Quadrangle
Inspection history, citations, penalties and survey trends for this long-term care facility in Haverford, Pennsylvania.
- Location
- 3300 Darby Road, Haverford, Pennsylvania 19041
- CMS Provider Number
- 395801
- Inspections on file
- 20
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Quadrangle during CMS and state inspections, most recent first.
The facility did not maintain an effective infection control program, as required by policy, due to the absence of a qualified Infection Preventionist and lack of participation in QAPI meetings. Two residents requiring Enhanced Barrier Precautions for conditions such as a suprapubic catheter and UTI did not have access to necessary isolation supplies, including gowns and gloves, despite appropriate signage being posted.
The facility did not ensure that residents and their representatives could submit grievances anonymously, as required by its policy. Grievance boxes were missing from designated public areas, and the only available out-going basket was unmarked and inaccessible to wheelchair users. Most residents interviewed were unaware of where to submit grievances.
Surveyors found that food items, including ice cream, crab legs, croissants, and pastries, were not properly labeled, dated, or covered in the kitchen's storage areas, and that freezer units lacked thermometers to monitor food safety. These actions did not comply with the facility's food storage and safety policies.
Staff failed to properly dispose of garbage and refuse, resulting in various trash items, stagnant water, and grime accumulating around the trash compactor area. The Culinary Director, Director of Maintenance, and Nursing Home Administrator observed the presence of debris, strong odors, and unsanitary conditions in multiple locations near the compactors.
A resident was not provided with the required written notice of charges for skilled care services after Medicare A coverage ended, resulting in the resident or responsible party paying out-of-pocket without being properly informed of the costs or their options. The Social Services Coordinator confirmed that the necessary SNF ABN notice was not issued.
Two residents experienced substantiated abuse and neglect: one was denied a replacement dose of pain medication after a nurse dropped it and failed to report or document the incident, resulting in unmanaged severe pain; another was subjected to verbal complaints and inappropriate physical contact by a nurse's aide. Facility investigations confirmed both incidents.
A resident's discharge was documented in the clinical record as being to home with family, but the MDS assessment incorrectly recorded the discharge as to a short-term general hospital. The nurse assessment coordinator confirmed the inaccuracy in the MDS documentation.
Two residents did not have comprehensive care plans addressing pain management, foot care, or the use of compression stockings, despite physician orders and ongoing needs. One resident with a shoulder fracture lacked a pain management plan, while another with diabetes and edema did not receive ordered podiatry consultations or have foot care addressed in the care plan. Compression stockings were not applied as ordered, and concerns about their fit were not communicated to the physician.
Two residents did not receive care according to physician orders, including the application of compression stockings and timely completion of Doppler studies to rule out DVT. Staff did not notify the physician about issues with the fit of compression stockings or delays in diagnostic testing, and there was no documentation of additional precautions or communication regarding the urgency of the tests.
A resident with diabetes and neuropathy had multiple physician orders for podiatry consultations, including for missing toenails and nail clipping, but was not seen by a podiatrist. The resident reported repeated requests for podiatry care, and staff confirmed the lack of follow-up, with observations noting long, hard, yellowish toenails.
A resident with a complex urological history was readmitted to the facility with a Foley catheter in place, but staff failed to obtain a physician order for the indwelling catheter upon readmission. The DON confirmed the absence of an order despite the catheter being in use, resulting in a deficiency related to nursing service requirements.
A resident admitted for IV antibiotic therapy did not have their PICC line dressing changed or required measurements of catheter length and arm circumference performed as ordered and per facility policy. Observations and record review confirmed the dressing remained unchanged since admission, and the DON verified it was overdue.
A resident with chronic respiratory failure and hypoxia was observed receiving continuous oxygen therapy at 2L/min via nasal cannula, as documented in care plans and confirmed by staff and the resident. However, there was no physician order for the oxygen therapy, which was acknowledged by nursing staff and the DON.
Two licensed nurses administered IV antibiotics and performed PICC line flushes for a resident receiving IV therapy, but the facility could not provide documentation verifying that these nurses had been evaluated for IV administration competency.
The facility did not document the number of blister pack medication cards during shift-to-shift narcotic reconciliation for two medication carts on the second floor. Both licensed nurses and the DON confirmed that required card counts were not completed, resulting in incomplete controlled drug records.
Surveyors observed two residents for whom infection control protocols were not followed: one resident's urinary catheter bag was found lying on the floor, and another resident on contact precautions for C. diff had a staff member enter their room without PPE. Staff interviews confirmed these lapses in infection prevention practices.
A resident suffered burns after spilling hot tea on their lap due to the facility's failure to check the hot water temperature before serving. The dietary aide did not measure the temperature, which was required by the facility's protocol. The resident, who was cognitively intact and independent with eating, sustained blisters and redness on the thigh, necessitating medical treatment.
A resident was hospitalized after a medication error at an LTC facility, where they were given medications intended for another resident and missed their prescribed doses. The error was discovered following the resident's medical emergency and subsequent hospital transfer. The facility's ADON acknowledged the mistake.
The facility failed to follow food safety protocols, as a cook used a white cutting board for both vegetables and raw ground beef, and a dietary aide handled raw crab cakes without gloves. Additionally, opened food items in storage lacked proper labeling with use-by dates, violating the facility's policy for food handling and storage.
The facility was found to have improper garbage disposal practices, with dumpsters left open and dirty plastics scattered around them. The area around the loading dock was also littered with cigarette butts. These issues were confirmed by the Food Service Director.
A resident sustained a hematoma on her forehead after her head hit a guard rail during a transfer by a nurse aide. The facility's investigation was incomplete, as it focused only on the nurse aide involved and did not include statements or interviews from other staff who provided care to the resident prior to the injury.
A facility failed to notify a resident's representative of hospital transfers and the reasons for these transfers in writing and in a language and manner they understood. The resident was transferred to the hospital on three occasions for febrile symptoms, systemic anemia, and acute kidney injury. Interviews with facility staff confirmed the lack of notification and the absence of a system to ensure such notifications.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy during multiple hospital transfers. The resident was transferred due to medical conditions such as fever, systemic anemia, and acute kidney injury. Interviews confirmed the absence of a system to ensure the provision of bed-hold policy information, including details on duration, payment, and return conditions.
The facility failed to monitor and document nutritional interventions for two residents, leading to deficiencies in maintaining their nutritional status. One resident experienced continual weight loss without documented supplement intake, while another resident with Crohn's disease had no recorded consumption of fortified pudding, as required by facility policy.
The facility failed to ensure nursing staff had the necessary competencies for medication and IV administration, leading to errors by two employees. One resident received incorrect medications, resulting in hospitalization, while another received improper IV fluid administration. The facility lacked evidence of staff competency in these areas.
Two residents in an LTC facility experienced significant medication errors. One resident was given medications without physician orders, leading to hospitalization, while another received Carvedilol despite low blood pressure. An LPN also improperly administered saline flushes. The DON confirmed these errors.
The facility did not ensure the Medical Director or a designated physician attended the QAPI Committee meetings for three months. A review of meeting sign-in sheets from January to April 2024 showed no evidence of their attendance, confirmed by the administrator. This was a violation of specific regulatory codes.
Failure to Maintain Effective Infection Control Program and Transmission Based Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically regarding Transmission Based Precautions for two residents. Facility policy requires a qualified Infection Preventionist (IP) to be present at least part-time, participate in the Quality Assessment and Assurance committee, and oversee the infection prevention and control program. However, interviews with the Director of Nursing and Nursing Home Administrator revealed that there was no IP currently in the building, and the facility relied on a regional RN who only visited a couple of times a month. Documentation showed the IP had not attended recent QAPI meetings and had not been present in the facility since early August, despite a high frequency of infections noted in the facility assessment. Clinical record reviews for two residents showed both required Enhanced Barrier Precautions due to conditions such as a suprapubic catheter and urinary tract infection. Observations found that while signage for Enhanced Barrier Precautions was posted on their room doors, the isolation supply bins outside their rooms lacked necessary equipment, including gowns and gloves. A registered nurse confirmed the absence of required isolation supplies, indicating a failure to implement proper infection control measures as outlined in facility policy.
Failure to Provide Accessible and Anonymous Grievance Submission
Penalty
Summary
The facility failed to ensure that residents and their representatives could file grievances or concerns anonymously, as required by their own grievance policy. The policy stated that grievance forms were available in several public areas and that completed forms could be anonymously delivered to an out-going box outside the Activities Room on the second floor. However, observations revealed that there were no grievance boxes present in the public areas of either the first or second floors, including outside the Activities Room. Instead, the only available out-going wall basket was located outside the social worker's office, mounted at a height inaccessible to residents in wheelchairs and lacking any identifying label. Interviews with staff confirmed the absence of grievance boxes in the designated areas, and the social worker reported that she typically completed grievance forms on behalf of residents. Additionally, interviews with five randomly selected residents revealed that most were unaware of the location of the grievance box, with only one resident recalling that the information was provided upon admission. These findings demonstrate that the facility did not provide residents and their representatives with a clear, accessible, and anonymous method to submit grievances, as outlined in their policy.
Failure to Store and Label Food According to Professional Standards
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an inspection of the 3rd floor kitchen, it was found that two ice cream freezer units lacked thermometers, making it impossible to determine the temperature of the stored ice cream. Additionally, several food items in the walk-in freezer, including various flavors of ice cream, crab legs, croissants, and apple pastries, were found either undated, improperly covered, or lacking expiration dates. Some ice cream containers had torn or ill-fitting lids, and one lid was saturated with a red-colored substance. Items were not consistently labeled with opening or expiration dates as required by facility policy. The facility's policy, revised in April 2022, requires all food items to be labeled, dated, and rotated using a First In First Out system, and mandates that all storage areas be equipped with properly calibrated thermometers. The observed deficiencies indicate that these procedures were not followed, as evidenced by the lack of proper labeling, dating, and temperature monitoring in multiple food storage areas. No information about residents or their conditions was provided in the report.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Facility staff failed to properly dispose of garbage and refuse, as observed during a tour of the trash compactor area near the loading dock receiving area. Observations made in the presence of the Culinary Director, Director of Maintenance, and Nursing Home Administrator revealed various trash items, including jar tops, cans, sugar packets, bottles, cardboard boxes, fall leaves, a dinner plate, and other debris scattered around the sides, front, back, and underneath the trash compactors. Some trash had been present for so long that it had turned black, appeared moist, and was unidentifiable. Additional items observed included a Styrofoam food container filled with dark stagnant water, scattered papers, plastic gloves, a white towel, a cigarette butt, and a clear plastic bag containing stagnant black water. The area also had a strong stench and visible grime on the ground surfaces surrounding the compactors. All parties listed were present for these observations.
Failure to Notify Resident of Financial Liability After Medicare Coverage Ended
Penalty
Summary
The facility failed to inform a resident or the resident's responsible party of the charges for skilled care services that were not covered under Medicare. Clinical record review showed that the resident received a Notice of Medicare Non-Coverage (NOMNC) indicating the end of Medicare A coverage, with a last covered date specified. After this date, the resident remained in the facility and continued to receive skilled services, which were paid for out-of-pocket until discharge. Facility documentation revealed that the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), which details the costs of care and the option to elect those services, was not provided to the resident or responsible party. An interview with the Social Services Coordinator confirmed that the notice should have been issued but was not, resulting in the resident or responsible party not being properly informed of their financial liability for services after Medicare coverage ended.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by two substantiated incidents involving two residents. In the first case, a resident with osteomyelitis who was on pain medication therapy experienced severe pain after a nurse dropped his prescribed oxycodone tablet during administration. The nurse and a supervisor attempted to locate the lost pill but were unsuccessful. The nurse did not provide a replacement dose, failed to report the resident's ongoing pain or the missed medication to the oncoming shift or physician, and did not document the incident on the Medication Administration Record. The resident subsequently reported severe pain, and the facility's investigation concluded that the nurse was neglectful in managing the resident's pain needs. In the second incident, a resident reported that a nurse's aide verbally complained about having to provide care and, during the interaction, grabbed the resident's finger tightly for several seconds after the resident expressed his desire to recover and walk again. The facility's investigation substantiated the allegation of verbal abuse and inappropriate physical contact by the aide. The aide involved was no longer employed at the facility at the time of the investigation, and the Director of Nursing who conducted the investigation was also no longer available for interview. Both incidents were confirmed through review of facility policies, clinical records, documentation, and interviews with residents and staff. The facility's own investigations substantiated the findings of neglect and abuse, demonstrating a failure to ensure that residents were free from all forms of abuse and neglect as required by policy and regulation.
Inaccurate Completion of Discharge MDS Assessment
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one of three closed records reviewed. Clinical record review for a resident showed a Discharge Note indicating the resident was discharged home with family. However, the Discharge MDS assessment documented that the resident was discharged to a short-term general hospital. During an interview, the nurse assessment coordinator confirmed that the resident had indeed discharged home and acknowledged that the discharge MDS assessment was not completed accurately. This discrepancy between the clinical record and the MDS assessment demonstrates a failure to ensure the accuracy of resident assessments as required.
Failure to Develop Comprehensive Care Plans for Pain, Foot Care, and Compression Stockings
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing pain management, foot care, and the use of compression stockings for two residents. For one resident with a left shoulder fracture and a physician's order for pain medication, there was no care plan developed for pain management despite the resident's ongoing need for pain control. This omission was confirmed through review of the resident's care plan and staff interviews. Another resident with multiple diagnoses, including diabetes and edema, had several physician orders for podiatry consultations and foot care, including nail clipping and assessment for neuropathy. Despite these orders and the resident's repeated requests to see a podiatrist, there was no evidence in the clinical record that the consultations occurred, and the resident's toenails were observed to be long, hard, and yellowish. The care plan did not address foot care needs for this resident, as confirmed by staff. Additionally, the same resident had physician orders for the application and removal of compression stockings to manage edema and reduce the risk of circulatory complications. The treatment administration record showed that the compression stockings were not applied for nearly a month, with only one entry indicating the resident was unable to tolerate them and the rest of the days left blank. There was no care plan in place for the use of compression stockings, and staff confirmed that the physician was not notified about the resident's complaint regarding the fit of the stockings.
Failure to Follow Physician Orders and Notify Physician of Delays in Diagnostic Testing
Penalty
Summary
The facility failed to follow physician orders regarding the application of compression stockings and did not notify or clarify with the physician about issues related to the completion of ordered Doppler studies for two residents. One resident, who had a history of diabetes, hypertension, hyperlipidemia, sleep apnea, and morbid obesity, was ordered to wear compression stockings during the day and remove them at night. Despite these orders, the resident reported that the stockings provided were too small and uncomfortable, and the assigned nurse confirmed that the resident was unable to tolerate them. There was no evidence that the physician was notified about the resident's inability to wear the stockings or that alternative arrangements were made. The treatment administration record showed that the stockings were not applied for most of the month, with only one entry indicating the resident was unable to tolerate them and the rest left blank. Additionally, the same resident had a physician order for a venous Doppler study after reporting left calf pain, but the test was not completed until several days later. There was no documentation that the facility clarified with the physician whether the Doppler should be expedited due to the resident's symptoms. Similarly, another resident with diagnoses including diabetes, hypertension, repeated falls, and colon cancer was ordered to have a bilateral lower extremity Doppler to rule out DVT after presenting with edema, warmth, and erythema. Despite ongoing symptoms and pain, the Doppler study was delayed, and there was no evidence that the physician was contacted to discuss the timing of the test. Interviews with staff confirmed that there was no documentation of physician notification regarding the residents' inability to tolerate compression stockings or the delays in completing Doppler studies. The clinical records also did not show evidence of additional precautions for possible DVT or communication with the physician about the urgency of the Doppler studies. These findings indicate that the facility did not provide care and treatment in accordance with physician orders and failed to ensure timely communication with the physician regarding changes in residents' conditions.
Failure to Provide Ordered Podiatry Services
Penalty
Summary
A resident with a history of diabetes, hypertension, and hyperlipidemia was admitted to the facility for rehabilitation following a fall at home. The resident had multiple physician orders for podiatry consultations, including for missing toenails, neuropathy in both legs, and toenail clipping. Despite these orders, there was no evidence in the clinical record that the resident was seen by a podiatrist during their stay. The resident reported having requested podiatry services on several occasions without follow-up from the facility. Observations revealed that the resident's toenails were long, hard, and yellowish. Facility staff confirmed that the resident had not been seen by a podiatrist as ordered by the physician.
Failure to Obtain Physician Order for Indwelling Catheter Upon Readmission
Penalty
Summary
A deficiency was identified when a resident with a history of chronic urinary tract infection, chronic tubulo-interstitial nephritis, benign prostatic hypertrophy with lower urinary tract symptoms, bladder neck obstructions, and a urogenital implant was readmitted to the facility following a hospital stay. Upon readmission, the resident had an indwelling Foley catheter in place, as documented in the service evaluation and health assessment. However, a review of the clinical record revealed that there was no physician order for the indwelling Foley catheter upon the resident's return to the facility. Observations confirmed that the resident had a Foley catheter and urine collection bag in use after readmission, but staff interviews and record reviews verified the absence of a corresponding physician order for the catheter. The Director of Nursing Services confirmed that the resident had a Foley catheter without an active order following readmission. This failure to obtain a physician order for the indwelling catheter constituted noncompliance with nursing service regulations.
Failure to Maintain and Monitor PICC Line for Resident Receiving IV Therapy
Penalty
Summary
The facility failed to ensure that intravenous (IV) devices were maintained according to professional standards of practice for a resident receiving IV therapy. Facility policy required that the circumference of the upper arm and the external length of the peripherally inserted central catheter (PICC) be measured at baseline, with each dressing change, and when clinically indicated. Additionally, the policy and physician orders specified that the IV dressing, caps, catheter length, and arm circumference should be checked and changed weekly, starting from the resident's admission. Review of the resident's clinical records, medication and treatment records, and progress notes revealed no documentation that the PICC dressing was changed or that the required measurements were performed at any time since admission. Observations confirmed that the PICC dressing was dated from the day before admission and had not been changed, as verified by both the resident and the Director of Nursing. The resident continued to receive IV antibiotics through the unchanged PICC line dressing.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a diagnosis of chronic respiratory failure with hypoxia was admitted to the facility and had a care plan in place for oxygen therapy related to chronic heart failure. Despite this, a review of the clinical record revealed that there was no physician's order for oxygen therapy. Documentation in the resident's daily skilled evaluation indicated that the resident was receiving continuous oxygen at 2 liters per minute via nasal cannula, and this was confirmed through both observation and staff interviews. The resident also reported ongoing use of oxygen. Further interviews with nursing staff and the Senior Director of Nursing Services confirmed that the resident was receiving oxygen therapy without a corresponding physician's order. The staff also described routine maintenance of the oxygen equipment, such as changing the tubing weekly. The lack of a physician's order for oxygen therapy constituted a failure to provide safe and appropriate respiratory care as required by regulation.
Lack of Documented IV Competency for Nursing Staff
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies and skill sets related to intravenous (IV) care for a resident with a peripherally inserted central catheter (PICC) line. Observations showed that a resident was receiving IV antibiotic therapy through a PICC line, with physician orders specifying administration of cefazolin every 12 hours and flushing of the IV line with normal saline every shift. Facility documentation confirmed that two licensed nurses administered the IV medication and performed the required flushes for this resident. However, upon review of facility records, there was no documentation available to verify that these two nurses had been evaluated for competency in IV administration. This lack of documented competency evaluation was confirmed by the regional nurse, who stated that the facility could not provide evidence of such assessments for the involved staff members.
Failure to Document Blister Pack Counts During Narcotic Reconciliation
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an account of all controlled drugs was periodically reconciled for two of three medication carts reviewed on the second floor nursing units A and C. According to the facility's policy, controlled medications are to be counted at the beginning and end of each shift by two authorized team members, with both the actual number of controlled medications and the number of unit-dose/blister pack medication cards verified and documented. However, observations revealed that the number of blister pack medication cards was not documented during the shift-to-shift narcotic medication reconciliation process for both medication carts. During interviews, licensed nurses responsible for the medication carts confirmed that the total count of medication cards was not documented as required. The Director of Nursing also confirmed that card counts were not completed during the reconciliation process for these units, acknowledging that this failure occurred. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Maintain Infection Control Precautions and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper management of contact precautions and urinary catheter care for two residents. For one resident with a history of chronic urinary tract infection and an indwelling Foley catheter, observation revealed that the urine collection bag was lying flat on the floor beneath the bed, with amber-colored liquid present in the tubing and bag. A licensed nurse confirmed the improper placement of the urine bag during the observation. For another resident with a diagnosis of malignant ascites and an active physician order for contact isolation precautions due to C. difficile infection, signage was posted on the resident's door instructing visitors to consult a nurse before entry. Despite this, a social worker was observed entering and exiting the resident's room without wearing any personal protective equipment (PPE). The social worker stated that PPE was only necessary when providing care and was unaware of the specific type of precaution in place until after consulting with a nurse, who confirmed the resident was on contact precautions for C. difficile.
Failure to Check Hot Water Temperature Results in Resident Burn
Penalty
Summary
The facility failed to ensure the hot water temperature was checked before serving it to a resident, resulting in actual harm. The incident involved a resident who was cognitively intact and independent with eating. After dinner, the resident was enjoying a cup of hot tea when it spilled onto their lap, causing a blister on the left upper and outer thigh. The facility's policy required hot beverages to be served at temperatures between 140 and 155 degrees Fahrenheit, but the temperature of the hot water provided to the resident was not checked by the dietary aide. The dietary aide, who served the hot beverage, admitted to not measuring the temperature of the hot water before serving it to the resident. The facility's protocol required the hot beverage temperature to be measured before being placed on the resident's tray, but this step was not followed. The dietary manager confirmed that the hot water provided to the resident had not been checked to verify if it was at a safe serving temperature. The incident was further compounded by the fact that the resident's meal was delivered directly to their room, and when the resident requested additional items like sugar or a tea bag, the dietary aide brought another cup of hot water without checking its temperature. This oversight led to the resident sustaining burns, with blisters and redness on the thigh, and required medical attention, including the application of Silvadene cream as prescribed by a physician.
Plan Of Correction
Resident R1 was immediately assessed by the charge nurse with first aide provided. Attending Physician was made aware. A new order was obtained for treatment to the area. A wound consultation was also ordered. The resident was noted as their own responsible party who was made aware of the treatment and consult orders. Resident R1 was discharged from the facility on 1.8.2025. No other residents were affected. Current residents have the potential to be affected. The dietary department will not serve hot liquids to residents that are outside the parameters of our policy regarding safe holding and serving temperatures for hot beverages. Hot beverage air pots without temperature indicators were removed from the units, and a Keurig coffee maker was removed from the unit. The Dietary Manager educated the dietary team members on the importance of completing and documenting temperatures of hot beverages prior to serving during each meal to ensure serving temperatures are within acceptable range. Hot temperature logs will be monitored by the Dietary Manager or designee daily for one month, followed by weekly for two months to ensure compliance. Non-compliance will be reported to the Administrator for follow-up. Findings will be submitted to the QAPI committee monthly, for three months for review. The committee will determine if further audits and/or actions are required. The Administrator is responsible for ensuring implementation of and ongoing compliance with this plan of correction and addressing and resolving variances as they may occur.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, as evidenced by an incident involving a resident, referred to as Resident R3. Upon admission, Resident R3's medications were incorrectly entered into the system by the Assistant Director of Nursing (ADON), resulting in the administration of medications intended for another resident. Specifically, Resident R3 was given gabapentin and melatonin, which were not prescribed for them, while their prescribed medications, including aspirin, Eliquis, atorvastatin, metoprolol tartrate, mirtazapine, and senna, were not administered. This error was discovered after Resident R3 experienced a medical emergency and was transferred to the hospital, where the discrepancy in medication records was identified. Resident R3 had a medical history that included COVID-19, pneumonitis, hypothyroidism, and hypertension. Upon admission to the hospital, Resident R3 was found to have shortness of breath, respiratory acidosis, and pleural effusion, and was diagnosed with sepsis due to COVID-19. The facility's Director of Nursing confirmed the medication error, and the ADON acknowledged responsibility for the mistake. The resident's family was informed, and it was noted that Resident R3 did not have a history of allergies to the medications they were incorrectly given.
Plan Of Correction
Resident R3 no longer resides in the facility. Resident R4's medications were reconciled by the Director of Nursing and noted with correctly prescribed medications. The attending physician reviewed the medications and validated accurate transcription. Current residents have the potential to be affected. An audit was completed by the consultant pharmacist with no transcription errors noted. The nurse who made the transcription error was educated by the Director of Nursing on the medication administration policy and the error during one-on-one counselling. Licensed nurses will be educated by the Director of Nursing (or designee) on the medication administration policy. The Director of Nursing will monitor admission orders daily for one (1) month followed by weekly for two (2) months to ensure compliance. Findings will be submitted to the QAPI committee monthly for three (3) months for review. The committee will determine if further audits/actions are required. The Administrator is responsible for ensuring implementation of and ongoing compliance with this plan of correction and addressing and resolving variances as they may occur.
Food Safety Protocols Not Followed
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a tour of the Food Service Department. The facility's policy requires the use of color-coded cutting boards for different food types, with red designated for raw meat and white for processed items. However, a cook was observed using a white cutting board for both vegetables and raw ground beef, violating the policy. Additionally, a dietary aide was seen handling raw crab cakes without wearing disposable gloves, further compromising food safety protocols. In the pantry and main refrigerator, opened food items such as cheeses, cut pineapple, and pulled raw meat were found with only a single date, lacking the required use-by date. The Food Service Director confirmed that all items should be labeled with a date upon delivery and, if opened, should be wrapped, labeled, and dated with both an open date and an expiration date. Prepared food should also be labeled with an expiration date of 72 hours after preparation. These lapses in food labeling and handling practices indicate a failure to maintain a proper system of First In First Out (FIFO) rotation, as required by the facility's policy.
Improper Garbage Disposal and Littering
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed in the receiving area. Five dumpsters were found with their lids open, exposing their contents, and dirty plastics were scattered around the dumpsters. Additionally, the ground surrounding the loading dock was littered with hundreds of cigarette butts. These observations were confirmed during an interview with the Food Service Director.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an alleged violation involving an unknown source of injury for a resident. The incident involved a nurse aide transferring the resident, during which the resident's head hit the guard rail, resulting in a hematoma on the right side of her forehead. The resident was subsequently sent to the hospital for further assessment. The facility's investigation included a statement from the nurse aide, Employee E13, who claimed that no incident occurred during her care and that the resident did not complain of any pain or incident. However, the hospital record indicated that the resident stated the injury occurred during a transfer by a nurse aide. The investigation was incomplete as the facility did not obtain statements or conduct interviews with other staff who provided care to the resident prior to the injury. The Administrator confirmed that the investigation focused solely on Employee E13, despite the resident alleging the injury occurred during a transfer from a previous shift. The Administrator also acknowledged that no other staff members were interviewed or provided statements regarding the care of the resident before the injury occurred.
Failure to Notify Resident's Representative of Hospital Transfers
Penalty
Summary
The facility failed to notify a resident and the resident's representative of hospital transfers and the reasons for these transfers in a timely manner, in writing, and in a language and manner they understood. This deficiency was identified for one resident, who was transferred to the hospital on three separate occasions for different medical conditions: febrile symptoms, systemic anemia, and acute kidney injury. Upon review of the clinical records, there was no evidence that the resident's representative was informed of these transfers in writing. Interviews with the Nursing Home Administrator, Director of Nursing, and Social Worker confirmed the lack of notification and the absence of a system to ensure such notifications were made prior to resident transfer or discharge.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident and their representative during multiple facility-initiated transfers to the hospital. Specifically, Resident R52 was transferred to the hospital on three separate occasions due to medical conditions including fever, systemic anemia, and acute kidney injury. However, there was no documented evidence that the resident or their representative received written notice of the facility's bed-hold policy at the time of these transfers. Interviews with the Nursing Home Administrator, Director of Nursing, and Social Worker confirmed that the facility did not provide the required bed-hold policy information, which should include details about the duration of the bed-hold, bed hold reserve payment, and the conditions for returning to a bed at the facility. Additionally, it was confirmed that there was no system in place to ensure that residents and their representatives received this information during facility-initiated transfers to the hospital.
Failure to Monitor and Document Nutritional Interventions
Penalty
Summary
The facility failed to adequately monitor and document the nutritional interventions for two residents, leading to deficiencies in maintaining their nutritional status. Resident R44, who was admitted with diagnoses including fracture and muscle weakness, experienced continual weight loss. Despite a physician's order for Boost Breeze supplement to be provided and recorded, there was no documentation of the resident's supplement intake for nutrition monitoring. This lack of documentation was confirmed by the Registered Dietitian, Employee E4. Similarly, Resident R55, who had a history of Crohn's disease and malnutrition, was eating approximately 50% of his meals. A physician's order for a fortified food program, specifically fortified pudding at lunch, was in place. However, the facility failed to document the amount of fortified pudding consumed by the resident, as required by their policy. This omission was also confirmed by the Registered Dietitian, Employee E4, indicating a failure to evaluate the resident's acceptance of the fortified food and overall nutrition intervention.
Nursing Staff Competency Deficiency in Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with intravenous line and medication administration. This deficiency was identified through the review of clinical records, facility documentation, and staff interviews. Specifically, two employees, E14 and E15, were involved in incidents that demonstrated a lack of competency. Employee E15 administered a medication error involving Sertraline and Lisinopril to a resident, which led to the resident being sent to the hospital for further evaluation. The facility could not provide evidence of Employee E15's competency in medication administration prior to the error. Additionally, Employee E14 administered intravenous fluids incorrectly to another resident, using normal saline flushes instead of following the physician's order for intravenous fluid administration at specified rates. The Director of Nursing confirmed that the nurse should have adhered to the physician's prescribed rate. The facility was unable to provide evidence of Employee E14's competency in intravenous medication administration. These incidents highlight the facility's failure to ensure that nursing staff had the necessary competencies to safely administer medications and intravenous treatments.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two of the five residents reviewed for medication administration. Resident R164 was mistakenly administered sertraline and lisinopril, medications for which there were no physician orders. This error led to the resident being sent to the hospital for further evaluation after the in-house nurse practitioner was unavailable. The Director of Nursing confirmed that the nurse did not follow appropriate medication administration practices and could not provide a reason for the error. Resident R167 was administered Carvedilol despite having a systolic blood pressure of 93, which was below the threshold specified in the physician's order. Additionally, the same nurse, Employee E14, made another error by administering 80 ml of normal saline flushes to Resident R38 within minutes, contrary to the physician's order for intravenous fluid administration at a specified rate. The Director of Nursing acknowledged these significant medication errors, emphasizing the nurse's failure to adhere to the prescribed administration rates.
Medical Director Absence at QAPI Meetings
Penalty
Summary
The facility failed to ensure the attendance of the Medical Director or a designated physician at the Quality Assurance Process Improvement (QAPI) Committee meetings for three consecutive months, from January 2024 through April 2024. This deficiency was identified through a review of the QAPI Committee meeting sign-in sheets, which showed no documented evidence of the Medical Director's presence, either virtually or in-person, during this period. An interview with the facility administrator on May 22, 2024, confirmed the absence of documentation proving the Medical Director's attendance at these meetings. This failure to comply with the regulatory requirement was noted under 28 Pa. Code 211.2(d)(5)(6)(7)(8)(10) and 28 Pa. Code 201.18 (e)(2)(3)(4).
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A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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