Pine View Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Broomall, Pennsylvania.
- Location
- 50 North Malin Road, Broomall, Pennsylvania 19008
- CMS Provider Number
- 395078
- Inspections on file
- 26
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 44
Citation history
Health deficiencies cited at Pine View Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents did not receive accurate, comprehensive wound assessments or timely pressure ulcer treatments as required by facility policy. For one resident, a buttock wound noted on readmission lacked description and measurements, and was not fully assessed until a wound physician visit days later, when it was identified as MASD and treated with Medihoney. For another resident, a sacral pressure ulcer present on admission was documented by the wound nurse and had an order for daily Medihoney, but the TAR showed no treatments for several days, and a wound NP first documented intact skin before later describing a Stage 3 sacral pressure ulcer present on admission. The DON confirmed gaps in assessment, documentation, and treatment for both residents.
Surveyors observed that a nurse performed wound care on two residents without following basic infection control practices. For each resident, the nurse placed wound care supplies directly on the bed, including on a used incontinence brief, and positioned clean items next to soiled dressings. During both wound treatments, the nurse failed to change gloves or perform hand hygiene between steps, despite handling contaminated materials and then applying Medihoney and clean bordered dressings to the wounds. In a later interview, the nurse admitted placing supplies on the bed due to lack of side tables and acknowledged forgetting to change gloves and perform hand hygiene, even though they knew these actions were required.
Two residents who required assistance with bathing did not receive scheduled showers, and there was no documentation of showers being provided or refused, despite physician's orders and care plans. Both residents were cognitively intact and required help due to incontinence and other medical conditions, but records and staff interviews confirmed the absence of both care and documentation over several months.
The facility did not follow physician orders for medication administration for two residents, including administering insulin and metoprolol when clinical parameters required the medications to be held, and failed to promptly act on an outside physician's antibiotic recommendation for another resident following a consult appointment.
The facility did not complete required safety assessments before placing air mattresses for several residents with cognitive and physical impairments, and failed to provide leg rests during wheelchair transport for a resident whose feet were observed dragging on the floor. Staff and administration confirmed that these safety measures were not in place as required.
The facility did not ensure proper documentation and accountability for controlled medications for two residents. In one case, doses of Oxycodone were signed out but not documented as administered in the MAR. In another case, Fentanyl patches were applied as ordered, but there was no evidence that two staff members witnessed and signed for the destruction of old patches, as required by policy.
Two residents with cognitive impairment and mobility needs were observed seated at a dining room table with their wheelchair brakes engaged, restricting their ability to move away from the table. Staff, including an LPN and the DON, confirmed that wheelchairs were routinely locked for residents at risk of falls, despite facility policy requiring residents to be free from restraints unless medically necessary.
The facility did not complete comprehensive MDS assessments and Care Area Assessments within the required regulatory time frames for multiple residents. Several assessments were completed one to three days late, and in one instance, a resident did not have an MDS completed in over a year. Staff confirmed these delays during interviews.
Quarterly MDS assessments were not completed within the required time frames for two residents. The ARD for each assessment exceeded the allowed completion window, as confirmed by the RNAC during staff interviews.
The facility did not complete and transmit required MDS assessments within the mandated 7-day timeframe for several residents, with both entry and discharge assessments being finalized weeks late. This was confirmed through review of records and staff interviews.
The facility failed to accurately complete MDS assessments for several residents, resulting in incorrect documentation of antipsychotic, opioid, anticonvulsant, and anti-anxiety medication use, as well as immunization status. These errors were confirmed by review of clinical records and staff interviews.
A resident with hepatic encephalopathy and a physician's order for long-term Rifaximin therapy did not have an individualized care plan addressing these needs. Review of clinical records, facility policy, and staff interviews confirmed that no care plan was developed or implemented for the resident's condition or ongoing antibiotic use.
The facility did not update care plans for two residents to accurately reflect their current clinical status, including the presence of pressure ulcers, use of IV fluids, antibiotics, and contact precautions. Clinical records and staff interviews confirmed that the care plans contained outdated interventions and did not match the residents' actual care needs.
A resident with cognitive impairment, bladder incontinence, and a history of UTIs was observed with an indwelling urinary catheter collection bag in direct contact with the floor, in violation of facility policy. Both an LPN and the ADON confirmed the improper placement of the catheter bag.
Two medication administration errors occurred when an LPN failed to have two residents rinse their mouths after receiving Fluticasone-Salmeterol (Advair) inhalation, as required by physician orders and manufacturer instructions. This resulted in a medication error rate of 8%, exceeding the acceptable threshold.
Surveyors found that an opened multidose vial of Aplisol TB solution was not dated when opened, and that narcotic boxes in two medication refrigerators, including one containing lorazepam intensol concentrate for a resident, were not permanently affixed, allowing the entire shelf to be removed. Staff confirmed these lapses in medication labeling and secure storage.
The facility did not obtain an FBI background clearance for an employee who had not lived in Pennsylvania for the past two years, as required. This oversight was identified during a personnel file review and confirmed in an interview with a staff member.
A resident with Alzheimer's and psychosis, known for combative behavior, fell and sustained a minor skin tear. The next day, a bruise above the right eye was reported by the resident's spouse, but the facility failed to conduct a thorough investigation. Only one staff statement was taken, and the DON incorrectly attributed the bruise to the fall, despite records indicating the resident did not hit their head.
A resident experienced a delay in treatment for a urinary tract infection due to the facility's failure to timely obtain a urine specimen as ordered by the physician. The resident showed signs of lethargy and confusion, prompting a urinalysis order on August 2, but the specimen was not collected until August 4. This delay postponed the start of antibiotic treatment until August 6, as confirmed by the DON.
A resident with multiple health conditions, including diabetes and impaired mobility, developed a Stage II pressure ulcer at the gastrostomy tube site due to inadequate monitoring and treatment by the facility. Despite being at risk for skin integrity issues, the facility failed to properly assess and treat the resident's condition, leading to the ulcer's development.
A facility failed to monitor a resident's significant weight loss, as required by its policy. The resident lost 14.4 pounds, or 8.8%, between two recorded weights. A note questioned the accuracy of this loss and recommended further weights, but no additional weights were obtained. The DON confirmed that a re-weight should have been completed.
A facility failed to document appropriate diagnosis and indications for the use of psychotropic medications for a resident. Lorazepam was administered without documented non-pharmacological interventions, and Seroquel was given without an appropriate diagnosis. The Director of Nursing confirmed the lack of documentation.
A resident with Atrial Fibrillation awaiting hip surgery was given a breakfast tray despite an NPO order before a scheduled TEE procedure. The resident consumed some food and drink, leading to the rescheduling of the procedure. The facility failed to provide documented evidence that the kitchen was informed of the NPO order.
Failure to Accurately Assess and Timely Treat Pressure-Related Wounds
Penalty
Summary
The facility failed to accurately and comprehensively assess and timely treat pressure-related skin impairments for two residents following readmission. For one resident, the readmission skin assessment documented a skin impairment on the right buttock but did not include a description of the wound or its size, contrary to facility policy requiring documentation of location, stage, length, width, and depth. A physician progress note later indicated a new small wound on the buttock with a request for wound care follow-up, yet the wound, identified on February 9, 2026, was not comprehensively assessed until the wound physician evaluated it on February 18, 2026. At that time, the wound was identified as MASD on the right buttock, measuring 2.0 x 1.4 x 0.1 cm, partial thickness, and a Medihoney treatment was ordered. The DON confirmed that this wound, identified upon readmission, was not comprehensively assessed until the wound physician visit. For the second resident, the readmission skin assessment noted scattered scabs on the abdomen and left leg. A subsequent skin assessment by the wound nurse documented a Stage 2 pressure ulcer to the sacrum present on admission. The wound nurse reported that they recheck residents' skin within 24 hours of admission to identify and address all skin impairments and confirmed that this resident was admitted with a Stage 2 sacral ulcer. A physician order for daily topical Thera Honey (Medihoney) to the sacrum was written, but the November Treatment Administration Record showed no evidence that the sacral wound was treated until several days later. Additionally, a wound NP note documented intact skin on one date, followed two days later by a note from the same NP describing a Stage 3 sacral pressure ulcer present on admission, measuring 3.0 x 2.0 x 0.2 cm, with continuation of Medihoney ordered. The DON confirmed there was no documented evidence of treatment for the sacral wound during the initial days after readmission and was unaware of the NP’s earlier inaccurate documentation of intact skin.
Improper Infection Control During Wound Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control practices during wound care treatments for two residents. For one resident with a physician’s order dated March 8, 2026, to cleanse a right buttock wound with NSS, pat dry, apply Medihoney, and secure with a silicone border twice daily, a wound care observation on March 9, 2026, at 10:40 a.m. showed that the nurse placed tissue paper on the bed and laid wet gauze, Medihoney in a cup, and a bordered dressing on top of it. The nurse then cleansed the right buttock wound with wet gauze and discarded the gauze in a trash can, but continued the procedure by applying Medihoney and a newly opened border dressing without changing gloves or performing hand hygiene. For a second resident with a physician’s order dated November 13, 2026, to cleanse the sacrum with NSS and apply Medihoney daily, an observation of sacral wound care on March 9, 2026, at 10:50 a.m. revealed that the same nurse opened the resident’s incontinence brief, repositioned the resident, and placed a cup with wet gauze, Medihoney in a medicine cup, and bordered gauze on top of the resident’s used incontinence brief in the bed. The nurse removed the old sacral dressing and placed it beside the clean supplies on the soiled brief, then cleaned the sacral wound with wet gauze from the cup and discarded the used gauze back into the same cup. The nurse proceeded to apply Medihoney and cover the wound with bordered gauze without changing gloves or performing hand hygiene at any point during the procedure. In a subsequent interview, the nurse acknowledged placing wound supplies on the bed due to lack of side tables and confirmed not changing gloves or performing hand hygiene, stating they forgot despite knowing it should have been done.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to two residents who required assistance with activities of daily living, specifically bathing. One resident, who was cognitively intact and required help with bathing and toileting due to an indwelling catheter and frequent bowel incontinence, had physician's orders and a care plan indicating scheduled showers twice weekly. However, a review of clinical records, nurse aide bathing reports, and the Treatment Administration Record (TAR) showed no documentation that the resident received showers as scheduled or that refusals were documented, as required. The Director of Nursing confirmed the absence of documentation for both the provision and refusal of showers over several months. Another resident, also cognitively intact and requiring assistance with bathing and toileting due to a history of cerebral vascular accident and frequent incontinence, reported not receiving a shower since admission and stated that showers were never offered. Physician's orders indicated scheduled showers twice weekly with instructions to document refusals. Review of the nurse aide bathing report and TAR revealed no evidence that the resident received or refused showers, nor that bed baths were provided as an alternative. The Director of Nursing confirmed the lack of documentation for this resident as well.
Failure to Follow Physician Orders for Medication Administration and Consult Recommendations
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for multiple residents. For one resident with severe cognitive impairment and insulin-dependent diabetes, staff administered Insulin Lispro on numerous occasions when the resident's blood glucose was below the threshold specified in the physician's orders. The orders clearly stated that insulin should be held if blood glucose was less than 110 mg/dl, but the medication was given repeatedly when readings were below this level, as documented in the Medication Administration Record. The Director of Nursing confirmed that insulin was not administered as ordered on the specified dates. Another resident, who was cognitively intact and had a diagnosis of prostate cancer, returned from a radiology oncology/urology appointment with a recommendation for Bactrim DS to treat a urinary tract infection. The consult note indicated that the antibiotic should be started and adjusted based on culture results. However, there was no documented evidence that the facility obtained or acted upon these recommendations in a timely manner. The consult note was not sent to the facility until several days after the appointment, and the Director of Nursing confirmed that the consult sheet with the antibiotic recommendation was not received or acted upon promptly. A third resident, who was cognitively impaired and had a history of stroke with dysphagia, was prescribed metoprolol tartrate with instructions to hold the medication if blood pressure was less than 130/80. Despite this, the Medication Administration Record showed that the medication was administered multiple times when the resident's blood pressure was below the specified threshold. The Director of Nursing confirmed that the medication was given when it should have been held according to the physician's orders.
Failure to Assess Air Mattress Safety and Provide Wheelchair Leg Rests
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards by not completing air mattress safety assessments for multiple residents prior to the use of air mattresses. Specifically, for eleven residents, including those with cognitive impairments, pressure ulcers, and other significant medical conditions, there was no documented evidence that an assessment was performed to identify potential safety hazards associated with the use of air mattresses. Physician orders and care plans indicated the use of air mattresses for pressure relief and skin integrity, but the required safety assessments were not completed before these devices were put in place. Observations confirmed that these residents were using air mattresses, and interviews with facility staff, including the Nursing Home Administrator, verified that no bed safety assessments had been conducted prior to the placement of the air mattresses. The residents involved had varying degrees of cognitive impairment and physical dependency, with some being at risk for falls, having pressure ulcers, or requiring bariatric equipment. Despite these risks, the facility did not document any evaluation of the safety of air mattress use for these individuals. Additionally, the facility failed to provide appropriate assistance devices during wheelchair transport for one resident. An LPN was observed pushing a resident in a wheelchair without leg rests, resulting in the resident's feet dragging on the floor. The LPN stated that leg rests were not used because the resident could self-propel, but acknowledged that they were not in place during transport. The Nursing Home Administrator confirmed that leg rests should have been used if the resident's feet were dragging, but that they were not routinely kept on wheelchairs for residents who could self-propel.
Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for two residents. For one resident who was cognitively intact and required assistance with care needs, there were multiple instances where doses of Oxycodone HCL were signed out on the controlled drug record, but there was no documented evidence in the clinical record or Medication Administration Record (MAR) that these doses were actually administered. This lack of documentation was confirmed by the Assistant Director of Nursing, who acknowledged the absence of records indicating administration of the signed-out doses. For another resident with cognitive impairment and a history of dysphagia following a stroke, physician orders required the application of a Fentanyl patch every three days. Although the MAR and controlled drug count record showed that the patches were applied as ordered, there was no documented evidence that two staff members signed for the destruction of the old patches after removal, as required by facility policy. The Director of Nursing confirmed that she was unaware of the requirement for two nurse signatures for the destruction of Fentanyl patches and acknowledged the lack of witness signatures for the relevant dates.
Failure to Prevent Unnecessary Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints not required for medical treatment. Both residents were cognitively impaired, required staff assistance for daily care, and used wheelchairs for mobility. According to their care plans and MDS assessments, they were at risk for falls. Observations revealed that both residents were seated at a dining room table with their wheelchair brakes engaged, preventing them from moving away from the table. The residents attempted to move or push away from the table but were unable to do so due to the locked wheelchairs. Staff interviews confirmed that it was common practice to lock the wheelchairs of residents at risk for falls while they were in the dining room. An LPN stated that this was done to prevent falls, and the DON indicated she did not consider this a restraint, despite the restriction of movement. The facility's policy stated that residents should be free from restraints unless needed for medical treatment, but there was no evidence that the use of locked wheelchairs in this context was medically necessary.
Failure to Complete MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments and Care Area Assessments (CAA) within the required time frames for nine residents. According to the Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments and CAAs must be completed no later than 13 days after admission, and comprehensive MDS assessments must be completed at least every 92 days. Review of clinical records and the CMS MDS validation report revealed that for several residents, the MDS assessments were completed one to three days late. In one case, there was no MDS completed in the prior 366 days for a resident. Staff interviews, including with the Registered Nurse Assessment Coordinator Consultant, confirmed that the comprehensive MDS assessments for the identified residents were not completed within the required time frames. The findings were based on documentation and assessment dates in the residents' clinical records, as well as the facility's adherence to the regulatory requirements outlined in the RAI User's Manual and state code.
Failure to Complete Quarterly MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frames for two residents. According to the Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment, and the assessment must be completed within 14 days after the ARD. For one resident, the quarterly MDS assessment had an ARD of August 2, 2025, but was not completed until August 19, 2025. For another resident, the quarterly MDS assessment had an ARD of May 8, 2025, but was not completed until May 26, 2025. These findings were confirmed by the Registered Nurse Assessment Coordinator Consultant during an interview.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were encoded and transmitted to the State within the required 7-day timeframe for five residents. Specifically, review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews revealed that both entry and discharge MDS assessments for several residents were not completed within the mandated period. For example, discharge and entry assessments for multiple residents were finalized well beyond the 7-day window after the assessment reference date (ARD), with some delays extending to several weeks. The Registered Nurse Assessment Coordinator Consultant confirmed that these comprehensive MDS assessments were not completed as required by regulation.
Inaccurate MDS Assessments for Medication and Immunization Documentation
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident receiving Risperdal for a chronic psychiatric illness, psychiatric consults documented that a gradual dose reduction (GDR) was clinically contraindicated, but the MDS assessment was incorrectly coded to indicate that no such documentation existed. Another resident received Tramadol, an opioid, for pain management throughout the assessment period, but the corresponding MDS section was not coded to reflect opioid administration. Similarly, a third resident received both Tramadol and Lamotrigine (an anticonvulsant) during the assessment period, but the MDS assessment failed to indicate the administration of these medications. Additionally, a resident who was offered and declined the influenza vaccine was incorrectly coded in the MDS as not having been offered the vaccine. Another resident received Lorazepam (an anti-anxiety medication) and oxycodone (an opioid) during the assessment period, but the MDS assessment did not reflect the administration of these medications. These inaccuracies were confirmed through interviews with the regional Registered Nurse Assessment Coordinator, who acknowledged the coding errors in the residents' MDS assessments.
Failure to Develop and Implement Individualized Care Plan for Hepatic Encephalopathy
Penalty
Summary
The facility failed to develop and implement an individualized care plan for one resident who was reviewed. According to the facility's policy, a comprehensive, person-centered care plan with measurable objectives and timetables should be created and updated for each resident, especially when there are significant changes in condition or new clinical needs. For the resident in question, clinical records showed a diagnosis of hepatic encephalopathy and a physician's order for long-term antibiotic therapy with Rifaximin. Despite these documented needs, there was no evidence that a care plan was created to address the resident's hepatic encephalopathy or the ongoing requirement for antibiotic treatment. This deficiency was confirmed through review of the resident's clinical records, facility policies, and staff interviews. The DON acknowledged that no care plan was in place for the resident's hepatic encephalopathy or long-term antibiotic use. The lack of a care plan was found during a review of the resident's quarterly MDS assessment and physician's orders, which indicated the need for such interventions.
Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to accurately reflect the current care needs of two residents. For one resident, multiple care plans indicated the presence of a stage three pressure ulcer, use of intravenous fluids, a midline intravenous catheter, administration of oral vancomycin, and the need for contact precautions. However, a review of the resident's clinical record, including the Medication Administration Record and physician's orders, showed no evidence that the resident had an active stage three pressure ulcer, was receiving intravenous fluids, had a midline catheter, was taking oral vancomycin, or was on contact precautions. The Director of Nursing confirmed that the care plans should have been updated to reflect the resident's current status. For another resident, the care plan documented that the individual was receiving intravenous antibiotics for sepsis and an ESBL infection and was on contact precautions. Review of the clinical record, including the Medication Administration Record and physician's orders, revealed no evidence that the resident was receiving intravenous antibiotics for sepsis/ESBL infection or required contact precautions. The Director of Nursing confirmed that the care plan should have been updated to reflect the resident's current care needs. These findings indicate that the facility did not revise care plans as required when residents' conditions changed.
Catheter Bag Improperly Positioned on Floor
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed with their catheter collection bag in direct contact with the floor, contrary to the facility's policy requiring catheter drainage bags to be kept off the floor. The resident was cognitively impaired, incontinent of bladder, and had a history of urinary tract infections. This observation was confirmed by both an LPN and the Assistant Director of Nursing, who acknowledged that the catheter bag should not have been on the floor. The failure to maintain proper catheter care was determined through review of policies, clinical records, direct observation, and staff interviews.
Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, as required. During medication administration observations, two errors were identified out of 25 opportunities, resulting in an 8% error rate. Specifically, a Licensed Practical Nurse (LPN) administered Fluticasone-Salmeterol (Advair) Inhalation Aerosol Powder to two residents without ensuring they rinsed their mouths after use, as directed by both the physician's orders and the manufacturer's instructions. The omission of this step was observed during the morning medication pass. Both residents had physician orders specifying the use of Fluticasone-Salmeterol for asthma and COPD, with explicit instructions to rinse the mouth after each administration to reduce the risk of side effects such as oral thrush. The LPN confirmed during an interview that she did not have the residents rinse their mouths after administering the medication. The Director of Nursing also confirmed that the mouth rinsing step should have been completed for both residents following administration of the inhaled medication.
Failure to Properly Label and Securely Store Medications
Penalty
Summary
Surveyors identified that the facility failed to properly label and store drugs and biologicals in accordance with professional standards. Specifically, an opened multidose vial of Aplisol TB solution was found in a medication storage refrigerator without a date indicating when it was opened, contrary to the manufacturer's instructions that require vials in use for more than 30 days to be discarded. Staff interviews confirmed that the vial was not dated upon opening. Additionally, the narcotic box in the refrigerator, although fixed to a shelf, could be removed from the refrigerator because the shelf itself was not permanently affixed, and the box did not contain any narcotic medications at the time of observation. Further observations revealed that a second medication refrigerator contained a separate box with two boxes of lorazepam intensol concentrate, a controlled liquid antianxiety medication prescribed to a resident. This box was also not permanently affixed, as the entire shelf it was mounted on could be removed from the refrigerator. Staff interviews, including with the DON, confirmed that the narcotic boxes in both refrigerators were not permanently affixed as required for the secure storage of controlled substances.
Failure to Obtain FBI Clearance for Employee
Penalty
Summary
The facility failed to obtain an FBI background clearance for an employee, identified as Employee E6, who was hired on April 24, 2024. Employee E6 had not resided within the Commonwealth of Pennsylvania during the previous two years, which necessitated an FBI clearance as per regulatory requirements. A review of Employee E6's personnel file revealed the absence of this clearance. This deficiency was confirmed during an interview with Employee E3 on August 28, 2024, and the information was subsequently conveyed to the Nursing Home Administrator and Director of Nursing.
Failure to Investigate Unknown Injury
Penalty
Summary
The facility failed to comprehensively investigate an unknown injury for a resident with Alzheimer's disease and psychosis, who had a severe cognitive impairment and was known for combative behavior and wandering. The resident, who was independent with ambulation, was observed to have fallen while attempting to walk, resulting in a minor skin tear on the left leg. However, the following day, the resident's spouse reported a bruise above the right eye, which was not initially documented or communicated. The facility's documentation and investigation into the bruise were inadequate, as only one staff statement was taken, and no thorough investigation was conducted to determine the bruise's origin. The Director of Nursing (DON) indicated that the bruise was from the fall, despite clinical records showing the fall was witnessed and the resident did not hit their head. The facility's policy required a comprehensive investigation of injuries of unknown origin, which was not followed in this case. The lack of a thorough investigation and failure to gather statements from all relevant staff members who had contact with the resident contributed to the deficiency, as the facility did not ensure the injury was properly investigated.
Delay in Obtaining Urine Specimen Leads to Treatment Delay
Penalty
Summary
The facility failed to timely obtain a urine specimen for testing according to physician orders for a resident, leading to a delay in treatment. The resident, who was noted to be lethargic and more confused than their regular baseline, was observed to occasionally jerk without awareness. A call was placed to the medical doctor, and the nurse practitioner was informed, but there was a delay in receiving a callback. The physician ordered a urinalysis and culture and sensitivity test to be conducted as soon as possible on August 2, 2024. Despite the order, the urine specimen was not obtained until August 4, 2024, during the day shift, which delayed the diagnosis and treatment of a urinary tract infection. The resident eventually received an order for the antibiotic Cipro on August 6, 2024, indicating a delay in the initiation of treatment. The Director of Nursing confirmed that the facility did not obtain the urine specimen in a timely manner, which resulted in the delay of treatment from July 31, 2024, until August 6, 2024.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and worsening of a pressure ulcer for a resident. The resident, who was admitted with multiple diagnoses including muscle weakness, dysphagia, hemiplegia, and diabetes, was at risk for skin integrity issues due to impaired mobility and incontinence. Despite these risks, the facility did not properly monitor or treat the resident's skin condition, particularly around the gastrostomy tube site, from April 29, 2024, to May 7, 2024. This lack of attention led to the development of a Stage II pressure ulcer at the peg tube site. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to assess and treat the resident's peg tube site appropriately. The resident's care plan included interventions such as monitoring skin integrity and conducting weekly full-body checks, but these measures were not effectively implemented. The pressure ulcer was eventually resolved by June 18, 2024, but the initial lack of proper care and documentation contributed to the development of the ulcer.
Failure to Monitor Resident's Weight Loss
Penalty
Summary
The facility failed to obtain and monitor weights for a resident, identified as Resident 83, which led to a deficiency in maintaining the resident's nutrition and hydration status. According to the facility's policy on Weight and Weight Change Management, residents are to be weighed monthly or more frequently if necessary. Resident 83's weight was recorded as 164.4 pounds on July 3, 2024, and then as 150.0 pounds on August 1, 2024, indicating a significant weight loss of 14.4 pounds or 8.8%. A weight change note on August 16, 2024, questioned the accuracy of this weight loss and recommended further weights to assess the validity of the weight status. However, no additional weights were obtained by August 28, 2024, despite the recommendation. An interview with the Director of Nursing confirmed that a re-weight should have been completed but was not.
Failure to Document Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate diagnosis and documentation for the administration of psychotropic medications to a resident. Specifically, the resident was prescribed Lorazepam, an anti-anxiety medication, to be administered as needed for agitation. However, the clinical records did not provide appropriate indications for its use beyond agitation, nor did they document any attempts at non-pharmacological interventions prior to administering the medication. This lack of documentation was confirmed during an interview with the Director of Nursing. Additionally, the resident was prescribed Seroquel, an antipsychotic medication, upon discharge from the hospital to promote sleep and reduce agitation. The facility's records showed that the resident was administered Seroquel multiple times over two months. However, there was no documentation of an appropriate diagnosis for the use of this antipsychotic medication. The Director of Nursing was unable to provide such documentation during an interview, indicating a failure to ensure the resident had an appropriate diagnosis for the use of antipsychotic medication.
Failure to Follow NPO Order for Resident
Penalty
Summary
The facility failed to ensure an NPO (nothing per mouth) order was followed for a resident scheduled for a Transesophageal Echocardiogram (TEE). The resident, who had a diagnosis of Atrial Fibrillation and was awaiting hip surgery, was aware of the NPO order but forgot about it on the day of the procedure. On the morning of the procedure, an agency nurse aide provided the resident with a breakfast tray, and the resident consumed a cup of orange juice and 2-3 spoons of cereal before being reminded of the NPO order by a nurse. This resulted in the rescheduling of the TEE procedure. The Director of Nursing (DON) reported that a communication form should have been sent to the kitchen to inform them of the NPO order, but the facility was unable to provide documented evidence that this was done. Interviews with the resident and staff confirmed the sequence of events, and the nursing progress notes corroborated the failure to follow the NPO order. This deficiency led to a delay in the resident's scheduled medical procedure.
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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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