as well as substantial to maximum assistance with sit-to-stand and toilet transfers. The care plan identified toileting deficits and an ADL self-care performance deficit related to depression, Parkinson's disease, and asthma, with interventions stating the resident required 1 staff member for personal hygiene, transfers, and toilet use. During observations on June 9, 2026, Resident 99 was found sitting in the room in a wheelchair with clear liquid pooling on the floor, and the resident's clothes and wheelchair were wet. The resident stated no staff came to assist with continence care during the entire night shift and activated the call bell. Employee E9 was observed entering the room, then returning to the nurses' station, and the call bell was turned off. Resident 99 stated Employee E9 told him/her to wait for assistance with continence care, and Employee E9 confirmed entering the room, seeing the need for continence care, turning off the call bell, and telling the resident to wait. The resident later stated continence care was not provided until day shift, and again reported not receiving continence care during the entire night shift on the following night. Review of the 30-day toileting task form showed no documentation of overnight toileting care for June 9 and June 10, 2026.
Failure to Follow Physician Orders for Oxygen, Dialysis-Related Medications, and Colostomy Care
Penalty
Summary
The facility failed to implement physician orders for multiple residents. One resident with COPD and dependence on supplemental oxygen had an order for ear mates to be attached to the oxygen tubing at all times to relieve pressure, but observation showed the oxygen tubing was not fitted with ear mates while the resident was receiving oxygen by nasal cannula. The resident stated they could not recall the last time ear mates had been attached, and the NHA and ANHA confirmed the finding. A resident with ESRD on hemodialysis and hypertension had an order for Hydralazine 25 mg every 12 hours, with instructions to hold for systolic blood pressure below 120 mm Hg. The April 2026 MAR showed Hydralazine was not administered on multiple days because the resident was on dialysis, and it was also administered five times when the systolic blood pressure was below the ordered parameter. Another resident with ESRD, hemodialysis, and hypertension had orders for dialysis care at bedside on Monday, Wednesday, and Friday, along with Sevelamer carbonate, Lisinopril, Hydralazine, and Clonidine for hypertension. For the resident with ESRD and hemodialysis, the June 2026 MAR showed Sevelamer, Lisinopril, and Hydralazine were not administered on multiple dialysis days because the resident was on dialysis. The May 2026 MAR also showed Clonidine was administered 86 times when the blood pressure was below the ordered parameter. A resident with a colostomy had physician orders for colostomy care every shift and Enhanced Barrier Precautions related to the colostomy, but the May and June 2026 records documented EBP while showing no documentation that colostomy care was provided. The NHA and DON confirmed there was no documentation of colostomy care being provided.
Failure to Follow Wound Treatment Orders
Penalty
Summary
The facility failed to follow wound treatment orders correctly and in a timely manner for one resident who was at risk for skin integrity impairment related to immobility and incontinence. The resident’s care plan included an air mattress, repositioning, and ordered treatment, along with Calamine-Zinc Oxide External Lotion to the buttocks each day and evening shift for skin protection. On April 1, 2026, nursing staff documented a new area of concern on the sacrum described as a large deep tissue injury, dry, measuring 2.8 x 2.0 x 0 cm, and deep purple in color. A wound consult on April 7, 2026, documented that the sacral wound had progressed to a Stage II and recommended Triade Hydrophilic wound dressing to the sacrum, but the recommendation was not entered as an order and was not followed. A subsequent wound consult on April 14, 2026, again recommended continuing Triade treatment, and that recommendation was also not followed. On April 21, 2026, the sacral wound was documented as Stage III measuring 1.0 x 0.5 x 0.1 cm with 70% slough, and honey hydrogel was recommended; the treatment was not started until April 23, 2026. The ADON confirmed that the Triade recommendation was not followed and that the honey hydrogel treatment was not followed in a timely manner.
Failure to Monitor Fluid Restrictions and Weight Loss
Penalty
Summary
The facility failed to ensure proper monitoring of fluid restrictions for two residents reviewed for nutrition and hydration needs. One resident had diagnoses including mild protein-calorie malnutrition, atherosclerotic heart disease, end stage renal disease, hypertensive heart and chronic kidney disease with heart failure, stage 5 chronic kidney disease, and fluid overload. The resident had a physician order for a 1500 ml fluid restriction, with specific amounts assigned to nursing and dietary staff, but review of May and June 2026 MARs and 30-day task documentation showed that the combined fluid intake either exceeded the ordered amount or was not documented. During interview, the DON confirmed staff was not accurately documenting the resident's fluid intake. The facility also failed to consistently monitor weights and timely address significant weight loss for another resident. That resident's weight decreased from 123.2 pounds to 110.6 pounds, a 10.23% loss over four months, and the resident's weight was not taken in March 2026. The significant weight loss identified in April 2026 was not addressed, and the physician was not notified until May 15, 2026. The RD stated the company had only begun seeing residents in the facility in May 2026 and could not explain why the March weight was missed or why the weight loss was not addressed sooner. The NHA confirmed the March 2026 weight was not monitored and the significant weight loss was not timely addressed.
Enteral Feeding Not Provided and Documented as Ordered
Penalty
Summary
The facility failed to provide enteral nutrition as ordered for one resident with a PEG tube. The resident was admitted with diagnoses including traumatic subarachnoid hemorrhage, diffuse traumatic brain injury, mild protein malnutrition, and dysphagia, and had lost 23 pounds between November 19, 2025, and June 12, 2026. A physician order dated March 5, 2026, directed Glucerna 1.5 at 80 ml per hour for 12 hours via PEG tube each evening, with a total volume of 960 ml, and required daily documentation of the total volume infused once feeding was completed. Review of the MAR for June 2026 showed total infusions ranging from 0 ml to 960 ml, and the May and June 2026 MARs included 15 days with total volume documented as NA, along with days documented as 0 ml, 300 ml, 100 ml, and 712 ml. During observation on June 12, 2026, the resident was still connected to the feeding pump, which was flashing inactive for 10 minutes, and the Glucerna bag dated June 11, 2026 had 200 ml remaining in the 1000 ml bag. The Unit Manager RN confirmed the feeding pump orders were not being followed and/or documented as prescribed, and the DON also confirmed the enteral feed orders were not being followed and/or documented properly.
Improper medication storage and unsecured homeopathic remedies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles. On the second-floor medication cart B, a licensed nurse observed one vial of Lantus insulin, two Lispro pen insulins, and one Lantus pen insulin that were opened and undated. The nurse stated that the insulins should have been dated when opened and did not know when they had been opened. On the third-floor medication cart A, a licensed nurse observed one Novolog insulin vial that was opened and undated, along with multiple other insulin vials and pens, including Lantus, Humalog, Novolog, Novolin, and Lispro, several of which were opened on various dates and one Lantus pen that was opened and undated. The facility also failed to secure a treatment cart on unit Two West. Observation of the unit hallway showed a treatment cart standing in the hallway that was unlocked at approximately 6:30 a.m. and again at approximately 9:30 a.m. The same cart remained unlocked during both observations, and this was confirmed by a nursing employee. Resident 12 was identified as cognitively intact and independent with activities of daily living and mobility, with diagnoses including anxiety disorder, major depressive disorder, psychotic disorder with delusions, and chronic obstructive pulmonary disease. The resident’s care plan stated that she wished to self-medicate with homeopathic treatments and keep them locked in her bedside table, but observation of her room showed multiple brown dropper bottles stored on a shelf under her television. The resident stated the bottles contained her oils, shared the room with a roommate, and nursing staff reported they did not track what homeopathic remedies she had, what they were for, or when they were taken.
Failure to Provide Ongoing Specialized OT for Hand Contracture
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that specialized rehabilitative services were provided as required for one resident. The resident was admitted with diagnoses including unspecified dementia with mood disturbance and left shoulder pain, and was observed on April 16, 2026, to have a significant left-hand contracture. Occupational therapy (OT) had evaluated the resident on August 22, 2025, and established short-term and long-term goals for achieving normal anatomical alignment of the left fingers for specified durations to facilitate joint mobility and prevent contractures. Treatment encounter notes showed that on August 28, 2025, the resident tolerated wearing a left hand roll for 3.5 hours with intact skin, and on September 3, 2025, tolerated 4 hours with no skin breakdown or redness, though pain was noted as “hurts.” Subsequent OT notes revealed that on September 4 and 5, 2025, the resident did not receive treatment for the left hand. On September 8, 2025, OT documented that the resident was showing a decline in cognition and sequencing for ADLs, was unable to use utensils appropriately, and was refusing the left hand splint and left hand hygiene. The OT discharge summary dated September 12, 2025, indicated that the short-term and long-term goals for the left hand were discharged. Review of the clinical record showed no evidence of further attempts at left hand treatment prior to the resident’s discharge. The Rehabilitation Director confirmed that therapy provided on September 4 and 5 did not address the left hand, and the Nursing Home Administrator confirmed these findings, supporting the determination that required rehabilitative services for the resident’s left hand contracture were not provided as planned.
Failure to Ensure Resident Access to Call Bell in Room
Penalty
Summary
Surveyors determined that the facility failed to ensure a working call system was available for a resident, as required for resident bathrooms and bathing areas. During a complaint survey on the seventh floor, an observation at approximately 11:09 a.m. showed Resident 13 sitting on the bedside without a call bell available to alert staff for assistance. Further inspection of the room revealed there was no call bell cord plugged into the wall and no call bell present anywhere in the room. Review of Resident 13’s clinical record showed the resident was admitted on a documented date, had a BIMS score of 15 indicating intact cognition, and carried diagnoses including schizoaffective disorder, bipolar type. Facility records from nonclinical rounds indicated that a call bell had been present in the resident’s room three days earlier. An interview with a staff member (Employee 5) confirmed the absence of a call bell for this resident, and the Nursing Home Administrator later confirmed these findings, constituting noncompliance with 28 Pa. Code 201.14(a) and 201.18(b)(1).
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.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,321 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Royersford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Phoenix Center For Rehabilitation And Nursing,the | 3 mi | ★★★★★ | 3 | 1 |
| Southeastern Pennsylvania Veteran's Center | 3.5 mi | ★★★★★ | 1 | 0 |
| Rehab At Shannondell | 5.6 mi | ★★★★★ | 21 | 0 |
| Sanatoga Center | 6.4 mi | ★★★★★ | 5 | 0 |
| King Of Prussia Skilled Nursing And Rehabilitation | 7.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.