Pennypack Rehab And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 8015 Lawndale Avenue, Philadelphia, Pennsylvania 19111
- CMS Provider Number
- 395135
- Inspections on file
- 27
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Pennypack Rehab And Care Center during CMS and state inspections, most recent first.
A resident's personal funds were not properly accounted for, as required by facility policy. The business office manager and administrator confirmed there was no documentation or record of financial transactions for the resident, despite the facility accepting responsibility for managing the resident's funds. Both staff members were also unaware of the sources of payment scheduled for the resident's account.
A resident with multiple medical conditions experienced two falls, but nursing staff did not assess, monitor, or document the incidents as required by facility policy. No vital signs were recorded, no clinical notes were made, and the physician was not notified until days later. This deficiency was confirmed through staff interviews and record review.
A resident was not informed of the services available or the charges for those services, including costs not covered by Medicare or Medicaid, at admission or during their stay. The admission agreement lacked required rate information, and no documentation was provided to the resident regarding service charges.
Surveyors found that multiple opened food items in the dietary department were not properly labeled with both an open date and a use by date, as required by facility policy. The Food Service Director confirmed that these labeling practices were not followed, resulting in a deficiency related to food storage and safety standards.
A container of unlabeled and undated food was found stored in a medication room refrigerator alongside vaccines. An LPN present was unable to identify the owner or the date the food was placed there, which was not in accordance with facility policies requiring proper labeling and separation of personal food items from medications.
A resident with diabetes, hypertension, a pressure ulcer, and heart failure reported that a nurse aide caused pain to a pressure ulcer and delayed care. The facility's investigation was incomplete, as the accused aide was not questioned about the specific allegations and four additional staff present during the shift were not interviewed.
A resident admitted for short-term rehabilitation and later discharged home did not have a required discharge MDS assessment completed, as confirmed by the DON and review of clinical records and facility policy.
A resident admitted with severe protein calorie malnutrition did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. The absence of this care plan, specifically addressing nutrition and weight status, was confirmed by the facility dietician and was not rectified until a comprehensive care plan was created several days later.
A licensed nurse administered a lidocaine 4% patch to a resident instead of the prescribed 5% patch due to unavailability of the correct strength in the medication cart and lack of knowledge on how to obtain it, resulting in failure to follow physician orders during medication administration.
A resident receiving enteral nutrition did not have their tube feeding supplies properly labeled with dates, and the recommended increase in tube feeding rate by the dietician was not implemented. The dietician communicated the recommendation to the DON, but the order was not entered or followed, and water flushes were not set at the correct rate as ordered.
A resident with COPD was observed receiving oxygen at 2 L/min via nasal cannula, despite a physician's order for 3 L/min every shift for SOB. The resident was unaware of the incorrect setting, and a nurse confirmed the discrepancy before adjusting the flow to the ordered rate.
A resident with cancer, heart failure, renal failure, and dementia did not have any documented physician or practitioner visits for several months, with the last recorded visit occurring many months prior. The DON confirmed the absence of required physician documentation in the clinical record.
The facility did not meet the required nurse aide to resident ratios during several shifts, as evidenced by a review of nursing schedules and confirmed by the Administrator and DON. The shortfall in nurse aide service hours occurred on multiple days and shifts, failing to provide the minimum required care for the resident census.
The facility did not meet the required LPN staffing ratios on the day shift for three consecutive days. On these days, the facility provided fewer LPN service hours than required for the resident census, as confirmed by the Administrator and DON.
The facility did not meet the required RN staffing ratios during overnight shifts for five consecutive nights. The facility provided significantly fewer RN service hours than the required 8 hours per shift, with a resident census ranging from 48 to 50. This deficiency was confirmed by the Administrator and DON.
A newly admitted resident with a complex medical history, including cerebral edema and seizure disorder, experienced a significant medication error when the facility failed to transcribe Depakote into their Medication Administration Record as per hospital discharge instructions. The error was confirmed by the Interim DON.
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for two residents. One resident was transferred due to severe abdominal pain and acute kidney failure, while another was transferred following a change in condition after joint replacement. The Nursing Administrator confirmed the lack of written notices for these transfers.
The facility failed to maintain an effective infection control program, as observed in the handling and storage of soiled and clean linens. Dirty hospital gowns were stored outside in large containers, and the laundry room was congested with insufficient separation of clean and soiled items. Additionally, clean linens were stored in racks without doors in shower rooms, alongside soiled linens in plastic bags, leading to potential contamination.
A facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident before the termination of Medicare A services. The resident's last covered day was in late June, but the NOMNC was not provided until mid-July, contrary to the facility's policy requiring notice at least two days prior to service termination. This was confirmed by the Nursing Home Administrator.
A deficiency was identified in the improper completion of the PASRR for a resident with multiple mental health disorders, including Major Depressive Disorder and Schizoaffective Disorder. The PASRR Level I form did not correctly indicate outcomes related to chronic disability, as confirmed by the DON.
A resident with multiple diagnoses, including dementia and lack of coordination, fell and sustained a hematoma. Despite a high fall risk score upon readmission, the resident's fall prevention care plan was not updated. The DON confirmed the care plan was not revised, violating several regulations.
A resident with severe cognitive impairment and multiple medical conditions, including pressure ulcers, did not receive adequate pain management. Despite being on a scheduled pain medication regimen, the resident frequently experienced severe pain, with levels documented as very strong to the worst possible. The facility failed to monitor and assess the effectiveness of the pain medication, and there was no evidence of appropriate response to the resident's severe pain prior to a change in medication.
The facility experienced a medication error rate of 11.54%, exceeding the acceptable threshold. Errors included administering the wrong form of Aspirin, incorrect dosage of Calcium with Vitamin D, and preparing to give Senna Plus instead of the prescribed Senna. These errors were confirmed by the LPNs involved.
A facility failed to implement its abuse policy when a resident reported being harmed by a nurse aide. The incident was not immediately reported to the appropriate authorities, and the nurse aide continued to work in the same area as the resident. Interviews revealed a lack of clear communication and proper reporting, resulting in a delay in addressing the resident's injury.
A resident reported that a CNA pushed her wheelchair into her bed, causing injury. Despite the resident's complaint and visible bruising, the incident was not immediately reported to the administrator or other required officials. The delay in reporting and investigating the incident was evident as the Director of Nursing only became aware of the situation the following day when she found a witness statement on her desk and initiated an investigation.
Failure to Maintain Resident Personal Funds Accounting
Penalty
Summary
The facility failed to maintain separate accounting and records for a resident's personal funds that were entrusted to the facility. According to the facility's policy, the business office manager was responsible for keeping detailed accounting records for each resident's personal needs account, including the date of admission, all deposits and withdrawals, the names of individuals involved in transactions, and receipts for charges and interest earned. However, for one resident who was admitted after a hospital stay for a cerebral vascular accident, right arm weakness, and atrial fibrillation, and who was cognitively intact, there was no documentation available to show that a personal funds account was established or maintained in accordance with generally accepted accounting principles. Interviews with the administrator and business office manager confirmed that the facility had no records of accounting or financial transactions for this resident's funds, despite having accepted responsibility for managing the resident's financial affairs. Additionally, both staff members were unaware of what insurances, pensions, or private pay funds were scheduled to be deposited into the resident's account to pay for their stay. This lack of documentation and awareness was identified through interviews, review of clinical records, and examination of the facility's policies and procedures.
Failure to Assess and Monitor Resident After Falls
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and monitored following two fall incidents. According to the facility's policy, staff are required to evaluate residents for possible injuries, record vital signs, notify the physician, and document any observed symptoms after a fall. However, after a resident with dementia, anxiety, mild intellectual disabilities, lack of coordination, and dysphagia experienced two falls, there was no evidence in the clinical record that nursing staff performed any assessments or documented the incidents. The nursing supervisor who discovered the resident on the floor did not complete an assessment, stating it was the responsibility of the next shift. The licensed nurse on the following shift also did not perform or document any assessment after witnessing the resident slide off the chair and fall again shortly after. Additionally, there was no documentation that the resident's physician was notified of either fall at the time they occurred. The physician confirmed that notification was not received until several days later, despite facility policy requiring timely notification. The lack of assessment, documentation, and physician notification following the falls was confirmed through staff interviews, review of clinical records, and facility documents.
Failure to Inform Resident of Service Charges and Coverage
Penalty
Summary
The facility failed to inform a resident, at the time of admission and during their stay, about the services available and the charges for those services, including any charges for services not covered under Medicare or Medicaid. Review of the clinical record and admission agreement for the resident showed that the section detailing charges for services not covered was left blank, and no documentation was provided to the resident regarding available services and associated costs. An interview with the business office manager confirmed that the rate information should have been provided to the resident upon admission, but this was not done.
Failure to Properly Label and Date Opened Food Items in Dietary Department
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the dietary department, surveyors observed multiple food items that had been opened but were not properly labeled with both an open date and a use by date, as required by the facility's Food Storage Policy. Specifically, bags of frozen green beans and carrots, a pack of frozen hamburgers, a gallon of milk, a container of Italian dressing, and a container of soy sauce were all found either missing a use by date or, in the case of the soy sauce, missing both an open date and a use by date. The Food Service Director confirmed during the tour that all food items should display both the date they were opened and a use by date, in accordance with facility policy. The lack of proper labeling and dating of these food items constituted a failure to follow established procedures for food safety and storage, as outlined in the facility's own policy and professional standards.
Unlabeled Food Stored with Vaccines in Medication Room Refrigerator
Penalty
Summary
A deficiency was identified when a container of food, which was neither labeled nor dated, was found stored in a refrigerator within the A/B wing medication storage room that also contained vaccines. This observation was made during a facility tour with a licensed nurse, who confirmed that she did not know the owner of the food or when it had been placed there. Review of facility policies revealed that medications are to be stored separately from food and that any food brought by family or visitors for residents must be labeled and stored in a manner that distinguishes it from facility-prepared food. The presence of unlabeled and undated food in a medication room refrigerator was not in accordance with these policies.
Incomplete Investigation of Abuse/Neglect Allegation
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of potential abuse/neglect involving a resident with multiple medical conditions, including diabetes, hypertension, a pressure ulcer on the left hip, and heart failure. The resident reported that a nurse aide shoved a bed pan under him, causing severe pain to his pressure ulcer, and delayed providing care after the resident had a bowel movement. The incident was reported to the State Survey Agency, and the facility initiated an investigation. However, the investigation was incomplete. The statement obtained from the accused nurse aide did not address the specific allegations made by the resident, and there was no evidence that the facility questioned the aide about the incident. Additionally, although two licensed nurses provided witness statements, four other staff members who were present during the shift were not interviewed, and there was no documentation of their input. The lack of comprehensive staff interviews and failure to address the resident's specific allegations resulted in an incomplete investigation.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a required discharge Minimum Data Set (MDS) assessment for one resident who was admitted for short-term rehabilitation and subsequently discharged home. According to the facility's policy, the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments by the interdisciplinary team. Clinical record review showed that the resident was discharged, but no discharge MDS assessment was found in the records. This was confirmed during an interview with the Director of Nursing, who acknowledged that the discharge MDS had not been completed for the resident.
Failure to Develop Baseline Care Plan for New Admission with Malnutrition
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one newly admitted resident diagnosed with severe protein calorie malnutrition. According to facility policy, a baseline care plan must be created within 48 hours to address the resident's immediate health and safety needs, including initial goals, physician orders, and dietary orders. Review of the clinical record for this resident showed no documented evidence of a baseline care plan addressing the resident's nutritional status and weight until several days after admission, when a comprehensive care plan was eventually developed. The absence of a baseline care plan was confirmed during an interview with the facility dietician, who acknowledged that no such plan was in place for the resident's nutrition. The deficiency was cited under 28 Pa Code 211.10(c) Resident care policies and 28 Pa Code 211.12(d)(5) Nursing services, as the facility did not follow its own policy or regulatory requirements for timely care planning upon admission.
Failure to Administer Medication as Ordered by Physician
Penalty
Summary
A deficiency occurred when a licensed nurse administered a lidocaine 4% patch to a resident's left shoulder during the morning medication pass, despite the physician's order specifying a lidocaine 5% patch. The nurse prepared and applied the 4% patch because only that strength was available in the medication cart and was unaware of where to obtain the correct 5% patch. Facility policy requires medications to be administered in accordance with prescriber orders, but this was not followed in this instance. The nurse confirmed the discrepancy during an interview, acknowledging the administration of the incorrect medication strength.
Failure to Implement Dietician Recommendations and Properly Label Enteral Feeding Supplies
Penalty
Summary
The facility failed to ensure appropriate enteral feeding practices for a resident receiving tube feedings. Observations revealed that the resident's Glucerna 1.5 tube feeding was infusing via a pump, but the bottle was not labeled with the date it was opened, and the water flush bag lacked both a name and date label. A licensed nurse was unaware of when the Glucerna bottle was opened, as it was already infusing at the start of her shift. Additionally, the water flushes were not set at the correct rate as ordered by the physician. Review of the clinical record showed that the registered dietician had recommended an increase in the tube feeding rate due to the resident's weight loss, but this recommendation was not implemented. The dietician stated she communicated her recommendations to the Director of Nursing, who was responsible for entering the order, but was unaware that the changes had not been made. The facility's policy required that recommendations from the dietician be communicated and followed up with appropriate documentation, which did not occur in this instance.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of chronic obstructive pulmonary disease (COPD) did not receive supplemental oxygen as ordered by the physician. The physician's order specified that the resident should receive oxygen at 3 liters per minute via nasal cannula every shift for shortness of breath. However, during an observation, the resident was found with the oxygen concentrator set at 2 liters per minute instead of the prescribed 3 liters per minute. The resident was unaware that the oxygen flow was set incorrectly and did not know who had adjusted it. A licensed nurse confirmed the physician's order for 3 liters per minute and, upon joint observation, verified that the concentrator was set at 2 liters per minute before adjusting it to the correct setting. This failure to administer oxygen at the prescribed rate constituted a deviation from both the physician's order and the facility's policy on oxygen administration.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident received required physician visits as mandated. Clinical record reviews and staff interviews revealed that a resident with multiple diagnoses, including cancer, heart failure, renal failure, and dementia, had not been seen by a physician or practitioner for an extended period. Specifically, there were no physician or practitioner notes in the resident's clinical record from November 2024 through June 2025, and the last documented physician visit occurred in August 2024. The Director of Nursing confirmed the absence of any physician or practitioner notes for this resident during the specified timeframe.
Facility Fails to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios as required by regulations effective July 1, 2023. Specifically, the facility did not have the required number of nurse aides per residents during various shifts from March 6, 2025, to March 10, 2025. On the day shift, the facility was short of the required nurse aide hours on March 7, March 8, and March 9, 2025. Similarly, the evening shift was understaffed on March 7 and March 9, 2025. The overnight shift also did not meet the required staffing levels on March 6 and March 8, 2025. The deficiency was confirmed through a review of nursing schedules and an interview with the Administrator and Director of Nursing on March 19, 2025. The facility's failure to meet the staffing requirements was evident in the shortfall of nurse aide service hours compared to the minimum required hours for the resident census on the specified dates. This lack of adequate staffing was acknowledged by the facility's administration during the interview.
Plan Of Correction
1. The facility reviewed the CNA ratios from March 6, 2025 through March 10, 2025. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on CNA ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to ensure ratios are met. 4. DON/designee will conduct daily audits to verify CNA ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios for Licensed Practical Nurses (LPNs) on the day shift for three consecutive days. Specifically, on March 8, 2025, the facility provided only 15.50 hours of LPN service for a census of 49 residents, falling short of the required 15.68 hours. On March 9, 2025, the facility provided 15.73 hours of LPN service for a census of 50 residents, below the required 16.00 hours. Similarly, on March 10, 2025, the facility again provided only 15.68 hours of LPN service for a census of 50 residents, not meeting the required 16.00 hours. This deficiency was confirmed in an interview with the Administrator and Director of Nursing on March 19, 2025.
Plan Of Correction
1. The facility reviewed the LPN ratios for March 8th, 9th, and 10th. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on LPN ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to ensure ratios are met. 4. DON/designee will conduct daily audits to verify LPN ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.
Failure to Meet RN Staffing Ratios on Overnight Shifts
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios of one Registered Nurse (RN) per 250 residents during the overnight shift for five consecutive nights from March 6, 2025, to March 10, 2025. A review of the nursing schedules revealed that on these dates, the facility provided significantly fewer RN service hours than the required 8 hours per shift, despite having a resident census ranging from 48 to 50. Specifically, the facility provided only 1.59 hours on March 6, 0.83 hours on March 7, 0.75 hours on March 8, 1.13 hours on March 9, and 0.90 hours on March 10. This deficiency was confirmed in an interview with the Administrator and Director of Nursing on March 19, 2025.
Plan Of Correction
1. The facility reviewed the RN ratios from March 6, 2025 through March 10, 2025. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on RN ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to add an LPN in place of the RN due to the waiver related to our building size to ensure ratios are met. 4. DON/designee will conduct daily audits to verify nursing ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.
Failure to Transcribe Medication Orders for New Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident was free from significant medication errors. Upon admission, the facility's policy required the admitting nurse to review the transfer record and notify the attending physician to review the admission medications. However, for one resident, this process was not followed correctly. The resident, who was admitted for skilled nursing care following a hospital discharge, had a list of prescribed medications that included Depakote 500 milligrams to be taken every 12 hours. Despite the hospital discharge summary indicating this medication, it was not transcribed into the resident's orders and Medication Administration Record as per physician instructions. The resident's medical history included cerebral edema, pulmonary embolism, diabetes, seizure disorder, and Cushing's syndrome. The error was confirmed during an interview with the Interim Director of Nursing, who acknowledged the transcription error. This oversight in medication management led to a significant medication error, as the prescribed Depakote was not administered according to the hospital's discharge instructions.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the representative of the Office of the State Long Term Care Ombudsman regarding the transfer of two residents to the hospital. Resident R2, who was admitted with neuromuscular dysfunction of the bladder and an infection due to an indwelling urethral catheter, was transferred to the hospital on two occasions: once for severe abdominal pain and blood in the urine, and later for acute kidney failure. Resident R36, admitted for aftercare following a joint replacement, was transferred to the hospital due to a change in condition. The Nursing Administrator confirmed that no written notices of these hospital transfers were provided to the Ombudsman for either resident. This deficiency was identified through a clinical record review and staff interview, revealing a failure to comply with the requirement to notify the Ombudsman of resident transfers, as mandated by 28 Pa. Code 201.29(h) regarding resident rights.
Inadequate Infection Control in Laundry and Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection control program concerning the handling of soiled and clean linens. Observations revealed that the facility's outside dumpster area contained large blue containers filled with dirty hospital gowns, which were waiting to be picked up by a laundry service. The laundry room, located in the basement, was accessible through a dusty and stained wooden staircase. The room was congested with various items, including clean and soiled clothing, housekeeping supplies, and mop heads, which were not sufficiently separated. The floor was dirty with black sticky particles, peeled paint, and rusted metal parts, and there was no clear designated area for soiled and clean items, leading to potential contamination. Further observations in the facility revealed that clean linens were stored in racks without doors, covered only by drapes, in shower rooms near resident rooms B6 and A10. Soiled linens were stored in the same shower rooms in plastic bags. These findings were confirmed with the Housekeeping Director, indicating a lack of proper separation and storage of clean and soiled linens, which is crucial for preventing contamination and maintaining an effective infection control program.
Failure to Timely Issue NOMNC
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident, identified as Resident R25, prior to the termination of Medicare A services. According to the facility's policy, a NOMNC should be issued at least two calendar days before the end of Medicare-covered services. Resident R25 was admitted with Medicare insurance for skilled nursing care, and their last covered day of Part A service was June 28, 2024. However, the NOMNC was not issued until July 17, 2024, which was after the termination of services. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to issue the NOMNC in a timely manner, as required by the facility's policy and regulations under 28 Pa. Code 201.29(f) regarding resident rights.
Improper Completion of PASRR for Resident with Mental Health Disorders
Penalty
Summary
The deficiency identified in the report pertains to the improper completion of the PASRR (Preadmission Screening and Resident Review) for a resident, referred to as Resident R16. The PASRR is a federally mandated process designed to identify individuals with mental illness or intellectual disabilities, ensure appropriate placement, and guarantee they receive necessary services. Resident R16 was admitted to the facility with several mental health diagnoses, including Major Depressive Disorder, Post-Traumatic Stress Disorder, Schizoaffective Disorder, and Anxiety Disorder. Despite these significant mental health conditions, the PASRR Level I form for Resident R16 did not appropriately indicate the outcomes that may or may not lead to chronic disability. The deficiency was confirmed through an interview with the Director of Nursing, who acknowledged the oversight. The report highlights that the PASRR Level I screening, which is required for all individuals considering admission to a Medicaid-certified nursing facility, was not completed correctly for Resident R16. This oversight could potentially impact the resident's placement and the services they receive, although the report does not explicitly state these consequences.
Failure to Revise Fall Prevention Care Plan
Penalty
Summary
The facility failed to revise the care plan for fall prevention for Resident R25, who was admitted on April 10, 2019, with diagnoses including unspecified dementia, anxiety disorder, unspecified glaucoma, muscle wasting and atrophy, and unspecified lack of coordination. On April 3, 2024, Resident R25 fell outside another resident's room, resulting in a hematoma on the left side of the forehead, and was subsequently sent to the hospital for evaluation and treatment. Upon readmission on April 8, 2024, a Fall Risk Evaluation was conducted, resulting in a Fall Risk Score of 21.0. Despite the fall and the updated fall risk evaluation, the care plan for Resident R25, which was initiated on January 5, 2023, and had a target date of April 2, 2024, was not updated or revised to reflect the new interventional status. This lack of revision and updating of the care plan was confirmed by the Director of Nursing on August 26, 2024. The deficiency was noted under the regulations 28 Pa Code 211.5(f) Clinical records, 28 Pa Code 211.11(d) Resident Care Plan, and 28 Pa Code 211.12(c)(d)(3) Nursing services.
Inadequate Pain Management for Resident with Severe Pain
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R38, who was documented with severe pain. The facility's policy for pain assessment and management, revised in October 2022, outlines a process that includes assessing for pain, implementing interventions, and monitoring the effectiveness of pain management. However, the facility did not adhere to this policy for Resident R38, who was admitted with multiple complex medical conditions, including a cerebral infarction, Parkinson's disease, and several pressure ulcers. The resident was assessed as severely cognitively impaired and completely dependent on staff for daily activities. Despite being on a scheduled pain medication regimen, the resident did not receive non-medication interventions for pain, and there was no evidence of appropriate monitoring for the effectiveness of the pain medication administered. Observations and records revealed that Resident R38 frequently experienced severe pain, with pain levels documented as very strong to the worst possible (8-10) during May, June, and July 2024. The resident's care plan included interventions to monitor and report signs of non-verbal pain, but there was no evidence that the facility responded appropriately to the resident's severe pain prior to a change in medication on August 2, 2024. Interviews with nursing staff confirmed that the resident's pain regimen was changed to Percocet as needed, but the facility could not demonstrate that they had adequately addressed the resident's pain prior to this change. This deficiency was identified under 28 Pa. Code 211.12(c) and 28 Pa. Code 211.12(d)(1-3) regarding nursing services.
Medication Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by errors observed during medication administration for three out of four residents. On August 21, 2024, a Licensed Nurse, Employee E3, administered the incorrect form of Aspirin to a resident. The physician's order specified Aspirin Enteric-Coated (EC) Tablet Delayed Release 81 MG, but the nurse administered a regular chewable tablet instead. This discrepancy was confirmed during an interview with the nurse. Additionally, another Licensed Nurse, Employee E4, administered the wrong dosage of Calcium with Vitamin D to a different resident. The physician's order required a 500-400 MG-UNIT tablet, but the nurse administered a 600 mg/10 mcg (400 IU) tablet. Furthermore, Employee E4 was observed preparing to administer Senna Plus to a resident, contrary to the physician's order for Senna Oral Tablet 8.6 MG. The administration was prevented, and the nurse confirmed the error. These incidents contributed to a medication error rate of 11.54% at the facility.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy for a resident, leading to an incident where a nurse aide allegedly caused harm. The resident, who has a history of mental health and physical conditions, reported that a nurse aide pushed her wheelchair into her bed, causing her knee to be hit and resulting in pain and bruising. The resident also claimed that the nurse aide threatened her verbally. Despite the resident's complaints and visible injury, the incident was not immediately reported to the appropriate authorities as required by the facility's policy. The incident occurred when the resident was sleeping, and the nurse aide was moving the resident's wheelchair. The resident's complaints were initially addressed by a licensed nurse who noted the incident and informed the physician, but the required immediate reporting to the administrator and other officials was not done. The nurse aide involved was not removed from the unit immediately and continued to work in the same area as the resident for the rest of the shift. Interviews with various staff members revealed a lack of clear communication and proper reporting of the incident. The social worker assumed that the necessary reporting had been completed due to the commotion in the hallway, but it was later confirmed that the incident was only reported to social services. The facility's failure to follow its abuse policy resulted in a delay in addressing the resident's injury and ensuring the safety of the resident from the alleged perpetrator.
Failure to Timely Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a timely investigation to rule out neglect and/or abuse for a resident. The incident began when the resident reported that a CNA pushed her wheelchair into her bed, causing her knee to be hit and resulting in pain. Despite the resident's complaint and visible bruising on her knee, the incident was not immediately reported to the administrator or other required officials as per the facility's policy. The delay in reporting and investigating the incident was evident as the Director of Nursing only became aware of the situation the following day when she found a witness statement on her desk and initiated an investigation. Interviews with various staff members revealed that there was confusion and a lack of immediate action following the resident's complaint. The licensed nurse who first addressed the resident's complaint did not report the incident to the administrator or other officials. Instead, the nurse documented the incident and notified the doctor, but no further action was taken to report the alleged abuse. The social worker, who was also informed of the incident, assumed that the necessary reporting had been completed by others and did not take further steps to ensure the incident was reported as required. The failure to follow the facility's abuse policy resulted in a delay in the investigation of the resident's complaint. The resident's account of the incident, along with the visible injury, was not promptly addressed, and the required notifications to state and local agencies, as well as other officials, were not made in a timely manner. This lack of immediate action and communication among the staff led to a significant delay in addressing the resident's allegations of abuse and neglect.
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.
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.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
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.
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.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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