Phoenix Center For Rehabilitation And Nursing,the
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenixville, Pennsylvania.
- Location
- 833 South Main Street, Phoenixville, Pennsylvania 19460
- CMS Provider Number
- 395284
- Inspections on file
- 25
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Phoenix Center For Rehabilitation And Nursing,the during CMS and state inspections, most recent first.
A resident with CHF and leg wounds was found with soiled and stained bed linens that had not been changed for several days after readmission. The linens had visible stains from coffee, blood, and food or juice spills, and staff were unaware of when they were last changed, resulting in a failure to provide a clean and homelike environment.
The facility did not provide written notice of its bed-hold policy to several residents or their representatives when they were transferred to the hospital, as confirmed by clinical record review and staff interviews. This deficiency involved residents with acute medical conditions and was identified through review of facility policies, records, and interviews with the DON.
A resident was given Tramadol on three occasions despite a pain score of zero, contrary to physician orders that specified use only for moderate to severe pain. Required non-pharmacological interventions were not attempted or documented before administering the medication, and the DON could not explain the rationale for this action.
Surveyors found that staff failed to follow physician orders for oxygen tubing changes, feeding assistance, and fluid restrictions for several residents, and did not timely address a skin condition for a resident with Alzheimer's disease. These deficiencies were confirmed through record review, observations, and staff interviews.
A resident's ability to smoke safely was not re-evaluated as required by facility policy, with the last assessment documented several months prior and no subsequent reassessments performed. The DON confirmed the lapse in ongoing evaluation, resulting in a failure to maintain a hazard-free environment.
The facility did not maintain safe hot water temperatures in resident rooms and shower rooms, with water readings exceeding regulatory limits. Staff failed to consistently monitor or document water temperatures, and there was no clear procedure for ensuring water safety before resident care, especially for nonverbal or cognitively impaired individuals. The issue persisted due to a broken boiler and lack of timely communication and oversight.
The Nursing Home Administrator did not ensure effective management of the facility's hot water system, leading to water temperatures above 110°F throughout the building. Despite being informed of the issue, no new interventions were implemented, and there was no documentation of temperature monitoring, placing residents at risk for serious injury from burns and resulting in Immediate Jeopardy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with unstageable sacrum pressure ulcers, one of whom also had a PEG tube. Observations revealed a lack of EBP signage or communication in their rooms, contrary to the facility's policy designed to minimize the spread of MDROs. The deficiency was confirmed by the DON and Nursing Home Administrator.
A resident was found fully clothed and covered with a blanket in their room, which had a non-functioning heating unit that emitted smoke and a burning plastic smell when used. The room temperature was measured at 68°F, and the resident reported feeling cold. The Nursing Home Administrator confirmed the heating unit was not working and that the temperature was uncomfortable for the resident.
A resident experienced a fall resulting in a head injury and was transported to the emergency department. The facility failed to immediately notify the resident's representative, as required by policy. The notification was delayed until several hours after the incident, which was confirmed by the DON during an interview.
The facility did not meet the required nurse aide staffing ratios during the day shift for four days in a reviewed week. The regulation mandates a minimum of one nurse aide per 10 residents, which was not achieved on several days. This was confirmed through a review of schedules and an interview with the Nursing Home Administrator.
The facility did not meet the required LPN staffing ratios on several occasions during a specific week. The day shift lacked the mandated one LPN per 25 residents on four days, the evening shift was short on one day, and the night shift did not meet the requirement on another day. This was confirmed by staffing data and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day for a week, with PPD hours ranging from 3.04 to 3.16. This was confirmed by the Nursing Home Administrator.
A resident with intact cognitive status was verbally abused by a staff member in the kitchen. The staff member threatened physical harm and used derogatory language, which was confirmed by multiple witnesses. Despite the abuse, the resident reported feeling safe and did not experience harm. The facility's investigation substantiated the incident, although all dietary staff had completed mandatory abuse training.
The facility failed to implement Enhanced Barrier Precautions for residents with medical devices, such as feeding tubes and catheters, as required by their policy. Observations showed no PPE or EBP signage in the rooms of affected residents, and the Nursing Home Administrator confirmed the absence of these precautions throughout the building.
The facility failed to monitor the nutritional status of three residents, resulting in significant weight changes that were not promptly addressed. One resident gained 15.8 pounds, another lost 32 pounds, and a third lost 7.3 pounds. Re-weights were requested but not conducted in a timely manner, and interventions were delayed, as confirmed by staff interviews.
A facility failed to offer Advance Directives to a resident upon admission, as confirmed by the absence of documentation in the clinical record and an interview with the Nursing Home Administrator. This issue was previously cited, indicating a recurring compliance problem.
A resident experienced a significant change in condition, with bright red bloody urine and blood clots observed from his Foley catheter. Despite facility policy requiring prompt notification, the physician was not informed of this change. Later, the resident was found lethargic with large clots and was sent to the ER. The Nursing Home Administrator confirmed the physician was not notified initially.
A resident experienced an unwitnessed fall while receiving care, leading to abnormal vital signs and eventual cardiac arrest. Despite the facility's policy requiring thorough investigation of such incidents, no comprehensive investigation was conducted to determine the cause of the fall and subsequent events. The resident was transferred to the hospital, where they were pronounced dead.
A resident experienced inadequate monitoring and care after returning from the hospital, with no vital signs or full assessment documented during a significant health change. The resident was later found at the hospital with severe symptoms. Additionally, the facility failed to schedule recommended urology follow-ups after hospital discharges.
A facility failed to assess the necessity of a Foley catheter for a resident upon admission and did not conduct a voiding trial until requested by the resident's spouse and an RN from an outside agency. The voiding trial was successful, indicating the catheter may not have been necessary.
A resident's tube feeding was not administered as per physician orders, with the enteral feed pump found turned off and lacking documentation for the interruption. The prescribed continuous feeding of Jevity 1.5 at 55 ml/hour was not maintained, resulting in a failure to provide the ordered nutrition.
The facility failed to provide timely respiratory treatment for a resident with Sepsis, COPD, and respiratory failure. Despite having a BIPAP order from the hospital, the order was not implemented until two days after admission due to a lack of communication and review of hospital documents by the DON.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident, recently readmitted with a diagnosis of congestive heart failure and skin openings on both legs, was found to have soiled and stained bed linens several days after returning to the facility. During an observation, the resident's mattress was only partially covered with a sheet, and both the mattress and additional sheets displayed large dried brown, red, and yellow stains. The resident reported that the stains were from coffee, blood from leg wounds, and food or juice spills, and stated that the bed sheets had not been changed since readmission several days prior. An interview with the nursing assistant assigned to the resident revealed that, as an agency staff member, they were unaware of when the bed linens were last changed and confirmed that the sheets had not been changed that morning. The Director of Nursing was informed of these findings. The facility failed to provide a clean, comfortable, and homelike environment for the resident, as required by regulation.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to the hospital for five out of ten residents reviewed. Clinical record reviews for multiple residents with significant medical conditions, such as acute respiratory failure, acute kidney injury, and gram-negative sepsis, showed that these individuals were transferred and admitted to the hospital. However, there was no documentation in their records indicating that the required bed-hold policy notification was given at the time of transfer. Interviews with the Director of Nursing confirmed that neither the residents nor their representatives received the bed-hold policy information upon discharge to the hospital. This deficiency was identified through facility policy review, clinical record review, and staff interviews, and was cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.
Failure to Follow Physician Orders and Non-Pharmacological Interventions for Pain Management
Penalty
Summary
A deficiency occurred when a resident was administered Tramadol HCl 50 mg on three occasions despite having a pain scale score of zero, which did not meet the physician's order specifying use only for moderate to severe pain. The clinical record also indicated that required non-pharmacological interventions, such as repositioning, distraction, massage, or other comfort measures, were not attempted or documented prior to administering the medication. The facility's policy required medications to be given according to physician orders and to utilize non-pharmacological interventions when appropriate, but these steps were not followed. During an interview, the DON was unable to provide a reason for the administration of Tramadol when the resident reported no pain.
Failure to Follow Physician Orders and Timely Address Resident Care Needs
Penalty
Summary
The facility failed to follow physician orders and provide timely care for several residents. For one resident with acute respiratory failure, oxygen tubing was not changed weekly as ordered, with documentation showing the tubing was last changed six days prior to the observed date, despite orders for weekly changes. Another resident with multiple sclerosis and dysphagia had physician orders for staff assistance with feeding, but was observed feeding themselves with their fingers on multiple occasions without staff assistance, contrary to the orders. A third resident with chronic kidney disease had a physician-ordered fluid restriction, but records showed that both nursing and dietary staff failed to monitor and document fluid intake properly, resulting in the resident receiving more fluids than prescribed on multiple days. Additionally, a resident with Alzheimer's disease developed a body rash that was reported in June, but there was no evidence in the clinical record that the skin issue was addressed or assessed for a month, until a physician order for Nystatin cream was given in late July. Staff interviews confirmed these failures to follow physician orders and to address the resident's skin condition in a timely manner.
Failure to Reassess Smoking Safety for Resident
Penalty
Summary
The facility failed to provide a hazard-free environment for one resident by not following its own smoking policy. According to the facility's policy, a resident's ability to smoke safely must be re-evaluated quarterly, upon a significant change in physical or cognitive status, and as determined by staff. Review of the clinical record for one resident showed that the most recent smoking assessment was completed on June 9, 2024, and no further assessments were documented. During an interview, the DON confirmed that no additional smoking assessments had been performed since that date. This lapse resulted in the facility not ensuring ongoing evaluation of the resident's ability to smoke safely, as required by policy.
Failure to Maintain Safe Hot Water Temperatures Creates Immediate Jeopardy
Penalty
Summary
The facility failed to maintain safe hot water temperatures in resident rooms and shower rooms across all three nursing units. Observations revealed water temperatures ranging from 124 to 129 degrees Fahrenheit, exceeding the Commonwealth of Pennsylvania's regulatory maximum of 110 degrees Fahrenheit. Maintenance staff confirmed that the water temperatures were too high and that the boiler responsible for residential hot water was broken, resulting in the use of a service area boiler that could not be adjusted below 135 degrees Fahrenheit. The issue was first noticed by the maintenance employee shortly after starting employment, and documentation showed that the necessary repair part had been pending for several weeks. Facility documentation could not provide evidence that water temperatures were being regularly monitored, recorded, or logged in resident care areas. There were no thermometers or temperature logs available in the shower rooms, and staff interviews revealed inconsistent practices for checking water temperature before resident use. Some nursing assistants reported relying on residents' feedback regarding comfort, which was not feasible for nonverbal or cognitively impaired residents. When asked, staff were unable to demonstrate the use of a thermometer or locate one for testing water temperature. The Nursing Home Administrator was unaware of the water temperature issue until returning from an absence, and no policy could be provided regarding staff procedures for ensuring safe water temperatures prior to showers. The lack of monitoring, documentation, and clear procedures for verifying water temperature before resident care led to the identification of Immediate Jeopardy to resident safety due to the risk of burns from excessively hot water.
Failure to Manage Hot Water Temperatures Creates Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator failed to effectively manage the facility's hot water system, resulting in water temperatures above 110 degrees Fahrenheit on all floors. Observations and interviews confirmed that the water was leaving the boiler at 135 degrees and could not be lowered due to a needed repair. The boiler designated for service areas was being used for residential areas, and there was no documented evidence that water temperatures were being monitored during this period. The Administrator was made aware of the issue upon returning from a leave of absence, but no new interventions were implemented to address the excessively hot water until the necessary boiler part could be installed. This lack of action and monitoring placed residents at risk for serious injury from burns and resulted in an Immediate Jeopardy situation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for two residents who required them. According to the facility's policy, EBP is an infection control intervention designed to reduce the transmission of Multidrug Resistant Organisms (MDROs) by employing targeted gown and glove use during high-contact resident care activities. The policy mandates that EBP should be implemented for residents with wounds or indwelling medical devices, regardless of MDRO colonization status, and for those with an infection or colonization with an MDRO when contact precautions do not otherwise apply. Clinical record reviews revealed that both residents had unstageable sacrum pressure ulcers, with one resident also having a percutaneous endoscopic gastrostomy (PEG) tube. Observations of their rooms showed a lack of EBP signage or communication, indicating that the necessary precautions were not being followed. The Director of Nursing and the Nursing Home Administrator confirmed that the EBP process was not adhered to for these residents, highlighting a deficiency in the facility's infection prevention and control program.
Plan Of Correction
POC- complaint survey 3/20/25 1. No residents were affected by the practice. 2. DON/designee will audit facility to determine which residents could be potentially affected. 3. DON/ADON will educate staff on EBP and EBP Policy will be posted at nursing station. 4. ADON/designee will round daily for four weeks then weekly thereafter to ensure enhance barrier precaution signs are hung and visible where necessary. Any findings will be presented in QAPI. 5. Corrective action will be completed by 4/4/2025.
Failure to Maintain Adequate Room Temperature for Resident Comfort
Penalty
Summary
The facility failed to provide a comfortable environment for a resident by not maintaining an adequate room temperature. Observations showed the resident was fully clothed and covered with a blanket while lying in bed, and the resident reported that the room's heating unit was not functioning. When the heating unit was turned on, it emitted smoke and a burning plastic smell, and the resident stated feeling cold. The room temperature was measured at 68 degrees Fahrenheit by the Nursing Home Administrator, who confirmed the heating unit was not working and acknowledged that the temperature was uncomfortable for the resident. These findings were based on direct observation, resident interview, and staff confirmation.
Failure to Notify Resident's Representative of Injury
Penalty
Summary
The facility failed to immediately notify the resident's representative of an accident involving a resident, which resulted in an injury. The incident involved a resident who was found on the floor with a pool of blood at the head and hands, indicating a fall. The resident sustained a contusion and a laceration on the forehead, which continued to bleed. Vital signs were taken, and emergency services were called, resulting in the resident being transported to the emergency department. Despite the severity of the incident, the resident's representative was not informed immediately, as the notification was delayed until later in the morning. The facility's policy, revised in December 2016, mandates prompt notification of the resident's representative in the event of an accident or incident resulting in injury. However, in this case, the notification was not made until several hours after the incident, contrary to the policy requirements. The Director of Nursing confirmed during an interview that the resident's representative was not notified immediately of the fall and subsequent hospitalization, highlighting a deficiency in adhering to the notification requirements outlined in 42 CFR Part 483 and the 28 PA Code regulations.
Plan Of Correction
1. D.O.N. / A.D.O.N. will provide education to nurses re policy of notification of change of condition and also use of INTERACT Tools for Change of Condition by 9-13-24. 2. D.O.N. / A.D.O.N. will provide education to nurses to enter all vital signs in Vital Signs tab instead of just nursing notes so that alerts for changes in condition are active by 9/13/14. 3. Clinical team will audit all changes in condition during clinical meeting by 9/1/24. 4. D.O.N. will develop a change in condition checklist that includes notifying responsible parties for each change of condition. Checklist to be completed at time of change. 5. D.O.N. will audit weekly for 4 weeks, then biweekly for one month, then monthly, with results reported to QAPI and to Regional Leadership Team.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios during the day shift for four out of seven days in the week of December 8, 2024. Specifically, on December 10, 12, 13, and 14, 2024, the facility did not provide the minimum of one nurse aide per 10 residents as mandated by the regulation effective July 1, 2024. This deficiency was identified through a review of nursing time schedules and confirmed during an interview with the Nursing Home Administrator on December 17, 2024, at 1:45 p.m.
Plan Of Correction
1. Scheduler will continue to schedule sufficient staffing for shift. 2. If a call off occurs, Scheduler or Shift Supervisor will check to see who can stay late or come in early and also post shift(s) with agency. 3. If aide position cannot be filled in time, Scheduler or Shift Supervisor will check to see if any nurses can stay late or come in early and will adjust staffing sheet to indicate any hours a nurse may have filled in as an aide. 4. Facility will continue to work on staff recruitment and retention as identified in our Facility Assessment. 5. Facility is participating in a job fair on 10/30/2024 to recruit more staff. 6. Facility will schedule additional staffing through staffing resources available to the facility.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) on multiple occasions during the week of December 8, 2024. Specifically, the facility did not have the mandated one LPN per 25 residents during the day shift on December 8, 10, 11, and 13, 2024. Additionally, the evening shift on December 13, 2024, did not meet the requirement of one LPN per 30 residents. Furthermore, the night shift on December 14, 2024, failed to have one LPN per 40 residents. This deficiency was confirmed through a review of facility staffing data and an interview with the Nursing Home Administrator on December 17, 2024, at 1:45 p.m., who acknowledged that the staffing ratios were not met on the specified dates.
Plan Of Correction
1. Scheduler will continue to schedule sufficient staffing for shift. 2. If a call off occurs, Scheduler or Shift Supervisor will check to see who can stay late or come in early and also post shift(s) with agency. 3. If aide position cannot be filled in time, Scheduler or Shift Supervisor will check to see if any nurses can stay late or come in early and will adjust staffing sheet to indicate any hours a nurse may have filled in as an aide. 4. Facility will continue to work on staff recruitment and retention as identified in our Facility Assessment. 5. Facility is participating in a job fair on 10/30/2024 to recruit more staff. 6. Facility will schedule additional staffing through staffing resources available to the facility.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for the week beginning December 8, 2024. A review of the nursing staffing documents revealed that the facility provided less than the required hours on each day of the week, with per patient day (PPD) hours ranging from 3.04 to 3.16. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 17, 2024, who acknowledged the shortfall in meeting the required direct care hours on the specified dates.
Plan Of Correction
1. Scheduler will continue to schedule sufficient staffing for shift. 2. If a call off occurs, Scheduler or Shift Supervisor will check to see who can stay late or come in early and also post shift(s) with agency. 3. If aide position cannot be filled in time, Scheduler or Shift Supervisor will check to see if any nurses can stay late or come in early and will adjust staffing sheet to indicate any hours a nurse may have filled in as an aide. 4. Facility will continue to work on staff recruitment and retention as identified in our Facility Assessment. 5. Facility is participating in a job fair on 10/30/2024 to recruit more staff. 6. Facility will schedule additional staffing through staffing resources available to the facility.
Verbal Abuse Incident Involving a Resident and Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving Resident 1 and Employee 3 (E3). The incident occurred when Resident 1, who had an intact cognitive status as per the Minimum Data Set assessment, attempted to enter the kitchen to offer help, believing the kitchen was short-staffed. During this interaction, E3 verbally abused Resident 1 by threatening physical harm and using derogatory language. Multiple investigation statements corroborated that E3 threatened to slap Resident 1 and used offensive terms, further stating that Resident 1 would not receive a meal. The facility's investigation confirmed the verbal abuse, and a mandated report (PB-22) substantiated the incident. Despite the abuse, Resident 1 reported feeling safe in the facility and did not experience harm from the incident. The facility's policy on abuse and neglect, last revised in November 2019, defines abuse as actions causing physical harm, pain, or mental anguish, which includes verbal abuse. The investigation revealed that all dietary department staff had completed mandatory abuse training prior to employment, yet the incident still occurred.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish Enhanced Barrier Precautions (EBP) for four residents who required them due to the presence of medical devices. The facility's policy mandates the use of EBP for residents with infections or colonization with Multidrug Resistant Organisms (MDROs), wounds, or indwelling medical devices. However, observations revealed that there was no evidence of Personal Protective Equipment (PPE) or EBP signage in the rooms of the affected residents. Resident 16 had a PEG feeding tube, Resident 54 and Resident 58 both had Foley catheters, and Resident 173 had both a Foley catheter and a PICC line for antibiotic usage. Despite these conditions, none of the rooms had the required PPE or EBP signage. The Nursing Home Administrator confirmed that Enhanced Barrier Precautions were not in place throughout the building, indicating a systemic failure to adhere to the facility's infection prevention and control policy.
Failure to Monitor Nutritional Status
Penalty
Summary
The facility failed to adequately monitor the nutritional status of three residents, leading to significant weight changes that were not promptly addressed. Resident 4 experienced a weight gain of 15.8 pounds, or 9.3%, between July 18 and August 1, 2024. Despite a registered dietitian's request for a re-weight on August 2, 2024, the re-weight was not conducted until August 20, 2024, as confirmed by Employee E3. Resident 15 showed a weight loss of 32 pounds, or 13.22%, from July 31 to August 8, 2024. A re-weight was requested on August 8, 2024, but was not completed, and the next recorded weight on August 20, 2024, indicated the initial weight was inaccurate. Employee E3 confirmed that the weight loss was not addressed until August 20, 2024, and noted that the resident's medical conditions and medications could have contributed to the weight changes. Resident 66 experienced a weight loss of 7.3 pounds, or 11%, between April 10 and May 17, 2024. A re-weight was requested on May 17, 2024, but was not completed, and the next weight recorded on June 4, 2024, confirmed the accuracy of the May 17 weight. The weight loss was not addressed until June 6, 2024, when a new intervention was ordered. The Nursing Home Administrator confirmed that the weight loss identified on May 17, 2024, was not addressed until June 6, 2024. These deficiencies indicate a failure to adhere to the facility's policy on timely weight monitoring and intervention.
Failure to Offer Advance Directives Upon Admission
Penalty
Summary
The facility failed to ensure that the formulation of Advance Directives was offered to a resident upon admission. Specifically, for Resident 223, there was no evidence in the clinical record that Advance Directives were formulated or offered to the resident's representative at the time of admission. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of any documentation or existence of Advance Directives for Resident 223. This issue was previously cited on two occasions, indicating a recurring problem with compliance in this area.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for one of the residents, identified as Resident 173. According to the facility's policy titled 'Change in a Residents Condition or Status,' revised in December 2016, the facility is required to promptly notify the resident, their attending physician, and representative of any significant changes in the resident's medical, mental, or emotional condition. On December 9, 2023, at 6:50 a.m., a nursing entry in Resident 173's progress notes indicated that the resident was found in bed with bright red bloody urine draining from his Foley catheter and bright red blood clots coming from his penis. However, there was no documented evidence that the resident's physician was notified of this significant change in condition. Later that day, at 3:40 p.m., another nursing entry noted that Resident 173 was lethargic and had large clots coming from his penis, with the Foley bag filled with bright red blood. A new order was received to send the resident to the emergency room for evaluation. An interview with the Nursing Home Administrator on August 22, 2024, confirmed that the resident's physician was not notified of the change in condition when the bleeding was first observed in the morning. This failure to notify the physician promptly is a violation of the facility's policy and the relevant Pennsylvania Code sections regarding clinical records and nursing services.
Failure to Investigate Resident Fall Leading to Cardiac Arrest
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident, which resulted in a possible injury and subsequent cardiac arrest. The resident, who was admitted for respite care, experienced an unwitnessed fall while a nurse aide was providing care. The aide attempted to prevent the fall but was unsuccessful. After the fall, the resident was assessed and found to have no apparent injuries, although vital signs were abnormal. The resident was transferred to the emergency room after the physician on call was contacted. During the transfer process, the resident stopped breathing, and CPR was initiated by EMTs. The resident was later pronounced dead at the hospital. The facility's documentation and clinical records did not provide evidence of a thorough investigation into the cause of the fall, the potential injury, and the resulting cardiac arrest. The Nursing Home Administrator confirmed that a comprehensive investigation was not conducted. The facility's policy requires that all alleged violations, including injuries of unknown source, be thoroughly investigated and reported, but this was not adhered to in this case.
Failure to Monitor Resident Health and Follow Hospital Discharge Instructions
Penalty
Summary
The facility failed to provide adequate care and monitoring for a resident following their transfer from an acute care hospital. The resident, who had a history of urinary issues, was found with a non-patent catheter and blood in the urine. Despite these significant changes in condition, there was no documented evidence of vital signs being taken or a full assessment being completed before the resident was sent to the emergency room. Upon arrival at the hospital, the resident was found to have a high fever, low blood pressure, low oxygen saturation, and signs of dehydration, indicating a severe deterioration in health status that was not adequately monitored by the facility. Additionally, the facility failed to follow up on hospital discharge instructions for the resident, which included recommendations for a urology consultation. Despite being discharged from the hospital on two separate occasions with instructions to follow up with urology, the facility did not schedule these appointments. This lack of follow-up care further demonstrates the facility's failure to adhere to recommended care protocols and adequately manage the resident's health needs.
Failure to Assess Foley Catheter Necessity
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Foley catheter. Resident 54 was observed with a Foley catheter, and upon review of the clinical record, it was found that there was no assessment conducted to determine the necessity of the catheter upon admission. Additionally, the facility did not attempt a voiding trial to assess the resident's ability to urinate independently after admission. It was only after a request from the resident's spouse and an RN from an outside agency that a voiding trial was conducted, which was successful. The Nursing Home Administrator confirmed that the facility did not assess the need for the catheter or attempt a voiding trial until it was specifically requested.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to ensure that tube feedings were delivered according to physician orders for a resident. Resident 16 had a physician's order for continuous enteral feeding with Jevity 1.5 at a rate of 55 ml/hour. However, observations revealed that the enteral feed pump was turned off at one point, and there was no documentation explaining why the pump was not functioning or how much feeding was missed. On one occasion, a new bottle of Jevity 1.5 was placed, but the pump was not running as ordered, leading to a discrepancy in the amount of nutrition provided to the resident. The clinical record lacked evidence to justify the interruption in the feeding schedule, indicating a failure to adhere to the prescribed nutritional plan.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide timely respiratory treatment and services for Resident CL1, who was admitted with diagnoses of Sepsis, COPD, and acute and chronic respiratory failure. Despite having a BIPAP order from the hospital dated February 10, 2024, and additional documentation uploaded to the resident's EMR on February 15, 2024, the BIPAP order was not implemented until February 17, 2024, two days after the resident's admission. This delay occurred because the admitting nurse relied on the transfer form from the hospital, which did not indicate the use of BIPAP, and the DON did not review the hospital documents that specified the need for overnight BIPAP use. Interviews with the admission staff and the DON revealed that the hospital documentation was uploaded to the resident's EMR for clinical staff to review, but the DON did not review these documents. The BIPAP order was only made after the resident's daughter informed the facility of the necessity. The clinical records review also failed to show that the physician was notified about the BIPAP order from the hospital. This lack of communication and timely action led to the deficiency in providing necessary respiratory care for Resident CL1.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
