Pottstown Skilled Nursing And Rehabilitation Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Pottstown, Pennsylvania.
- Location
- 724 North Charlotte St, Pottstown, Pennsylvania 19464
- CMS Provider Number
- 395402
- Inspections on file
- 27
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Pottstown Skilled Nursing And Rehabilitation Cente during CMS and state inspections, most recent first.
A resident with CHF, an LVAD, and coronary artery disease did not receive care in accordance with multiple physician orders. Records showed missing documentation of required LVAD self-tests, LVAD parameter monitoring (rate, pulse index, power, speed), vital signs, and doppler mean BP checks on several occasions. Staff also failed to document ensuring LVAD backup batteries were charged and verified, obtaining ordered daily weights, converting the LVAD to battery power daily and back to main power at bedtime, and assessing for driveline infection each shift. When the resident was transferred to the hospital for a change in condition, there was no documented evidence that the required LVAD backup controller, extra batteries, and clips accompanied the resident, and the DON confirmed there was no evidence that these physician orders were implemented.
Surveyors identified multiple environmental deficiencies affecting several units and the beauty salon, including peeling and missing wallpaper above a resident’s bed, separated and bubbled wallpaper with exposed drywall, and numerous stained ceiling tiles over resident beds and in hallways. Hallways showed large black-stained areas with dried liquid on walls, air conditioner units with black substances and dried drip marks, dark dried liquid on walls near room doors, and a handrail coated with a black substance. Additional findings included black marks along hallway walls, a pervasive musty odor in one hallway, and black discoloration on wallpaper above the sink and hair dryer chairs in the beauty salon, all in violation of state regulatory requirements for a safe, clean, and comfortable environment.
The facility failed to maintain current and accurate nurse staffing information on the required public posting. Surveyors observed that the staffing data displayed in the lobby was several days out of date, and the DON later confirmed that the posted information was incorrect and did not reflect the actual staffing for that day.
Physician-ordered wound care was not consistently provided or documented for three residents with conditions such as diabetes, hemiplegia, and heart failure. Required treatments for pressure sores and skin care were missed on multiple occasions, as confirmed by clinical record review and staff interview.
Surveyors found that the facility did not post accurate nurse staffing information, including the correct date, resident census, and actual hours worked by RNs, LPNs, and CNAs. The Administrator confirmed the posted data was not current or accurate for staffing hours and census.
The facility failed to assess and manage incontinence for three residents, leading to a deficiency. A resident was not placed on a scheduled toileting program despite being identified as a candidate. Two other residents experienced frequent incontinence without proper assessment or intervention. The DON confirmed the lack of documentation and evaluation.
A resident with significant physical limitations was not provided with a handbell to call for assistance, as required by their care plan. The resident, who had conditions such as hemiplegia and muscle weakness, was observed multiple times without the handbell, and the DON confirmed it should have been provided.
The facility failed to develop comprehensive care plans for two residents, omitting interventions for urinary incontinence despite assessments indicating the need. Another resident's care plan lacked interventions for bowel incontinence, despite frequent incontinence and the need for staff assistance. The DON confirmed the absence of documented interventions.
A resident with diabetes, muscle weakness, dizziness, and giddiness, requiring assistance for bed mobility and transfers, was identified as at risk for falls. The care plan included placing floor mats on both sides of the bed, but observations revealed the mats were not in place. The DON confirmed the mats should have been used.
A resident with schizoaffective disorder and PTSD did not receive timely medication changes and lacked a care plan for PTSD. Despite a psychiatric recommendation to switch antidepressants, the resident continued on the old medication. The DON acknowledged the delay and absence of a care plan.
The facility failed to secure controlled substances, specifically lorazepam, in a locked, permanently affixed compartment in the first floor medication room refrigerator. This was against the facility's policy and regulatory requirements, as confirmed by the DON during an interview.
The facility did not post required contact information for State agencies and advocacy groups, nor a statement about filing complaints with the State Survey Agency. This was confirmed through interviews and observations, revealing a violation of resident rights regulations.
A resident with a history of stroke, requiring moderate assistance with personal hygiene, was observed with facial hair on her lower face over two days. She expressed a desire for the hair to be removed, but noted that staff were sometimes too busy to assist. The care plan indicated staff should assist with grooming, which was confirmed by the DON.
The facility failed to ensure accurate MDS assessments for two residents. One resident's Braden scale indicated a change in pressure sore risk, which was not reflected in the MDS. Another resident was prescribed an anti-coagulant, but the MDS inaccurately recorded an anti-platelet medication. The DON confirmed the inaccuracies.
A facility failed to follow a physician's order for a resident with hypotension, requiring midodrine administration only if systolic blood pressure (SBP) was below 130 mm/Hg. The medication was given 14 times without documented blood pressure checks, as confirmed by the DON.
A resident with brain traumatic injury, dementia, and hand contractures did not receive the prescribed care to prevent further contractures. The care plan required a right palm protector to be applied daily, but observations showed the resident without it, with the protector left on the nightstand. The DON confirmed the resident was supposed to wear the palm guard.
A facility did not follow its policy and a physician's order to change and label oxygen tubing weekly for a resident with chronic respiratory failure and a tracheostomy. Observations showed the tubing was outdated and not labeled, which was confirmed by the DON.
Failure to Follow LVAD-Related Physician Orders and Monitoring Requirements
Penalty
Summary
The deficiency involves the facility’s failure to implement multiple physician orders for a resident with congestive heart failure, a left ventricular assist device (LVAD), and atherosclerosis of coronary artery bypass grafts. Clinical record review for a specified period in January 2026 showed missing documentation that staff performed required LVAD self-tests every shift on two occasions. Staff also did not document required LVAD parameters (pump rate, pulse index, pump power, pump speed) and vital signs on six occasions, and there was no documented evidence that staff used a doppler to obtain mean blood pressure twice daily as ordered. In addition, staff failed to document that they ensured backup LVAD batteries were on charge and verified every shift on two occasions. Further review showed that staff did not document obtaining daily weights on four occasions, despite orders to monitor weights and notify the provider of significant changes. There was no documented evidence that staff converted the LVAD to battery power once daily and returned it to main power at bedtime on two occasions. Staff also failed to document observing for signs and symptoms of driveline infection every shift on three occasions. When the resident was transferred to the hospital for a change in condition, there was no documented evidence that the resident was sent with the ordered backup controller, two extra batteries, and two extra clips. In an interview, the DON confirmed there was no evidence that staff implemented these physician orders as required.
Environmental Disrepair and Contamination on Multiple Units and Beauty Salon
Penalty
Summary
Failure to provide a safe, clean, comfortable, and homelike environment was evidenced by multiple areas of environmental disrepair and contamination observed on three nursing units and in the beauty salon. On the resident care units, surveyors observed missing and peeling wallpaper above a resident’s bed, separated and bubbled wallpaper below an air conditioner unit with exposed drywall, and dark marks on hallway walls. Several ceiling tiles in resident rooms and hallways were stained, including brown, red, and dark stains above resident beds and near air conditioner units. In one hallway, a stained ceiling tile was located above peeling wallpaper and exposed drywall that had a black substance on it. Additional observations included large black-stained areas with dried liquid on a hallway wall, air conditioner units with black substances and dried black drip marks along the bottom, and dark dried liquid substances on hallway walls near resident room doors. A handrail below an air conditioner unit was covered along its corner piece with a black substance. There were black marks along the length of a hallway wall and a pervasive musty odor in that hallway during the observation period. In the beauty salon, black discolored areas were present on the wallpaper above the sink area and above the hair dryer chairs. These conditions were cited under 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.18(b)(1) Management.
Failure to Post Current and Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information as required. During a tour of the facility on January 21, 2026, at 9:14 a.m., surveyors observed that the nurse staffing information posted in the lobby was dated January 14, 2026, indicating it had not been updated for several days. In an interview conducted on January 21, 2026, at 2:15 p.m., the Director of Nursing confirmed that the staffing data posted in the lobby was incorrect, verifying that the information displayed did not reflect the current nurse staffing for that day.
Failure to Administer Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to implement physician-ordered wound treatments for three out of five sampled residents. For one resident with diabetes and kidney disease, staff did not provide the prescribed daily wound care for a pressure sore on the right toe on three specific dates, as evidenced by missing documentation in the Treatment Administration Record (TAR). Another resident with hemiplegia, hemiparesis, and hypertension did not receive the ordered application of amlactin lotion to the left toes and foot on multiple dates, as indicated by gaps in the TAR. A third resident with heart failure and atrial fibrillation did not receive the required wound care for a spinal pressure sore on two occasions, with no evidence of treatment recorded in the TAR. These deficiencies were confirmed through clinical record review and staff interview, which established that the wound treatments ordered by physicians were not consistently administered or documented. The administrator acknowledged the lack of evidence that the residents received the prescribed wound care on the specified dates.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
Surveyors observed that the facility failed to post current and accurate nurse staffing information at the beginning of each shift, as required by federal regulations. On August 12, 2025, at 11:00 a.m., the posted nurse staffing information in the main lobby displayed an incorrect date and resident census. Additionally, the staffing hours listed did not accurately reflect the actual total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. During an interview later that day, the Administrator confirmed that the posted nurse staffing information was not accurate for both staffing hours and resident census for that date. No information about specific residents or their medical conditions was provided in the report. The deficiency was based solely on the inaccurate and outdated information posted and confirmed by facility leadership.
Plan Of Correction
1. & 2. The current and accurate nurse staffing information was posted immediately for 8/12/2025. 3. The DON and scheduler were educated on the regulatory requirement for posting current and accurate staffing information, including the facility name, current date, total number and actual hours worked by RNs, LPNs, CNAs, and the census by shift. 4. To ensure continued compliance, the NHA/designee will complete daily audits X 4 weeks, weekly audits X 2 weeks, and monthly audits X 1 month. 5. Date of compliance is 8/15/2025.
Failure to Assess and Manage Incontinence
Penalty
Summary
The facility failed to adequately assess and manage bladder and bowel incontinence for three residents, leading to a deficiency in care. Resident 45, who was admitted with conditions including diabetes and hypertension, was identified as a candidate for a scheduled toileting program. However, despite the assessment, the resident was not placed on such a program, and the type of urinary incontinence was not identified in the care plan. There was no documented evidence of a scheduled toileting program being implemented for this resident. Similarly, Resident 77, admitted with diabetes and a urinary tract infection, was frequently incontinent of urine and bowel but was not on a toileting program. The facility did not identify the type of incontinence or develop specific interventions to address it. Resident 129, with diagnoses including diabetes and kidney failure, experienced a change in bowel incontinence status from frequently to always incontinent, yet there was no documentation of an assessment or implementation of a toileting program. The Director of Nursing confirmed the lack of documentation and evaluation for these residents.
Plan Of Correction
Part 1. Resident 45 and 77 types of urinary incontinence were identified and interventions were put into place immediately. Resident 129 change of condition bowel incontinence frequency was identified and interventions were put into place immediately. Part 2. Residents who were admitted or re-admitted to the facility within the last 30 days were reviewed for continence management for incontinence assessment completion. If identified as not having an incontinence assessment in place, it was completed and scheduled as per policy and procedure. Part 3. Nursing education completed to complete fecal and urinary incontinence assessments upon admission/re-admission, change of condition, quarterly and annually. Part 4. To prevent recurrence, the facility will audit new admissions, re-admissions and those due for quarterly assessments to ensure incontinence assessments are completed. Auditing will be completed weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. Results will be reviewed monthly at QAPI. Part 5. Date of compliance is May 13, 2025.
Failure to Provide Accessible Call Bell for Resident
Penalty
Summary
The facility failed to ensure that call bells were accessible for a resident, identified as Resident 13, who had significant physical limitations. Resident 13 had diagnoses including hemiplegia, hemiparesis, contracture of muscle, and muscle weakness, which required extensive assistance from staff for mobility and activities of daily living. The care plan for Resident 13 included an intervention for staff to provide a handbell to call for assistance due to the resident's self-care deficit and risk for behavioral symptoms. On April 8, 2025, Resident 13 was observed in bed without a handbell at multiple times throughout the day. During an interview, Resident 13 stated that she could not find her handbell. The Director of Nursing confirmed that the handbell should have been provided to Resident 13 to call for assistance, indicating a failure to accommodate the resident's needs as outlined in the care plan.
Plan Of Correction
Part 1. Resident #13 was provided with a hand bell as care planned. Part 2. Residents with/without psychiatric diagnosis were audited to ensure care planned interventions for a call light or alternative communication device is in place at all times. Facility audit completed to ensure each resident has a call bell clip to secure the call bell within easy access of the resident. Part 3. Facility staff education on ensuring residents with/without psychiatric dx are provided with a call light or alternative communication devices as care planned and that call bells are accessible. Part 4. Residents with/without a psychiatric dx will be audited to ensure care planned interventions for call bells are in place. Auditing will occur weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. Audit results will be reviewed monthly at QAPI. Part 5. Date of compliance is May 13, 2025.
Failure to Address Incontinence in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans addressing individual resident needs as identified in their comprehensive assessments for two of the 28 sampled residents. Specifically, Resident 45, who was admitted with diagnoses including diabetes, heart disease, and hypertension, had a Minimum Data Set (MDS) assessment and Care Area Assessment (CAA) summary indicating that urinary incontinence should be addressed in the care plan. However, there was no evidence of interventions for urinary incontinence in Resident 45's care plan. Similarly, Resident 77, admitted with diagnoses including diabetes, urinary tract infection, and hypertension, also had an MDS CAA summary noting the need to address urinary incontinence, but the care plan lacked corresponding interventions. Additionally, the facility did not implement interventions for bowel incontinence in the care plan of Resident 129, who was admitted with diabetes and hypertension. The MDS indicated that Resident 129 was alert, frequently incontinent of bowel, and required staff assistance for toileting. Despite these needs, the care plan did not include interventions to address bowel incontinence. The Director of Nursing confirmed the absence of documented evidence for interventions addressing urinary or bowel incontinence in the care plans of the mentioned residents.
Plan Of Correction
Part 1. Residents 45 and 77 care plans were updated to include urinary continence. Resident 129 care plan was updated to include bowel incontinence. Part 2. Like residents with urinary or bowel incontinence have been audited to identify any missing care planned interventions. Any change in condition or newly admitted residents will be reviewed daily during clinical meetings. Part 3. Nursing staff education on including appropriate interventions for urinary and bowel incontinence and documenting the interventions in the care plan. Part 4. Residents identified with urinary and bowel incontinence will be audited to ensure appropriate interventions are in place. Auditing will occur weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. Audit results will be reviewed at QAPI. Part 5. Date of Compliance is May 13, 2025.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure safety interventions were in place for Resident 45, who was at risk for falls. Resident 45 had medical conditions including diabetes, muscle weakness, dizziness, and giddiness, and required staff assistance for bed mobility and transfers. The care plan identified the resident as being at risk for falls due to impaired mobility, with an intervention to place floor mats on both sides of the bed while the resident was in bed. However, during multiple observations, the floor mats were not in place while the resident was in bed. This was confirmed by the Director of Nursing during an interview.
Plan Of Correction
Part 1. Resident #45 was immediately provided with fall mats as care planned. Part 2. Like residents with care planned fall mats were audited to ensure the fall mats were properly in place. Part 3. Facility staff education provided to ensure care planned fall mats are in place as indicated. Part 4. Residents identified as being care planned to use fall mats will be audited to ensure placement as indicated. Auditing will be completed weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. 5. Date of compliance is May 13, 2025.
Failure to Provide Timely Mental Health Treatment and Care Planning
Penalty
Summary
The facility failed to provide timely and appropriate services and treatment for a resident diagnosed with schizoaffective disorder, PTSD, and auditory hallucinations. The resident, who was alert and oriented, exhibited mood issues such as feeling down, trouble sleeping, fatigue, and negative self-perception. A psychiatric consultation recommended discontinuing the current antidepressant, Lexapro, and starting a new one, Zoloft, to address increased depressive and anxiety symptoms. However, as of April 9, 2025, the resident continued to receive Lexapro, and the recommendation for Zoloft had not been reviewed or ordered by the physician. Additionally, the facility did not develop a care plan with specific interventions to address the resident's PTSD diagnosis. The Director of Nursing acknowledged that the medication change recommendation was not implemented in a timely manner and that no care plan was developed for the PTSD diagnosis. This lack of timely action and care planning contributed to the deficiency in providing appropriate mental health services to the resident.
Plan Of Correction
Part 1. Resident # 27's care plan was immediately updated to include a newer diagnosis of PTSD. Social Services intervention to include a discussion with the resident to ensure psycho/social components of well being are addressed. The medication recommendations of changing Lexapro to Zoloft was updated in the resident's medication orders. Part 2. A 30-day look back was completed to review new admissions/re-admissions for PTSD diagnosis and any medication changes. Any new admissions/re-admissions will have a diagnosis and medication review during the morning clinical meeting. Current facility residents with a PTSD diagnosis were identified and reviewed. Care plans were assessed for completion. Part 3. Facility staff education completed on PTSD care planning requirements and updating recommended medication changes. Part 4. To prevent recurrence, the facility will audit the diagnosis and medication recommendations of new/re-admissions and appropriately care plan for the diagnosis of PTSD. Auditing will be completed weekly X 4 weeks, Bi-weekly X 4 weeks and monthly X 1 month. Results will be reviewed at QAPI. Part 5. Date of compliance is May 13, 2025.
Failure to Secure Controlled Substances in Medication Room
Penalty
Summary
The facility failed to ensure that medications with the potential for abuse, specifically controlled substances, were secured in a locked, permanently affixed compartment at all times in one of the four medication rooms on the first floor. This deficiency was identified during an observation on April 9, 2025, at 12:31 p.m., when it was noted that the first floor medication room refrigerator contained 12 vials and two bottles of a Schedule IV anti-anxiety medication, lorazepam, which were not secured in a locked compartment within the refrigerator. The facility's policy, last reviewed on March 31, 2025, required that controlled substances listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976 be separately locked in permanently affixed compartments, including those stored in refrigerators. During an interview on the same day at 10:20 a.m., the Director of Nursing confirmed that the controlled medications should have been locked within a separate, locked, and permanently affixed compartment of the refrigerator, indicating a failure to adhere to the facility's policy and regulatory requirements.
Plan Of Correction
Part 1. The first floor medical room refrigerator was repaired to have a secured lock. Part 2. Facility medical room refrigerators were inspected to ensure each refrigerator had a functioning locked compartment. Part 3. Staff education completed regarding the locking of the refrigerated narcotic medications. Part 4. To prevent recurrence, unit med room refrigerators will be audited to ensure the locking mechanism is functioning properly. Auditing will occur weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. Audit results will be reviewed monthly at QAPI. Part 5. Date of compliance is May 13, 2025.
Failure to Post Required Contact Information for State Agencies
Penalty
Summary
The facility failed to ensure that information regarding how to contact State agencies and advocacy groups, including a statement that residents may file a complaint with the State Survey Agency, was accessible to all residents, visitors, and staff. This deficiency was identified during a confidential family interview on April 8, 2025, where it was revealed that such information was not available and posted for all residents, visitors, and staff. Additionally, an observation confirmed the absence of posted information that included a statement about filing complaints with the State Survey Agency. In an interview conducted on April 9, 2025, the Administrator confirmed that the names and phone numbers of various advocacy groups, including the State Survey Agency, were not posted and available to residents, staff, and visitors. This lack of accessible information is a violation of the requirement to post pertinent contact information and a statement regarding the right to file complaints, as outlined in the federal regulations and the 28 Pa. Code 201.29(a)(c.1) concerning resident rights.
Plan Of Correction
Part 1. The required postings were established and made available for all on 4/09/2025. Part 2. The required correction was made immediately upon notification. No other review of related infraction is indicated. Part 3. The NHA was educated on the regulation for required postings to be made available for all to reference. Part 4. Required postings will be audited for accessibility/placement weekly X 4 weeks, bi-weekly X 4 weeks, and monthly X 1 month. Audit results will be reviewed at QAPI. Part 5. Date of compliance is May 13, 2025.
Failure to Assist Resident with Grooming
Penalty
Summary
The facility failed to provide grooming services to maintain the dignity of a resident, identified as Resident 51, who had a history of stroke and required moderate assistance with personal hygiene, including shaving. Observations on two consecutive days revealed that the resident had facial hair on her lower face, which she expressed a desire to have removed. The resident mentioned that staff were sometimes too busy to assist her. The resident's care plan included an intervention for staff to assist with grooming as needed. The Director of Nursing confirmed that staff were responsible for assisting the resident with grooming.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the current status of two residents. For one resident, the Braden scale assessments indicated a change in pressure sore risk from mild to moderate between March and April 2024. However, the MDS assessments from March and May 2024 did not reflect this risk. Another resident, diagnosed with atrial fibrillation, was prescribed an anti-coagulant medication, apixaban, in May 2024. Despite this, the MDS assessment inaccurately recorded the resident as being on an anti-platelet medication. Interviews with the Director of Nursing confirmed that the MDS assessments were inaccurately coded and did not reflect the residents' current conditions.
Failure to Implement Physician's Orders for Blood Pressure Monitoring
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with hypotension. The physician's order, dated June 20, 2024, required the administration of midodrine three times a day, with the condition that the medication should not be given if the resident's systolic blood pressure (SBP) exceeded 130 mm/Hg. A review of the resident's June medication administration record (MAR) showed that the medication was administered 14 times without documented evidence that the blood pressure was assessed prior to administration, as per the physician's order. During an interview on June 27, 2024, the Director of Nursing confirmed the absence of documented evidence that the resident's blood pressure was taken before administering the medication, as required by the physician's order.
Failure to Apply Palm Protector for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary services to prevent further contractures and limitations in range of motion for a resident with a history of brain traumatic injury, dementia, and contractures of the hands. The resident's care plan included an intervention to apply a right palm protector in the morning and remove it at night, with a goal of achieving normal anatomical alignment of the right hand for at least four hours daily. However, observations on multiple occasions revealed that the resident was in bed without the right palm protector in place, despite it being prescribed in the care plan. The right palm guard was found on the nightstand beside the resident's bed during these observations. The Director of Nursing confirmed that the resident was supposed to wear the right palm guard as per the care plan.
Failure to Change and Label Oxygen Tubing
Penalty
Summary
The facility failed to adhere to its policy and a physician's order regarding the maintenance of oxygen tubing for a resident receiving oxygen therapy. The policy required that oxygen delivery tubing be changed every seven days and labeled with the date and initials. A clinical record review showed that a resident with chronic respiratory failure and a tracheostomy had a physician's order to change the oxygen tubing weekly on Tuesday nights, with each component labeled accordingly. However, observations revealed that the resident's oxygen tubing was dated from nearly a month prior, and the tracheostomy aerosol tubing was not dated or labeled. The Director of Nursing confirmed that the tubing should have been labeled per the physician's order and facility policy.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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