Philadelphia Protestant Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 6500 Tabor Road, Philadelphia, Pennsylvania 19111
- CMS Provider Number
- 395961
- Inspections on file
- 21
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Philadelphia Protestant Home during CMS and state inspections, most recent first.
Surveyors found that all rated doors inside a stairwell enclosure between Personal Care and Skilled Nursing failed to positively latch, and a hollow wooden door of unknown fire rating was sealed within a fire-rated wall. These issues were confirmed by facility staff.
Surveyors determined that the facility did not provide documentation of two required semi-annual inspections for the kitchen fire suppression system. This was confirmed by facility leadership during the survey exit interview.
Surveyors found that the facility did not maintain or inspect its fire alarm system as required, with missing documentation for smoke detector sensitivity testing, annual and semi-annual inspections, and multiple device troubles indicated on the fire alarm panel. Facility leadership confirmed the lack of records and the ongoing alarm issues.
Surveyors found that the facility did not have a required fire watch policy in place for situations when the fire alarm system is out of service for more than four hours in a 24-hour period. This was confirmed through document review and interviews with the Maintenance Supervisor and Director of Safety/Security.
The facility did not maintain required documentation for fire sprinkler system inspections and testing, including supervisory devices, alarm devices, main drain tests, control valves, and other components. Additionally, a damaged sprinkler head was observed, and facility leadership confirmed the absence of inspection reports and the damaged equipment.
The facility did not provide documentation for annual fire extinguisher maintenance and technician certification, and a fire extinguisher in the main kitchen was found blocked. These deficiencies were confirmed by facility leadership during the survey.
The facility did not provide documentation for the annual 90-minute load test and annual fuel quality test of the emergency generator, as confirmed by the Maintenance Supervisor and Director of Safety/Security. This failure affected the entire facility and indicated non-compliance with required emergency power system maintenance and testing.
Surveyors found that medical gas cylinders were improperly stored and identified on all four floors, with excessive numbers of tanks and freestanding cylinders in multiple oxygen closets. These practices did not meet NFPA requirements for gas cylinder storage, as confirmed by facility leadership during the exit interview.
Surveyors found that the door to a third-floor trash room, classified as a hazardous area, did not self-close or positively latch as required. This issue was confirmed by facility staff during the inspection.
Surveyors found that two resident rooms had wooden door wedges holding corridor doors open, preventing them from closing as required for fire safety. Facility staff confirmed that the wedges impeded proper door closure.
The facility did not conduct or document nine of twelve required quarterly fire drills, with missing records for all shifts in three separate quarters, as confirmed by facility leadership during interviews and document review.
A resident room was found to have an outlet multiplier and extension cord in use, contrary to NFPA 101 requirements that prohibit using such devices as substitutes for fixed wiring. The unauthorized use was confirmed by facility staff during the survey.
Surveyors found that the facility did not review or update its Emergency Preparedness Plan within the required annual timeframe. Documentation confirming the annual review was not available, and this deficiency was confirmed during interviews with the Maintenance Supervisor and Director of Safety/Security.
Surveyors found that the Emergency Preparedness Plan did not include required policies and procedures for addressing the resident population, including persons at-risk, available emergency services, and continuity of operations. Facility leadership confirmed the absence of this documentation, affecting the entire facility.
The facility did not maintain documentation of cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials as required in its emergency preparedness plan, and this was confirmed by facility leadership during survey interviews.
Surveyors found that the facility did not conduct or document the required annual full-scale emergency exercise or an additional exercise, as confirmed by interviews with facility leadership and a lack of supporting documentation.
The facility did not notify the Department of Health before starting major renovations, failed to obtain required plan approvals, and lacked up-to-date Life Safety Code floor plans and a carbon monoxide alarm evacuation policy with staff in-service, as confirmed by facility leadership.
Surveyors determined that the facility did not conduct or document the required annual 90-minute test of battery backup emergency lighting. This was confirmed by facility leadership during the survey process.
Surveyors found that grievance forms were not readily accessible to residents on three nursing units, contrary to facility policy and federal requirements. Instead, staff reported that the social worker typically interviews individuals with concerns and completes the forms, limiting residents' ability to file grievances independently or anonymously.
A resident with multiple medical conditions who required extensive transfer assistance was put to bed by staff against their wishes, following a nurse's directive. The resident later reported bruising and soreness, and an internal investigation confirmed a violation of the resident's right to participate in their care decisions.
A resident with a history of depression, anxiety, hyperlipidemia, and acute kidney failure exhibited repeated inappropriate sexual comments and anxiety-related behaviors toward staff, as documented in nursing notes. Despite these incidents, the care plan was not updated to address the resident's inappropriate sexual behavior, contrary to facility policy and regulatory requirements.
A brown pill capsule, not identified as belonging to any resident, was found on a pantry area next to resident dining tables. An LPN confirmed the pill did not match any medications dispensed on the unit. Facility policy requires secure medication administration and supervision, but the presence of the pill in a resident-accessible area demonstrates a lapse in maintaining a safe environment.
Two nurse aides did not complete the required 12 hours of annual in-service training, and the facility could not provide documentation to show compliance with federal training requirements. This was confirmed through review of records and interviews with the DON and administrator.
The facility's arbitration agreement failed to meet federal regulatory requirements, affecting 102 residents. The agreement lacked necessary language stating it was not a condition for admission or continued care, did not allow for rescission within 30 days, and did not ensure open communication with officials. The facility administrator confirmed these deficiencies.
A resident with severe cognitive impairment and a history of wandering was able to elope from the facility due to inadequate supervision and the absence of a wander-guard device. Despite expressing a desire to leave and exhibiting increased confusion, the resident exited the nursing unit undetected, using an elevator that did not alarm due to the lack of a wander-guard. The resident was later found outside the facility, highlighting a failure in maintaining resident safety.
A facility failed to document the rationale and duration for a PRN order of Ativan for a resident, as required by regulations. The resident's clinical record did not include the necessary documentation from the attending physician or prescribing practitioner, which was confirmed by the Nursing Home Administrator.
Failure to Maintain Fire Resistive Rating of Exit Stair Enclosures
Penalty
Summary
Surveyors observed that the facility failed to maintain the fire resistive rating of exit stair tower enclosures across all four levels of the component. On the ground floor, all four rated doors inside the stairwell enclosure leading to the stair tower between Personal Care and Skilled Nursing did not positively latch. Additionally, a hollow wooden door, of unknown fire rating, was found sealed within a door frame set in a cinder block wall inside the stairway enclosure. These findings were confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
All non-latching doors have been adjusted and doors now latch appropriately. Doors will be monitored during environmental rounds by maintenance staff. The hollow area identified was tested and no door present behind sheetrock. That area consists of two layers of 5/8" sheetrock. Inspection holes were filled with red fire stop caulking to maintain fire barrier.
Failure to Complete Required Kitchen Fire Suppression System Inspections
Penalty
Summary
The facility failed to ensure that the kitchen fire suppression system underwent the required semi-annual inspections. During a documentation review, surveyors found that the facility could not provide records showing that two of the mandated semi-annual inspections had been completed for the kitchen fire suppression system. This was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security, who acknowledged that the inspection reports were not available at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Semi-annual inspections were completed. Facility will ensure documentation of testing is available for survey team during all inspections.
Failure to Maintain and Inspect Fire Alarm System
Penalty
Summary
The facility failed to maintain and inspect its fire alarm system as required, impacting the entire building. During document review, the facility was unable to provide records of smoke detector sensitivity testing within the past two years, annual inspection and testing, semi-annual visual inspections, semi-annual valve supervisory switch checks, and semi-annual testing of vane and pressure switch waterflow alarm devices. Additionally, observation revealed that the fire alarm panel displayed 95 device troubles at the time of the survey. These findings were confirmed in an exit interview with the Maintenance Supervisor and Director of Safety/Security, who acknowledged the lack of required documentation and the presence of multiple device troubles on the alarm panel.
Plan Of Correction
Fire alarm system was inspected on January 6th & 7th, 2025, and documentation received from contractor. Facility will ensure documentation is available for survey team. Facility will ensure that any troubles identified on fire panel are promptly addressed and contractor is notified if necessary.
Missing Fire Watch Policy During Fire Alarm Outage
Penalty
Summary
The facility failed to maintain required policies for the fire alarm system, specifically lacking a fire watch policy to implement in the event the fire alarm system was out of service for more than four hours in a 24-hour period. During a document review, it was found that there was no such policy available, which is necessary to ensure safety when the fire alarm system is not operational. This finding was confirmed during an interview with the Maintenance Supervisor and Director of Safety/Security.
Plan Of Correction
Fire watch policy in place. Facility will ensure policy is available for survey team during all inspections.
Failure to Maintain and Inspect Fire Sprinkler System
Penalty
Summary
The facility failed to maintain, inspect, and test its fire sprinkler system as required, as evidenced by the absence of documentation for quarterly and annual testing and inspection activities. Specifically, there was no documentation available for the inspection and testing of supervisory devices, mechanical waterflow alarm devices, main drain tests, control valves, sprinkler gauges, internal valve inspections, internal pipe inspections, and obstruction investigations for the required periods. Additionally, during an observation, a sprinkler head was found to be damaged, with a frangible bulb missing its fluid. The Maintenance Supervisor and Director of Safety/Security confirmed that the required inspection reports were not on-site and acknowledged the damaged sprinkler head.
Plan Of Correction
Sprinkler system was inspected January 20th - 24th, 2025, and documentation was received from the contractor. The facility will ensure documentation is available for the survey team during all inspections. The contractor has been contacted to repair a broken sprinkler head identified during the survey. Maintenance team will monitor sprinkler heads during environmental rounds.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers as required. During document review, the facility was unable to provide the annual maintenance report and the certificate for the technician who performed the annual fire extinguisher maintenance and testing. Additionally, an on-site observation revealed that a fire extinguisher located inside the main kitchen, on the kitchen side wall of the dietary office, was blocked. These findings were confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. No information regarding residents or their medical conditions was included in the report.
Plan Of Correction
Fire extinguisher inspection was completed on 3/7/2025. Facility will ensure documentation of inspection and technician's certificate are available for survey team during all inspections. Cart removed from in front of blocked fire extinguisher. Staff will be educated to ensure fire extinguishers are not blocked. Supervisors will audit weekly for 4 weeks to ensure fire extinguisher is not blocked.
Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator as required by NFPA standards, affecting the entire facility. During a document review, it was found that the facility could not provide documentation for the annual 90-minute load test and the annual fuel quality test for the emergency generator. These tests are necessary to ensure the generator and its associated equipment are capable of supplying power within the required timeframe and that the fuel used is of appropriate quality. Interviews with the Maintenance Supervisor and Director of Safety/Security confirmed that the documentation for these required tests was missing. The absence of these records indicates that the facility did not complete or could not verify completion of essential maintenance and testing procedures for the emergency power system.
Plan Of Correction
Contractor has been contacted to schedule annual 90-minute load test and fuel quality test. Director of Maintenance will ensure tests are conducted annually and that documentation is available for survey team during all inspections.
Improper Storage and Identification of Medical Gas Cylinders
Penalty
Summary
Surveyors observed that the facility failed to properly store and identify medical gas cylinders across all four floors. Specifically, on the fourth, third, and second floors, oxygen closets adjacent to rooms 4815, 3815, and 2815 each contained more than 12 tanks, with the third floor also having 2 freestanding cylinders. On the first floor, the oxygen closet in the service corridor contained approximately 50 stored cylinders and 15 freestanding cylinders. These storage practices did not comply with NFPA 101 and NFPA 99 requirements for gas cylinder storage, including limitations on the number of cylinders, proper enclosure, and segregation of full and empty cylinders. The improper storage was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. The report does not mention any specific residents or patient conditions related to the deficiency, nor does it describe any immediate consequences resulting from the improper storage. The deficiency was based solely on the observed storage conditions and the facility's failure to meet regulatory standards for medical gas cylinder management.
Plan Of Correction
Oxygen storage capacity will be limited to 12 full tanks on the 2nd, 3rd, and 4th floors, and 50 full tanks on the 1st floor. Staff educated on storage capacity and that all tanks must be placed in holders and not free-standing. Nurses will audit at the beginning of each shift, and supervisors will perform random audits to monitor compliance.
Deficient Self-Closing and Latching Door in Hazardous Area
Penalty
Summary
Surveyors observed that the facility failed to ensure the door to the trash room on the third floor was self-closing and positively latching, as required for hazardous area enclosures. During the inspection, it was noted that the rated door did not close automatically or latch securely when tested. This deficiency was confirmed during an exit interview with the Maintenance Supervisor and the Director of Safety/Security, who acknowledged that the door did not function as required.
Plan Of Correction
Door has been fixed and is latching appropriately. Doors will be monitored during environmental rounds by maintenance staff.
Corridor Doors Blocked Open with Wedges
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with fire safety regulations on two of four levels. Specifically, during an inspection, it was found that a resident room on the fourth floor and another on the second floor each had a wooden door wedge holding the door open. These wedges prevented the doors from closing as required to resist the passage of smoke and maintain corridor safety. The Maintenance Supervisor and Director of Safety/Security confirmed during an exit interview that the use of door wedges inhibited the proper closing of the doors. The deficiency was identified through direct observation and staff confirmation, with no mention of any specific resident conditions or medical histories related to the incident.
Plan Of Correction
Door stops have been removed from doors. All other rooms checked for door stops and none noted. Staff will be educated to not use door stops. Residents and families will be educated upon admission that door stops cannot be used, and current residents will be educated regarding door stops at the next resident council meeting. The resident welcome book has been updated to include education regarding door stops and will be distributed to all residents upon admission and to all current residents.
Failure to Conduct and Document Required Quarterly Fire Drills
Penalty
Summary
The facility failed to ensure that the required quarterly fire drills were conducted and properly documented for nine out of twelve required instances. Specifically, there was no documentation available to confirm that fire drills had been conducted on all shifts for the 1st, 3rd, and 4th quarters. This was determined through interviews and a review of facility records, during which the facility was unable to provide the necessary logs to demonstrate compliance with fire drill requirements. The Maintenance Supervisor and Director of Safety/Security confirmed the absence of documentation for the specified shifts and quarters during the exit interview. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
Missing fire drill documentation is on hand. Director of Safety & Security will ensure fire drills are conducted and that documentation is available for survey team during all inspections.
Improper Use of Extension Cord and Outlet Multiplier
Penalty
Summary
The facility failed to comply with NFPA 101 requirements regarding the use of electrical equipment, specifically power cords and extension cords. During an observation on the third floor, a resident room was found to have an outlet multiplier and an extension cord in use, which is not permitted as a substitute for fixed wiring. This unauthorized use was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. The deficiency was identified on one of four floors within the facility, and the report documents the direct observation and confirmation of the improper use of electrical equipment.
Plan Of Correction
Extension cord and outlet multiplier have been removed. Resident rooms will be audited with weekly environmental rounds. Staff will be educated to notify maintenance if extension cord is found. Residents will be educated at next resident council meeting. All new residents and families will be educated upon admission.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, as required by federal regulations. During an interview and document review, it was found that the Emergency Preparedness Plan had not been reviewed or updated within the required timeframe. This deficiency was identified through documentation review and confirmed during interviews with the Maintenance Supervisor and Director of Safety/Security. No documentation was available to demonstrate that the annual review and update of the Emergency Preparedness Plan had occurred. The lack of updated records affected the entire facility, as the plan is intended to address emergency preparedness for all residents and staff. There were no specific residents or patient medical histories mentioned in relation to this deficiency.
Emergency Preparedness Plan Lacks Required Resident Population Policies
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included policies and procedures addressing the resident population, specifically persons at-risk, the types of services the facility could provide during an emergency, and continuity of operations such as delegations of authority and succession plans. This deficiency was identified through document review and interviews conducted on June 30, 2025, which revealed that the required documentation was not present in the facility's Emergency Preparedness Plan. During the exit interview with the Maintenance Supervisor and Director of Safety/Security, it was confirmed that the necessary documentation addressing these critical components was not available. The lack of these policies and procedures affected the entire facility, as the plan did not meet the regulatory requirements for addressing the needs of the resident population in emergency situations.
Plan Of Correction
Policy in place and will ensure that policy is present in emergency preparedness binder for future surveys.
Failure to Document Emergency Preparedness Collaboration
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Specifically, the plan did not contain documentation of the facility's efforts to contact these officials or evidence of participation in collaborative and cooperative planning efforts. This deficiency was identified through document review and interviews conducted on June 30, 2025. During the exit interview with the Maintenance Supervisor and Director of Safety/Security, it was confirmed that the required documentation was not available. The lack of a documented process and evidence of communication or collaboration with emergency preparedness officials affected the entire facility.
Plan Of Correction
Policy in place and will ensure that policy is present in emergency preparedness binder for future surveys. E 0009
Failure to Conduct and Document Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale emergency exercise or an accepted substitution, as well as the additional required exercise or accepted substitution, within the previous 12 months. This deficiency was identified through document review and interviews conducted on June 30, 2025. The surveyors found that there was no documentation available to demonstrate that these emergency preparedness exercises had been completed as mandated by federal regulations. During the investigation, interviews were conducted with the Maintenance Supervisor and the Director of Safety/Security. Both individuals confirmed that the necessary documentation for the emergency exercises was not available for review. This lack of documentation indicated that the facility did not meet the regulatory requirement to test its emergency plan through the specified exercises. The deficiency affected the entire facility, as the emergency preparedness exercises are designed to ensure that all staff are familiar with and able to implement the emergency plan. The absence of these exercises and the corresponding documentation was confirmed during the exit interview with facility leadership.
Plan Of Correction
Disaster drills have been scheduled for 2025. The Director of Safety & Security will develop the schedule and ensure at least two drills are scheduled annually. Facility emergency preparedness plan was activated in May 2025 due to elopement. Documentation was added to the emergency preparedness binder. A community-based drill is scheduled for September 2025.
Failure to Notify Department and Maintain Required Safety Documentation
Penalty
Summary
The facility failed to notify the Pennsylvania Department of Health prior to initiating external window renovations throughout the building and additional interior renovations to a shut down wing on the ground floor following water damage. This action was taken without obtaining Department-approved plans, as confirmed by the Maintenance Supervisor and Director of Safety/Security during the exit interview. The lack of notification and approval was determined through observation, document review, and staff interviews. Additionally, the facility did not provide portable Life Safety Code Floor Plans that included required information such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. During the survey, it was also found that the facility lacked a carbon monoxide alarm evacuation policy plan and had not conducted associated staff in-service training, as required by the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. These deficiencies affected the entire facility and were confirmed by facility leadership during the exit interview.
Plan Of Correction
Approval for window renovation received from DSI on 5/15/25. Facility will ensure that approval is obtained prior to beginning any future renovations. Facility will ensure that floor plans are readily available for future surveys. Carbon monoxide policy in place. Staff will be educated on carbon monoxide policy.
Failure to Document Annual Emergency Lighting Test
Penalty
Summary
The facility failed to ensure that annual 90-minute testing of battery backup emergency lighting was conducted and documented as required. During a document review, surveyors found that the facility could not provide documentation showing that the required annual testing of emergency lighting had been performed. This deficiency was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security, who acknowledged the absence of the annual testing report. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
90-minute test of battery backup lighting completed and on file. Facility will ensure that proof of testing is available for survey team during all inspections.
Grievance Forms Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that grievance forms were available and accessible to residents on all three nursing units, specifically the second, third, and fourth floors. During a facility tour, it was observed that there were no grievance forms readily accessible to residents without them having to ask for assistance. The facility's policy states that grievances may be filed anonymously through secure drop boxes located on each unit, but these forms were not present or accessible as required. Additionally, a review of the facility's grievance logs over a six-month period revealed only one grievance filed, suggesting limited resident access or awareness of the grievance process. Interviews with staff indicated that the social worker typically interviews anyone with a concern and fills out the grievance form on their behalf, rather than residents having direct access to the forms. This practice does not align with the facility's policy or regulatory requirements, which mandate that residents must be able to file grievances independently and anonymously if desired. The lack of accessible grievance forms and reliance on staff to initiate the process contributed to the deficiency cited by surveyors.
Plan Of Correction
Grievance forms have been placed on all units next to the grievance submission box. Residents will receive education on the grievance process at the resident council meeting. The resident welcome book has been updated to include information regarding grievances and the grievance officer, and will be distributed to all new and current residents. The grievance officer or designee will conduct weekly audits to ensure forms are available for residents and to collect any grievances that may have been submitted. The grievance policy has been updated. Grievances will be reported at quarterly QAPI meetings.
Failure to Honor Resident's Right to Choose Bedtime
Penalty
Summary
A deficiency was identified when staff failed to honor a resident's right to self-determination regarding their bedtime. The resident, who had diagnoses including adjustment disorder with depressed mood, anxiety disorder, gait and mobility abnormalities, muscle weakness, abnormal posture, and a history of falls, required extensive assistance from two or more staff for transfers. On the date in question, the resident reported that two staff members attempted to put them to bed before they were ready. Despite the resident's refusal, a nurse instructed the staff to proceed, and the resident was physically transferred to bed against their wishes. The following day, the resident was found to have bruising on both upper arms, which was brought to the attention of nursing staff by the resident's family. The resident also reported soreness in the right upper extremity. An internal investigation confirmed that the resident's rights were violated when staff transferred the resident to bed without consent, although it could not be determined if the bruising was directly caused by the incident.
Plan Of Correction
F 0561 Staff will be educated regarding residents' rights and self-determination. Residents will be educated at resident council regarding their rights and how to file a grievance if they feel their rights have been violated. The resident welcome book has been updated to include information regarding grievances and the grievance officer and will be distributed to all new and current residents.
Failure to Revise Care Plan for Inappropriate Sexual Behavior
Penalty
Summary
A deficiency was identified when the facility failed to revise a resident's care plan to address inappropriate sexual behavior, despite documented incidents. The facility's policy requires that care plans be revised as changes in a resident's condition dictate and reviewed at least quarterly. However, clinical record review for a resident admitted with depression, anxiety, hyperlipidemia, and acute kidney failure showed multiple nursing notes documenting the resident making sexual comments and inappropriate remarks toward staff, as well as displaying anxiety and frequent call bell use when staff did not respond as desired. Despite these documented behaviors, the resident's current care plan did not include any interventions or plans to address the inappropriate sexual behavior. This omission was confirmed by the Director of Nursing. The lack of care plan revision occurred even though the facility's own policy and federal regulations require care plans to be updated to reflect changes in resident behavior and needs.
Plan Of Correction
All residents with currently documented behaviors and those on psychotropic medication will be audited to ensure care plans are accurate. Staff will be educated on updating care plans to reflect residents' needs. Care plan policy has been updated. The DON or designee will conduct audits weekly for 4 weeks, then perform random audits monthly for 3 months of care plans for residents with behaviors or on psychotropic medication to ensure accuracy. Care plans will also be reviewed and updated with each MDS to reflect the current needs of each resident.
Unsecured Medication Found in Resident Dining Area
Penalty
Summary
A deficiency was identified on the second floor nursing unit where a brown pill capsule was found on top of a pantry area next to resident dining tables. The pantry area was not being utilized at the time, and the items present included plastic bags, napkins, a radio, and the pill capsule. Upon observation, a licensed nurse confirmed that the pill resembled a vitamin capsule but did not match any medications dispensed to residents on that unit. Facility policy requires that medications be administered safely and as prescribed, including verifying resident identity, checking medication labels and expiration dates, and ensuring that the medication cart is closed and locked when out of the nurse's sight. The presence of an unaccounted-for pill in a resident-accessible area indicates a failure to maintain a safe environment free of accident hazards and to provide adequate supervision to prevent such incidents.
Plan Of Correction
Staff will be educated to be aware of not leaving medication or any other hazardous material where residents may be able to access them. Supervisor or designee will audit dining rooms before and after each meal to ensure area is clean and free of hazards. Audits will be conducted 3 times a week for 4 weeks then weekly for 3 months.
Failure to Ensure Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that two of seven nurse aides completed the required 12 hours of annual in-service training as mandated by federal regulations. Review of facility documentation and staff interviews confirmed that Employees E9 and E10, both current nurse aides, did not have evidence of completing the annual in-service training. The facility's policy on education and training, revised March 31, 2025, requires ongoing education to maintain staff competency, but the facility was unable to provide documentation showing that these two employees met the annual training requirement. This finding was confirmed with the facility's director of nursing and administrator.
Plan Of Correction
All new CNAs will be required to attend an additional orientation day to complete required training prior to starting. All CNAs will be required to attend an additional day of training during each calendar year to complete required courses on site. Department head will conduct monthly audits to monitor training. Staff will be educated on changes to training process. Policy has been updated. Trainings will be reported at QAPI meetings.
Deficient Arbitration Agreement Language
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement contained the required regulatory language as per federal regulations S483.70(n) for all 102 residents reviewed. The review of the facility's documentation and interviews with staff revealed that the arbitration agreement offered to residents or their representatives did not comply with several specific requirements outlined in the regulations. These deficiencies were identified during a survey conducted by reviewing the facility's admission agreements and arbitration clauses. The arbitration agreement lacked explicit language stating that signing the agreement was not a condition for admission or continued care at the facility, as required by S483.70(n)(1) and S483.70(n)(4). Additionally, the agreement did not grant residents or their representatives the right to rescind the agreement within 30 days of signing, as mandated by S483.70(n)(3). Furthermore, the agreement contained no provisions ensuring that it did not discourage communication with federal, state, or local officials, which is a requirement under S483.70(n)(5). An interview with the facility administrator confirmed these deficiencies, acknowledging that the arbitration agreement, which was part of the facility's admission agreement, did not include the necessary regulatory language. The administrator stated that all residents or their representatives were offered this arbitration agreement upon admission, but the agreement did not meet the federal requirements, leading to the identified deficiencies.
Failure to Prevent Resident Elopement Due to Lack of Supervision and Assistive Devices
Penalty
Summary
The facility failed to adequately supervise Resident R108, who was at risk for elopement due to severe cognitive impairment and a history of wandering. The facility's policy required the use of a wander-guard tag to prevent elopement, but Resident R108 did not have this device care planned for her safety. Despite being severely cognitively impaired and expressing a desire to leave the facility, the resident was able to exit the fourth floor nursing unit without staff knowledge by using the elevator, which did not alarm or lock due to the absence of a wander-guard. Resident R108 had a history of memory loss, frequent falls, and was admitted to the facility with severe cognitive impairment. The resident expressed a desire to go home and was noted to be wandering and confused, looking for her husband. On multiple occasions, the resident exhibited increased confusion and expressed suicidal ideation, stating a desire to jump out of a window. Despite these indicators, the facility did not implement adequate measures to prevent the resident from leaving the premises. On May 18, 2024, Resident R108 was found missing from the nursing unit and was later discovered outside the facility on a stone ledge near the main entrance. The Director of Nursing confirmed that the resident did not have an alarming device, and the wander-guard system was not activated, allowing the resident to use the elevator and exit the building without detection. This incident highlights a failure in the facility's responsibility to maintain the safety and security of its residents, particularly those at risk for elopement.
Failure to Document PRN Psychotropic Medication Rationale and Duration
Penalty
Summary
The facility failed to ensure compliance with regulations regarding PRN (as needed) orders for psychotropic medications. Specifically, for Resident R21, there was an order for Ativan, a medication used to treat anxiety, to be administered every four hours as needed for agitation/aggression. However, the clinical record lacked documentation from the attending physician or prescribing practitioner that provided the rationale for the use of this psychotropic medication and did not specify the expected duration of the PRN order. This deficiency was confirmed during an interview with the Nursing Home Administrator, Employee E1, who acknowledged the absence of the required documentation in Resident R21's medical record.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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