Providence Rehab And Hlthcare Ctratmercyfitzgerald
Inspection history, citations, penalties and survey trends for this long-term care facility in Yeadon, Pennsylvania.
- Location
- 600 South Wycombe Ave, Yeadon, Pennsylvania 19050
- CMS Provider Number
- 395989
- Inspections on file
- 32
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Providence Rehab And Hlthcare Ctratmercyfitzgerald during CMS and state inspections, most recent first.
Three residents with significant medical conditions experienced misappropriation of their personal property by a facility employee, including unauthorized use of financial cards and possession of fare cards. The incidents were discovered following a family report and a police investigation, with no additional residents reporting missing property or finances.
A resident with cerebral palsy and mobility impairments was left unattended on a bed that was not in the lowest position during a bathing routine. The staff member stepped away to request cream, and the resident subsequently slid off the bed and hit her head on a nightstand. Staff interviews confirmed that the bed was not lowered as required by the care plan, leading to the fall.
A facility did not conduct a thorough investigation after a resident, who required assistance with personal hygiene due to physical limitations, alleged neglect when a nurse aide refused to help with toileting hygiene. Although policy required statements from all involved staff, the facility failed to obtain written statements from several key staff members who were present or involved in the incident, resulting in an incomplete investigation.
A resident admitted with a PICC line did not have required baseline and ongoing measurements documented, including catheter length and arm circumference, as ordered by the physician and facility policy. The PICC line dressing was not changed as required, and observations confirmed the dressing was peeling and dated prior to admission. No documentation of necessary assessments or dressing changes was found in the resident's records.
Staff did not follow infection control protocols for two residents: one with a multi-drug resistant organism was transferred by staff wearing only gloves instead of full PPE as required, and an air mattress for another resident with pressure wounds was left uncovered on the floor while being prepared for use.
Two residents were found living in unsanitary and cluttered conditions, with one requiring total assistance and the other exhibiting ongoing behaviors that contributed to a dirty environment. Staff and management confirmed repeated challenges in maintaining cleanliness due to resident refusals and behaviors, resulting in persistent foul odors, soiled linens, and cluttered rooms.
The facility did not maintain and inspect its fire alarm system according to NFPA standards. A document review revealed the absence of documentation for a required semi-annual visual fire alarm inspection. This deficiency impacts the entire facility, as confirmed by the Administrator and Maintenance Director.
The facility failed to maintain the sprinkler system, with storage found within 18 inches of sprinklers in multiple locations, including storage rooms on the first floor. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain and inspect the emergency generator, affecting the entire facility. Documentation for weekly battery voltage and monthly battery conductance testing was missing. Additionally, a Low Fuel alarm was observed on the generator annunciator panel at the Nurses' Station. These issues were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain egress doors free from obstructions, as the emergency magnetic door release mechanisms were non-functional at three locations on the first floor. This issue was observed and confirmed during an exit interview with the Administrator and Maintenance Director.
A delayed egress door on the first floor of the facility, across from a resident room, failed to alarm and open as required by NFPA 101 standards. This deficiency was confirmed by the Administrator and Maintenance Director during an exit interview, affecting one of two floors in the facility.
The facility did not maintain portable fire extinguishers as required by NFPA 10 standards. An observation revealed that the fire extinguisher in the Elevator Machine Room on the first floor was blocked by storage. This was confirmed in an interview with the Administrator and Maintenance Director.
The facility did not comply with NFPA 70, as storage was found within three feet of electrical panels on the first floor, violating the required clearance. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility's emergency preparedness plan lacked documentation on the role of the Ambulatory Surgical Center under a waiver declared by the Secretary, affecting the entire facility. This was confirmed during a document review and an exit interview with the Administrator and Maintenance Director.
A facility failed to maintain a clean and odor-free environment for a resident with severe cognitive impairment and multiple medical conditions. Observations revealed persistent offensive odors and unclean conditions, including a strong odor of urine and bowel movement, a foul sour odor near the resident's bed, and dried spillage on medical equipment. Despite initial cleaning efforts, the odors and unclean conditions persisted, as confirmed by staff interviews.
The facility failed to protect residents from the misappropriation of narcotic medications, as discrepancies in narcotic counts were discovered for two residents. The facility's policy on controlled substances was not followed, leading to missing medications and documentation. Interviews revealed that staff did not reference the narcotic index during counts, resulting in oversight of missing narcotics.
A facility failed to develop a comprehensive care plan for a resident with diabetes, despite the resident's need for insulin injections and blood sugar monitoring. The deficiency was confirmed by a nurse, who acknowledged the absence of a care plan addressing the resident's diabetes management.
A resident's medication was left unattended on their over-bed table on two occasions, despite the resident's refusal to take it due to concerns about increased urination. The unattended medication, which included potassium chloride and a diuretic, posed a safety risk as it could have been taken by another resident. The facility acknowledged the lapse in maintaining a safe environment.
A medication labeling error occurred when a nurse administered a nasal spray to a resident using a bottle labeled with another resident's name. The facility's policy requires verification of the resident's identity and medication label checks, which were not properly followed, leading to this deficiency.
A medication labeling deficiency occurred when a nurse administered a nasal spray to a resident using a bottle labeled with another resident's name. The facility's policy requires verification of the resident's identity and medication label checks, which were not followed, leading to the administration of medication with incorrect labeling.
The facility did not adhere to professional standards for food service safety. Observations revealed bread stored on the floor in the freezer, standing water in the dish room due to a clogged drain, and visible dirt and crumbs in the prep area. The convection oven had burned-on food, and the plate heater was dirty. These issues were confirmed by the Food Service Director.
A resident receiving enteral nutrition had their feeding bag improperly labeled, missing critical information such as the resident's name, formula, infusion rate, and preparer's initials. This was confirmed by an LPN during an observation, indicating a failure to adhere to facility policy and physician orders.
The facility failed to ensure that three residents, who were severely cognitively impaired, had the capacity to understand and sign binding arbitration agreements. Despite facility policy requiring informed consent, a concierge relied on personal judgment rather than reviewing clinical records, leading to the signing of agreements by residents unable to make informed decisions.
A facility failed to follow its infection control policy by not using gowns during wound care for a resident with a stage four pressure ulcer. Despite the care plan requiring enhanced barrier precautions, two staff members only wore gloves, neglecting the use of gowns, which was confirmed by a nurse after the observation.
The facility failed to notify the Ombudsman of emergency transfers and discharges for four residents. These residents experienced various medical emergencies, including changes in mental status, elevated blood pressure, low blood sugar, and breathing difficulties, leading to hospital transfers. Documentation confirming notification to the Ombudsman was absent, as confirmed by the DON.
The facility failed to ensure that call bells were within reach for four residents, with some call bells being non-functional or incorrectly placed. Staff confirmed these issues, which violated the facility's policy on call light accessibility.
The facility failed to ensure complete and accurate documentation of wound care treatments for a resident. Missing entries on the Treatment Administration Record for specific dates indicated that the treatments were not completed or documented as required, despite physician's orders for detailed wound care procedures.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation of their property for three residents. One resident, who had diagnoses including hemiplegia, hemiparesis, and dementia, was found to have missing access, debit, and credit cards, with unauthorized purchases made using these cards. The incident was brought to the facility's attention by the resident's family. During the subsequent police investigation, an employee was identified as the perpetrator and was found in possession of fare cards belonging to two additional residents, both of whom had medical conditions such as muscle wasting, systemic lupus erythematosus, anemia, and lymphedema. These two residents were unaware that their cards were missing. Facility documentation and interviews confirmed that no other residents reported missing property or finances, and all interviewed residents stated they felt safe. The affected residents no longer resided at the facility at the time of the investigation. No further incidents or perpetrators were identified through facility or police investigation.
Failure to Implement Fall Prevention Interventions During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions for a resident with cerebral palsy, muscle weakness, and significant mobility impairments. The resident, who required extensive assistance with bed mobility and used a wheelchair, had a care plan in place specifying that the bed should be kept in the lowest position at all times except during care. Despite this, during a bathing routine, the nurse assistant left the resident unattended on the bed, which was not in the lowest position, while stepping away to request cream for skin care. As a result, the resident slid off the bed and struck her head on the nightstand, sustaining pain and injury. Interviews with staff confirmed that the bed was not lowered before the nurse assistant left the resident, contrary to the care plan and facility policy. The Director of Nursing acknowledged that the bed should have been lowered before the staff member left the resident unattended, as direct care was no longer being provided at that moment.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident who required staff assistance with personal hygiene and toileting due to orthopedic aftercare, muscle weakness, and an ADL self-care performance deficit. The incident occurred when a nurse aide refused to assist the resident with hygiene after toileting, despite the resident's inability to clean herself properly due to swollen legs. The resident, her roommate, and several staff members confirmed that the aide told the resident to clean herself and subsequently left the room, after which another aide was assigned to provide care. Following the incident, the facility initiated an investigation as required by policy, which mandates obtaining statements from all staff members who had contact with the resident during the period of the alleged incident. However, the investigation was incomplete, as written statements were not obtained from all relevant staff, including the social services assistant, a licensed nurse who interacted with the resident immediately after the incident, and the nurse aide who provided care following the event. The nursing supervisor and the Director of Nursing both confirmed that these statements were not collected, despite their involvement or presence during the incident. The deficiency was identified through review of facility policies, documentation, clinical records, and interviews with residents and staff. The failure to obtain comprehensive witness statements from all involved parties resulted in an incomplete investigation of the neglect allegation, contrary to the facility's own policies and regulatory requirements.
Failure to Maintain and Document PICC Line Care per Standards
Penalty
Summary
The facility failed to maintain intravenous (IV) devices in accordance with professional standards of practice for one resident who was admitted with a peripherally inserted central catheter (PICC) line. Upon admission, the resident's assessment did not include required measurements such as the total catheter length, external catheter length, or arm circumference, despite facility policy and physician orders mandating these assessments. The resident received antibiotic medication through the PICC line, and the dressing was observed to be peeling and dated prior to admission, indicating it had not been changed as required. Further review of the resident's clinical records, including medication administration records, progress notes, evaluations, and care plan, revealed no documentation of the PICC line external catheter length, total catheter length, or arm circumference at any time since admission. Physician orders specifically required documentation of these measurements and regular dressing changes, but these were not completed or recorded. Observations with the Director of Nursing confirmed that the PICC line dressing had not been changed since admission, and the required assessments and documentation were not performed.
Failure to Follow Infection Control Protocols for Precautions and Equipment
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols for two residents. For one resident colonized with a multi-drug resistant organism (CRE), both Enhanced Barrier Precautions and Contact Precautions were ordered and signage indicated the need for surgical masks, eye protection, gowns, and gloves during care. However, during a transfer using a hoyer lift, two staff members were observed wearing only gloves, despite acknowledging that gowns were also required. This was confirmed in interviews, where staff admitted to not following the full PPE requirements as outlined in facility policy and physician orders. In a separate incident, another resident with multiple pressure wounds and a physician order for a pressure-reducing air mattress was observed to have an air mattress placed directly on the floor without any protective covering. The mattress was being inflated in preparation for use, but was left exposed to potential contamination from dirt and debris. A licensed nurse confirmed the mattress was on the floor and uncovered at the time of observation.
Failure to Maintain Safe, Clean, and Homelike Environment for Two Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. One resident, who required total assistance for activities of daily living, enteral feeding, and used a urinary catheter, was observed in a room with a foul odor, two large bags of laundry at the door, and a floor soiled with food, crumbs, papers, and other personal items scattered around. The resident's roommate was observed lying on a bed with no sheets, and the room was cluttered and unsanitary. Staff interviews confirmed ongoing challenges in maintaining cleanliness due to the roommate's behaviors, including refusal of care and not allowing staff to touch his belongings. The second resident, who had intact cognition and a diagnosis of diabetes, exhibited ongoing behavior concerns related to cleanliness and unsanitary conditions. Nursing notes documented repeated incidents of the resident refusing personal care, using linen to clean himself after defecating, and keeping his environment cluttered with clothes, trash, and feces. Staff reported that despite multiple daily attempts to clean the room, the resident often refused assistance and quickly returned the room to an unsanitary state. Facility leadership confirmed the first resident's high risk for infection and the ongoing behavioral issues of the second resident.
Failure to Maintain Fire Alarm System
Penalty
Summary
The facility failed to maintain and inspect its fire alarm system as required by NFPA 101, NFPA 70, and NFPA 72 standards. During a document review on January 21, 2025, it was discovered that the facility could not provide documentation of a semi-annual visual fire alarm inspection within six months of December 12, 2024. This deficiency affects the entire facility, as confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
The documentation of the semiannual visual fire alarm inspection was missed. Annual was performed and semi-annual is scheduled. The Maintenance Director was in-serviced on ensuring that the semi-annual visual fire alarm inspection takes place every 6 months. The Maintenance Director has scheduled in TELs, our work order system, the testing of the semi-annual visual fire alarm inspection. The Maintenance Director will review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system as required, affecting the entire facility. During observations on January 21, 2025, between 9:38 a.m. and 9:42 a.m., it was noted that there was storage within 18 inches of a sprinkler in multiple locations. Specifically, at 9:38 a.m., storage was observed on the first floor in the storage room across from Occupational Therapy, and at 9:42 a.m., in the storage room across from the Elevator Machine Room. This condition was observed throughout the facility. An exit interview with the Administrator and the Maintenance Director confirmed the presence of storage within 18 inches of a sprinkler.
Plan Of Correction
The items in the storage room across from the occupational therapy gym and the elevator machine room that was within 18" of the ceiling has been removed. The facility has determined that storage in the facility have the potential to be affected. The Maintenance Director in-serviced staff on ensuring that nothing gets stored within 18" from the ceiling throughout the building. The Maintenance Director will conduct weekly audits of throughout the building weekly. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Maintain Emergency Generator and Inspect Electrical Systems
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which affected the entire facility. During a document review, it was found that the facility could not provide documentation for weekly battery voltage testing and monthly battery conductance testing. This lack of documentation was confirmed during an exit interview with the Administrator and the Maintenance Director. Additionally, an observation revealed that the remote generator annunciator panel at the Nurses' Station on the first floor had a Low Fuel alarm. This issue was also confirmed during the exit interview with the Administrator and the Maintenance Director. These deficiencies indicate a failure in maintaining the essential electrical systems as required by NFPA standards.
Plan Of Correction
The weekly battery voltage tests and monthly battery conductance testing were completed. The Maintenance Director was in-serviced on ensuring that the weekly battery voltage testing and the monthly battery conductance testing are completed accurately. The Maintenance Director will audit the accuracy and completion of the voltage testing. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Maintain Egress Doors Free from Obstructions
Penalty
Summary
The facility failed to maintain egress doors free from obstructions, affecting one of two floors. During observations conducted on January 21, 2025, between 9:54 a.m. and 10:05 a.m., it was noted that the emergency magnetic door release mechanisms were not functioning at three specific locations on the first floor. These locations included the stairwell doors across from resident rooms 131, 121, and 114. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:15 a.m. on the same day.
Plan Of Correction
The emergency magnetic door release at the stairwell door across from resident room 131, 121, and 114 are now fully functioning. The facility has determined that all emergency magnetic doors have the potential to be affected. The Maintenance Director was in-serviced on ensuring that the emergency magnetic doors are fully functioning. The Maintenance Director will monitor the emergency magnetic doors weekly. The Maintenance Director will review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.
Delayed Egress Door Malfunction
Penalty
Summary
The facility failed to maintain the functionality of delayed egress doors, which is a requirement for ensuring safe evacuation in case of emergencies. During an observation on January 21, 2025, it was noted that the delayed egress door located on the first floor, across from resident room 231, did not alarm or open as it should have. This deficiency was identified during a survey, indicating a lapse in the facility's adherence to the National Fire Protection Association (NFPA) 101 standards for egress doors. The issue was confirmed during an exit interview with the Administrator and the Maintenance Director, who acknowledged that the door failed to perform its intended function. This deficiency affects one of the two floors in the facility, potentially compromising the safety of residents and staff in the event of an emergency. The report does not provide details on any specific residents affected or any immediate consequences resulting from this deficiency.
Plan Of Correction
The delay egress door across from room 231 was fixed and is now functioning. The facility has determined that all egress doors have the potential to be affected. The Maintenance Director was in-serviced on ensuring that the egress doors alarm and open. The Maintenance Director will monitor the functioning of the egress doors weekly. The Maintenance Director will review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.
Obstructed Fire Extinguisher in Elevator Machine Room
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards. During an observation on January 21, 2025, at 9:40 a.m., it was noted that the portable fire extinguisher in the Elevator Machine Room on the first floor was obstructed by storage items. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at 10:15 a.m. on the same day.
Plan Of Correction
The portable fire extinguisher in the elevator room was unblock. The facility has determined that all fire extinguishers have the potential to be affected. The Maintenance Director in-serviced staff to ensure that the fire extinguishers in the building do not get blocked. The Maintenance Director will randomly audit the fire extinguishers throughout the building. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Non-compliance with NFPA 70 Due to Inadequate Clearance
Penalty
Summary
The facility failed to comply with NFPA 70, National Electric Code, regarding electrical wiring and equipment. During an observation on January 21, 2025, it was noted that there was storage within three feet of electrical panels in two locations on the first floor. Specifically, the storage was found in the storage room across from Occupational Therapy and in the Laundry Dryer Room. According to NFPA 70 110.26(A)(1), a clearance of three feet is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
The storage within three feet of the electrical panels across from the Occupational Therapy room and the laundry dryer room have been removed. The facility has determined that all electrical panels in the building have the potential to be affected. The Maintenance Director has in-serviced the staff to ensure that storage remains three feet from the electrical panels throughout the building. The Maintenance Director will randomly audit electrical panels throughout the building weekly. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Deficiency in Emergency Preparedness Plan Documentation
Penalty
Summary
The facility was found to be deficient in its emergency preparedness plan, specifically lacking policy and procedure documentation regarding the role of the Ambulatory Surgical Center under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficiency affects the entire facility as it pertains to the provision of care and treatment at an alternate care site identified by emergency management officials. During a document review on January 21, 2025, it was revealed that the facility could not provide the necessary documentation for their Emergency Preparedness Plan concerning the roles under a waiver declared by the Secretary. An exit interview with the Administrator and the Maintenance Director confirmed the absence of this critical documentation.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. The Emergency Prepared Plan policy and procedure documentation concerning the Roles under a Waiver Declared by Secretary was located and placed in the Emergency Prepared Plan. The Maintenance Director was in-serviced on ensuring that the Emergency Prepared Plan is complete and updated. The Maintenance Director will monitor and review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for Resident R79, as evidenced by persistent offensive odors and unclean conditions in the resident's room. Resident R79, who was admitted to the facility with severe cognitive impairment and multiple medical conditions including anoxic brain damage, pressure ulcers, heart failure, and respiratory failure, was dependent on a feeding tube and required assistance with all activities of daily living. Observations revealed a strong odor of urine and bowel movement emanating from the resident's room, along with a foul sour odor near the resident's bed. Additionally, there was a large puddle of tube feeding formula on the floor and dried spillage on the feeding pole and oxygen concentrator. Despite initial cleaning efforts, the dried spillage on the medical equipment remained, and the foul odor persisted. Subsequent observations confirmed that the strong odors continued to be present in the hallway and the resident's room over several days. Interviews with the Director of Nursing and the Regional Director of Environmental Services corroborated the presence of the odors and the unclean state of the medical equipment. The facility's failure to address these issues resulted in a deficiency related to maintaining a clean and comfortable environment for the resident.
Plan Of Correction
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. Resident R79's room was thoroughly cleaned and disinfected. The room is free from offensive odor. A house-wide audit was performed of all resident rooms to ensure that rooms were free from offensive odors. Housekeeping staff will be in-serviced on ensuring that resident rooms are free from offensive odors. The Director of Nursing/Designee will conduct a random audit of five resident rooms weekly for four weeks and then monthly for three months. The audits will ensure that resident rooms are free from offensive odors. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Protect Residents from Narcotic Diversion
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically involving the diversion of narcotic medications for two residents. The facility's policy on controlled substances, which mandates strict procedures for handling, storing, and documenting narcotic medications, was not adhered to. The policy requires that only authorized personnel handle these substances, and that they be counted and documented accurately at each shift change. However, discrepancies in the narcotic count were discovered, indicating a failure to follow these procedures. For one resident, a physician's order for Oxycodone was not properly managed, as the narcotic count was correct during several shift changes, but later the medication and its documentation were found missing. The investigation revealed that a page from the narcotic book had been ripped out, and the medication was unaccounted for. Similarly, for another resident, 30 tablets of Oxycodone were delivered and counted correctly initially, but were later found missing during a shift change. Interviews with the Director of Nursing revealed that the staff did not follow the facility's policy on counting controlled substances, as they failed to reference the narcotic index during counts, leading to the oversight of missing narcotics. This deficiency was identified as past non-compliance, indicating that the facility had not ensured residents were free from misappropriation of their property, specifically regarding the handling of controlled substances.
Failure to Develop Diabetes Management Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with diabetes, which is a requirement according to their policy on Comprehensive Person-Centered Care Plans. The resident, who was admitted in February 2024, had a diagnosis of diabetes and required insulin injections. Despite having active physician orders for blood sugar monitoring and insulin administration, the facility did not create a care plan addressing the resident's diabetes management or their dependence on insulin medications. The deficiency was confirmed during an interview with a licensed nurse, who acknowledged that no care plan was developed for the resident's diabetes and insulin needs. This oversight was identified during a review of the resident's care plan, which lacked any mention of diabetes management, despite the resident's medical condition and treatment requirements.
Plan Of Correction
Residents R80's care plan was updated to reflect diabetes management. A house-wide audit was completed of all diabetic residents to ensure that they have a diabetic care plan in place. Licensed staff will be in-serviced on ensuring that residents have a comprehensive care plan related to diabetes management. The Director of Nursing/Designee will conduct a random audit of 5 residents with diabetes to ensure that a comprehensive care plan related to diabetes management has been developed. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Medication Safety Lapse for Resident
Penalty
Summary
The facility failed to maintain a safe environment for Resident R213 by leaving medication unattended on the resident's over-bed table on two separate occasions. During an initial tour, a pill was observed in a dose cup on the resident's table, which the resident refused to take due to concerns about increased urination. The following day, the same situation was observed, and the nurse, Employee E7, discarded the pill after the resident again refused it, citing the same reason. The nurse reported to the unit manager that the resident must have spit the pill out after initially taking it. Resident R213 was admitted with a diagnosis of non-ST-elevation myocardial infarction and was prescribed a regimen that included potassium chloride and a diuretic, among other medications. The unattended medication posed a risk as it could have been ingested by another resident, compromising the safety of the environment. The facility's administration confirmed that the medication should not have been left on the over-bed table, acknowledging the lapse in providing a safe environment for residents.
Plan Of Correction
The medication left on resident R213's over bed table was removed. A house-wide audit was completed to ensure that each resident's environment was safe related to medication being left on the residents' over bed table. Licensed staff will be in-serviced on ensuring that a safe environment is maintained related to medication being left on residents' over bed tables. The Director of Nursing/Designee will conduct a random audit of 5 residents' environments to ensure that a safe environment is maintained related to medication being left on an over bed table. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Medication Labeling Error During Administration
Penalty
Summary
The facility failed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional principles. This deficiency was identified during an observation of medication administration for a resident, where a licensed nurse administered a nasal spray labeled with another resident's name. The facility's policy on medication administration requires that medications be administered safely and as prescribed, with the individual administering the medication verifying the resident's identity and checking the label three times to ensure the right resident, medication, dosage, time, and method of administration. In this case, the nurse picked up a box labeled with the current resident's name and room number but administered a nasal spray bottle that had a typewritten label with a different resident's name. The nurse confirmed that the bottle used was incorrectly labeled with another resident's name. This incident involved a resident who was admitted with a diagnosis of Acute Sinusitis and had a physician's order for Fluticasone Propionate Nasal Suspension. The error was discovered during a medication administration observation, highlighting a failure in the facility's medication labeling and administration process.
Plan Of Correction
Resident R42's fluticasone propionate was placed in the correct box. House wide audit completed to ensure that medication were properly and accurately labeled in accordance with currently accepted professional principles. Licensed staff will be in-serviced to ensure that medications are properly and accurately labeled in accordance with currently accepted professional principles. The Director of Nursing/Designee will conduct a random audit of 5 residents' medications to ensure that they are properly and accurately labeled in accordance with currently accepted professional principles. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional principles. During an observation of medication administration, it was found that a nurse administered a nasal spray to a resident using a bottle labeled with another resident's name. Specifically, the bottle of Fluticasone nasal spray used for Resident R42 was labeled with Resident R78's name, despite being administered to Resident R42. This discrepancy was confirmed during an interview with the nurse at the time of the observation. Resident R42 was admitted to the facility with a diagnosis of acute sinusitis and had a physician's order for Fluticasone Propionate Nasal Suspension for allergy relief. Resident R78, who had been discharged from the facility, had a similar order for the same medication, which was discontinued upon discharge. The facility's policy requires that medications be administered safely and as prescribed, with verification of the resident's identity and medication label checks. However, these procedures were not followed, leading to the administration of medication with incorrect labeling.
Plan Of Correction
Resident R42's fluticasone propionate was placed in the correct box. A house-wide audit was completed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional standards. Licensed staff will be in-serviced to ensure that medications are properly and accurately labeled in accordance with currently accepted professional principles. The Director of Nursing/Designee will conduct a random audit of 5 residents' medications to ensure that they are properly and accurately labeled in accordance with currently accepted professional principles. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, several deficiencies were observed. In the walk-in freezer, two cardboard boxes of bread were found sitting directly on the floor. In the dish room area, there was standing water on the floor due to a clogged floor drain, and dietary staff were using a shop vacuum to collect the water. The under-table shelves in the prep and cooks area were visibly dirty with dust and crumbs, and the tray slides under the coffee urn were stained with dark brown liquid. The inside of the convection oven had dark black burned-on food substances on all surfaces, and the plate heater had dirt and crumbs on the inside surfaces where clean plates are stacked. These findings were confirmed by the Food Service Director during an interview.
Plan Of Correction
The two cardboard boxes of bread were removed from the floor. The standing water from the dish room area was removed and a plan has been put into place to fix the floor drain. The under-table shelves and floors in the prep area and cooks' area was cleaned and disinfected. The tray slides under the coffee urn were cleaned and disinfected. The surfaces on the inside of the convection oven were cleaned. The inside surfaces of the plate heater was cleaned. Full audit of the kitchen was completed. Variances addressed as needed. Dietary staff will be in-serviced on ensuring that food is stored, prepared, distributed, and served in accordance with professional standards for food service safety. The Director of Nursing/Designee will conduct five random audits of the walk-in freezer, dish room area, under-table shelves, floor, tray slides, convection oven, and plate heater to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Improper Labeling of Tube Feeding Bags
Penalty
Summary
The facility failed to ensure proper labeling of tube feeding bags for a resident, identified as Resident R79, who was receiving enteral nutrition. The resident, admitted to the facility in September 2023, had significant medical conditions including anoxic brain damage and dysphagia, necessitating the use of a feeding tube. According to the physician's orders, the resident was to receive Peptamen AF formula in 375 mL boluses four times daily, with specific instructions to change and label the feeding bag and administration set daily with the resident's name, date, time, and initials of the person preparing the feeding. During an observation on January 12, 2025, it was noted that the tube feeding bag in use for Resident R79 was only labeled with the date, lacking the resident's name, formula, infusion rate, and the preparer's initials. Employee E8, a licensed nurse, confirmed that the bag was not properly labeled according to the facility's policy and the physician's orders. This oversight in labeling could potentially lead to errors in the administration of the resident's nutritional support.
Plan Of Correction
Resident R79's tube feed label was updated. A house-wide audit of residents with tube feedings was completed to ensure that tube feedings were labeled properly. Licensed staff will be in-serviced to ensure that tube feedings are properly labeled. The Director of Nursing/Designee will conduct a random audit of five residents to ensure that tube feedings are properly labeled. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Ensure Residents' Capacity to Sign Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three residents. The facility's policy requires that residents or their representatives be informed of the nature and implications of binding arbitration agreements to make informed decisions. However, the facility did not adhere to this policy, as evidenced by the cases of three residents who were severely cognitively impaired and yet were noted to have verbally signed the agreements. These residents had diagnoses such as dementia, Alzheimer's Disease, and cognitive communication deficits, with BIMS scores indicating severe cognitive impairment. Employee E11, a concierge responsible for obtaining signatures on the arbitration agreements, did not review the residents' clinical records to assess their cognitive status. Instead, she relied on her personal judgment to determine if residents were capable of signing the agreements. This resulted in the signing of agreements by residents who were not capable of understanding them, as they were severely cognitively impaired and unable to make informed decisions. The facility's failure to ensure proper understanding and capacity before signing the agreements led to this deficiency.
Plan Of Correction
Resident R44, R41, and R72's binding arbitration agreements have been removed. A house-wide audit was completed to ensure that the residents who signed a binding arbitration agreement have the capacity to understand the terms of the agreement. The admission director and concierge will be in-serviced to ensure that residents have the capacity to understand the terms of a binding arbitration agreement before signing them. The Director of Nursing/Designee will conduct a random audit of five residents to ensure that they have the capacity to understand the terms of a binding arbitration agreement before signing them. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Implement Enhanced Barrier Precautions for Wound Care
Penalty
Summary
The facility failed to maintain effective infection control practices related to enhanced barrier precautions for a resident with a stage four pressure ulcer. The facility's policy on Enhanced Barrier Precautions, dated March 2024, requires the use of gowns and gloves during high-contact care activities, such as wound care, to prevent the transmission of multi-drug resistant organisms. However, during an observation on January 12, 2025, it was noted that two employees, a licensed nurse and a nurse aide, provided wound care to the resident's sacral wound while only wearing gloves, neglecting to wear gowns as required by the policy. The resident in question was admitted to the facility in September 2023 and had a diagnosis of a stage four pressure ulcer in the sacral region, which is the most severe stage of a pressure sore and has a high risk of infection. The resident's care plan, dated April 29, 2024, specified the need for enhanced barrier precautions, including the use of gloves and gowns during wound care. Despite this, the employees did not adhere to the required precautions, as confirmed by the licensed nurse during an interview following the observation.
Plan Of Correction
Employee E8 and E9 were rein-serviced on maintaining effective infection control practices related to enhanced barrier precautions. A house-wide audit was completed of residents with enhanced barrier precautions to ensure that staff were maintaining effective infection control practices related to enhanced barrier precautions. Staff members will be in-serviced to ensure that the facility maintains effective infection control practices related to enhanced barrier precautions. The Director of Nursing/Designee will conduct a random audit of five residents to ensure that staff are maintaining effective control practices related to enhanced barrier precautions. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
Failure to Notify Ombudsman of Emergency Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for four residents. Clinical record reviews revealed that Resident R2 experienced a change in mental status and was transferred to a hospital following a cardiologist's consultation. Resident R3 had elevated blood pressure and was unresponsive, leading to a hospital transfer. Resident R4 had low blood sugar, facial swelling, and difficulty swallowing, prompting a physician-ordered hospital transfer. Resident R6 experienced breathing difficulties and low oxygen levels, resulting in a hospital transfer. Both Residents R2 and R6 did not return and were discharged from the facility. Further investigation showed that there was no documentation available to confirm that the Ombudsman was notified of these emergency transfers and discharges. An interview with the Director of Nursing confirmed the absence of such documentation for the residents involved. This lack of notification is a violation of the facility's responsibility to inform the Ombudsman of such significant events, as required by the relevant state codes.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that residents' call bells were within reach, affecting four out of 25 residents observed. During an observation of the first and second-floor units, it was noted that a resident's call bell was hanging over her bedside table, making it inaccessible. Interviews with staff confirmed the observation. Another resident's call bell was found clipped to a bed but plugged into the wrong socket, and the call button was missing, rendering it non-functional. This issue was confirmed by both the resident and the unit manager, who acknowledged that the call bells for two residents were switched and that one was broken. Further observations revealed that another resident's call bell was also hanging over her bedside table and was not within reach. The unit manager confirmed this observation. The facility's policy on answering call lights emphasizes the importance of ensuring that call lights are plugged in and functioning at all times, which was not adhered to in these instances. The deficiencies were noted under the Pennsylvania Code for nursing services.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that Resident R1's medical records were complete and accurately documented regarding wound care treatments. The facility's policy on wound care documentation requires detailed recording of the type of wound care given, date and time, resident's position, name and title of the individual performing the care, changes in the resident's condition, assessment data, resident's tolerance, any complaints, refusal of treatment, and the signature and title of the person recording the data. However, the review of Resident R1's clinical records revealed missing documentation for wound care treatments on specific dates. Specifically, there were no nurse's initials entered on the Treatment Administration Record (TAR) for the evening shifts of December 15, 2023, December 22, 2023, and December 28, 2023, indicating that the treatments were not completed or documented as required. Resident R1 was admitted to the facility with diagnoses including Adult Failure to Thrive, Chronic Kidney Disease stage IV, Essential Hypertension, muscle wasting, and muscle weakness. The physician's orders for wound care included cleansing the sacrum with normal saline solution, applying Desitin and foam dressing, and using Dakins solution for wound care. Despite these orders, the facility's failure to document the wound care treatments accurately and completely on the specified dates constitutes a deficiency in maintaining proper medical records and safeguarding resident-identifiable information as per accepted professional standards.
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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