Quakertown Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Quakertown, Pennsylvania.
- Location
- 1020 South Main Street, Quakertown, Pennsylvania 18951
- CMS Provider Number
- 395405
- Inspections on file
- 20
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Quakertown Center during CMS and state inspections, most recent first.
A resident with a history of toe infection had a physician order for staff to clean both great toes and apply bacitracin ointment. On one occasion, the resident reported that the nurse did not perform this ordered treatment, and review of the Treatment Administration Record showed no documentation that the cleaning and ointment application were completed as prescribed, indicating a failure to follow physician orders for skin care.
The facility did not ensure that hot food was served at required temperatures on one nursing unit, contrary to its “Food Prep” policy that mandates hot foods be above 135°F and cold foods at or below 41°F. Several residents reported that their meals were often served cold. A test tray audit conducted after the last meal trays were delivered on the affected unit found that crunchy buttermilk chicken measured 126.5°F and green beans measured 132°F, and both items were cool to taste. The Dietary Manager acknowledged that hot foods should have been at least 135°F at the time of service, confirming noncompliance with facility policy and state regulatory requirements.
Surveyors found that the facility did not follow its own “Food Prep” policy requiring food temperatures to be recorded at the time of service and monitored during meal service. Review of the kitchen temperature logs showed no documented holding temperatures for breakfast and lunch to verify that food was maintained at safe internal temperatures. The Dietary Manager acknowledged that temperatures should have been recorded for these meals at the time of service but were not.
A resident and their representative were not provided with a reconciliation of all pre- and post-discharge medications at the time of a planned discharge. Despite a request from the representative for this information, the facility did not supply the required documentation, as confirmed by the Administrator.
The facility failed to maintain its fire alarm system components in operable condition. A fire alarm report noted that the FACP had broken acknowledge, silence, and reset buttons, and recommended a new panel. Verification of repair was not available during the survey, as confirmed in an exit interview with the Administrator and Maintenance Director.
The facility did not conduct the required annual 90-minute test for emergency lighting, as they could not provide documentation for the past 12 months. This deficiency was confirmed during an interview with the Administrator and Maintenance Director.
The facility did not maintain a hazardous area enclosure in the laundry room, affecting one of the five smoke compartments. Both doors were propped open with wedges, preventing them from closing and latching. This was confirmed during an exit interview with the Administrator and Maintenance Director.
A deficiency was identified in the facility's corridor door maintenance, specifically in the Ice Machine Room, where the door failed to latch properly, compromising its ability to resist smoke passage. This issue was confirmed by the Administrator and Maintenance Director during an exit conference.
The facility failed to ensure that smoke barrier doors were maintained to resist smoke passage in two of five smoke compartments. Observations revealed that the smoke doors outside the medical records area and outside a resident room did not close smoke tight when tested. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain a safe, clean, and comfortable environment, with deficiencies observed in multiple rooms. Issues included marred walls, missing closet doors, dust accumulation, broken tiles, and stained surfaces. These conditions were found across both the South Wing and North Wing, affecting the overall living conditions for residents.
A resident with bipolar disorder and heart failure experienced a significant weight gain and was on olanzapine, an antipsychotic medication. However, the MDS assessment inaccurately recorded the resident's weight and failed to acknowledge both the weight gain and the administration of the antipsychotic medication.
The facility failed to develop comprehensive care plans for two residents, as required by federal regulations. One resident with chronic kidney failure and another with epilepsy and rheumatoid arthritis had care area assessments indicating the need to address urinary incontinence. However, the quarterly MDS summaries showed frequent incontinence without any interventions documented in their care plans. The DON confirmed the absence of documented interventions for these care areas.
A facility failed to provide person-centered pain management for a resident with chronic conditions, as PRN pain medications lacked defined parameters for use. Despite orders for tramadol, ibuprofen, and acetaminophen, only tramadol was administered frequently without specific guidelines, while the other medications were not used. The DON confirmed the absence of necessary parameters, indicating a deviation from the facility's pain management policy.
A facility failed to complete pre-dialysis assessments for a resident with end-stage renal disease, as required by their policy. The resident, who had a physician's order for dialysis three times a week, did not have the necessary pre-dialysis communication forms completed on multiple occasions. This deficiency was confirmed by the DON.
The facility failed to ensure psychotropic medications were prescribed for specific diagnoses for two residents. One resident with Alzheimer's, anxiety, and stroke was given Seroquel for agitation without a documented diagnosis. Another resident with PTSD and depression was prescribed haloperidol and quetiapine for psychosis without evidence of a specific diagnosis. The DON confirmed the orders should have included specific diagnoses.
The facility failed to meet the required NA to resident ratios on several occasions. The day shift ratio of one NA per ten residents was not met, the evening shift ratio of one NA per eleven residents was not adhered to, and the night shift ratio of one NA per fifteen residents was also not maintained. These deficiencies were identified through a review of nursing schedules over a 21-day period.
The facility did not meet the required LPN to resident ratios on three occasions. On one day, the day and evening shifts were understaffed, lacking the mandated one LPN per 25 and 30 residents, respectively. Additionally, on another day, the night shift did not meet the required one LPN per 40 residents. These deficiencies were identified through a review of nursing schedules.
The facility did not meet the required minimum of 3.2 hours of direct resident care per day on three occasions, providing only 2.97 and 2.90 hours on specific days. This shortfall was identified during a review of nursing schedules over a 21-day period.
Failure to Perform Ordered Toe Skin Treatment and Document Care
Penalty
Summary
The facility failed to provide ordered skin treatment for a resident with a history of toe infection. Clinical record review showed that since November 4, 2025, the physician had ordered staff to clean both great toes and apply an antibacterial ointment (bacitracin). During an interview on January 30, 2026, the resident reported that on January 27, 2026, the nurse did not perform this ordered toe treatment. Review of the Treatment Administration Records for that date revealed no documented evidence that nursing staff completed the prescribed cleaning and bacitracin application to both great toes as ordered by the physician. This deficiency was cited under 28 Pa. Code 211.12(d)(5) related to nursing services.
Failure to Serve Hot Food at Required Temperatures on One Nursing Unit
Penalty
Summary
The facility failed to provide food at an appetizing and policy-compliant temperature on one of two nursing units (North Unit). Facility policy titled “Food Prep,” dated December 18, 2025, required that hot foods be served at temperatures greater than 135°F and cold foods at temperatures no greater than 41°F. During interviews conducted on January 10, 2026, between 11:40 a.m. and 12:00 p.m., three residents (Residents 1, 2, and 3) reported that their food was often served cold. A test tray audit performed on January 10, 2026, at 12:33 p.m., after the last resident meal tray had been served from the dining cart on the North Unit, showed that the crunchy buttermilk chicken was at 126.5°F and the green beans were at 132°F, and both items were cool to taste. During this observation, the Dietary Manager confirmed that hot food should have reached at least 135°F at the time of service, indicating that the food served did not meet the facility’s temperature standards, in violation of 28 Pa. Code 201.14(a) and 201.18(b)(3).
Failure to Record Food Holding Temperatures During Meal Service
Penalty
Summary
The facility failed to record food temperatures at the time of service in the main kitchen as required by its own policy and regulatory standards. The facility’s policy titled “Food Prep,” dated December 18, 2025, stated that food temperatures would be recorded at the time of service and monitored periodically during meal service. On review of the facility’s food temperature log on January 10, 2026, at 12:15 p.m., there was no documented evidence that holding food temperatures were obtained at the time of or during service for breakfast and lunch to ensure that food maintained safe internal temperatures. During this review period, the Dietary Manager confirmed in an interview that food temperatures should have been recorded for breakfast and lunch at the time of service, but they were not.
Failure to Provide Medication Reconciliation at Discharge
Penalty
Summary
The facility failed to provide a resident and/or the resident's representative with a reconciliation of all pre- and post-discharge medications at the time of a planned discharge. Clinical record review showed that the resident was discharged without documented evidence that this medication reconciliation was given. Additionally, the resident's representative specifically requested the medication reconciliation after the discharge, but it was not provided at that time. The Administrator confirmed in an interview that the required reconciliation was not given to the resident or their representative at discharge.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on February 10, 2025, it was discovered that a fire alarm report dated January 15, 2025, included an inspector's comment noting that the Fire Alarm Control Panel (FACP) had broken acknowledge, silence, and reset buttons, and recommended a new panel. During an exit interview with the Administrator and the Maintenance Director, it was confirmed that verification of the repair was not available at the time of the survey.
Plan Of Correction
1) The facility will contact vendors for quotes on repairs to the panel. 2) A time limited waiver was submitted for repairs to the panel. 3) The facility will make repairs to the panel.
Failure to Conduct Annual Emergency Lighting Test
Penalty
Summary
The facility failed to ensure that emergency lighting was tested annually, as required by NFPA 101 standards. During a document review on February 10, 2025, it was found that the facility could not provide documentation of a 90-minute annual test for their emergency lighting over the past 12 months. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1) Maintenance was able to find paperwork after the audit was completed. 2) Maintenance was educated on how to find Emergency Lighting documentation. 3) Maintenance will audit the online monitoring system weekly to monitor regulatory tasks three times a week for 8 weeks, then monthly x2. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
Failure to Maintain Hazardous Area Enclosure in Laundry Room
Penalty
Summary
The facility failed to maintain a hazardous area enclosure, specifically in the laundry room, which affected one of the five smoke compartments in the facility. During an observation on February 10, 2025, at 11:00 a.m., it was noted that both doors of the laundry room were propped open with door wedges, preventing them from closing and latching as required. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 1:15 p.m.
Plan Of Correction
1) Laundry doors were closed and door wedges were removed. 2) Staff were educated that door wedges are not to be used in the facility. 3) Laundry rooms will be audited three times a week for 8 weeks, then monthly for two months. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
Corridor Door Latching Deficiency
Penalty
Summary
The facility was found to have a deficiency related to the maintenance of corridor doors, specifically in one of its five smoke compartments. During an observation conducted on February 10, 2025, at 11:45 a.m., it was noted that the door to the Ice Machine Room failed to latch properly. This failure to latch compromises the door's ability to resist the passage of smoke, which is a requirement for corridor doors in such facilities. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director on the same day at 1:15 p.m. The inability of the door to latch was acknowledged by the facility's representatives, indicating a lapse in maintaining the required safety standards for corridor doors. This issue affects the facility's compliance with regulations designed to ensure the safety and protection of residents and staff from smoke in the event of a fire.
Plan Of Correction
1) Parts were ordered for the door latch in the Ice Machine Room. 2) Maintenance will replace the latch when the part is received. 3) The maintenance director or designee will perform random weekly audits for 8 weeks, then monthly for two months, as part of a preventive maintenance plan to ensure corridor doors do not have problems closing. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
Smoke Barrier Doors Failed to Close Smoke Tight
Penalty
Summary
The facility failed to maintain doors in smoke barrier walls to resist the passage of smoke in two of five smoke compartments. During an observation on February 10, 2025, it was noted that the smoke doors outside the medical records area and outside resident room 147 did not close smoke tight when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1) The facility contacted an outside vendor for repair quotes on fire doors. 2) The facility will have outside vendor make repairs and a timed limited waiver was submitted for repairs to the panel. 3) The maintenance director or designee will perform weekly audits for 8 weeks, then monthly for two months, as part of a preventive maintenance plan to ensure corridor doors do not have problems closing. Results of the audit will be presented at the monthly QAPI meetings for review and or recommendations.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents on both the South Wing and North Wing. Observations revealed multiple deficiencies across various rooms. In room 120, the walls were heavily marred, while room 121 had marred walls and a closet missing both doors. Room 123 also had a closet missing both doors. In room 125 bed H, a fan was found with a heavy accumulation of dust and dirt. Room 127's bathroom had a broken floor tile in front of the toilet and a water-stained ceiling tile. Room 129 and room 131 had heavily marred walls, with room 131 also having a large hole in the drywall and a water-stained ceiling tile in the bathroom. Additional issues were noted in other rooms: room 133 had a windowsill covered with dirt and debris, and the wallpaper was peeling behind bed W. Room 134 bed W had a broken dresser drawer handle. Room 135's ptac unit contained debris and dirt, and the bathroom floor was buckled. In room 137 bed W, a solid black thick substance was splattered on the floor. Room 98's bathroom had a brown stain along the bottom molding and a black-stained floor tile. Room 116 had an accumulation of dust in the window corner and on the curtain. Lastly, room 109 had a layer of floor material lifted away from the base in the entryway.
Plan Of Correction
1. The fan in room 125, bed H, has been cleaned and dusted by the housekeeping staff. Housekeeping staff also cleaned the windowsill in room 133, the PTAC unit (ductless air conditioning unit) in room 135, the solid black substance in room 137, bed W, and the dust on the window and curtain in room 116. Room 123 had the closet doors replaced. Room 134 bed W the dresser drawer handle was repaired. Room 127 had the tile repaired and the ceiling tile replaced. Room 131 had the ceiling tile replaced. Room 133 had the wallpaper reglued to the wall. Rooms 120, 121, 129, and 131 will have marred walls repaired. Room 131 will have the hole repaired. Room 135 will have the bathroom floor redone. Room 98's bathroom wall and floor will be repaired. Room 109's floor will be replaced in the area that was lifted away from the base. 2. The maintenance director and housekeeping director will conduct a building wide audit of walls, closet doors, floors and furniture for areas of repair needed. 3. The housekeeping director will reeducate housekeeping staff on maintaining standards of cleanliness of the building. 4. Maintenance director and Housekeeping director will conduct weekly audits of walls, closet doors, floors, and furniture in resident rooms for areas that need repaired x 8 weeks, then monthly x2. Audits will be reviewed at the QAPI meeting for review or recommendations.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident diagnosed with bipolar disorder and heart failure. The resident experienced a significant weight gain of 13.9% over six months, increasing from 152.4 pounds to 173.6 pounds. Despite this, the MDS assessment dated November 8, 2024, inaccurately recorded the resident's weight as 146 pounds and failed to acknowledge the significant weight gain. Additionally, the assessment incorrectly indicated that the resident did not receive antipsychotic medication during the review period, despite records showing the resident had been receiving olanzapine since May 17, 2024.
Plan Of Correction
1. The MDS of Resident 7 was modified. 2. A house wide audit was conducted by CRC for residents with completed MDS for the past 30 days to verify accuracy of coding of antipsychotic medications and weights. 3. NPE or designee will re-educate the CRC on accurate coding of antipsychotic medications and weights on the MDS. Residents scheduled for MDS completion will be reviewed during clinical meeting to verify antipsychotic and weight accuracy. 4. CRC and/or designee will conduct weekly audits of MDS completed weekly x 8, then monthly x 2 to verify accuracy antipsychotic medications and weight documentation. Audits will be reviewed at the QAPI meeting for review or recommendations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as required by federal regulations. Resident 112, admitted with chronic kidney failure, had a care area assessment indicating the need to address urinary incontinence in the care plan. However, the quarterly MDS summary showed frequent urinary incontinence without any interventions documented in the care plan. Similarly, Resident 115, diagnosed with epilepsy and rheumatoid arthritis, also had a care area assessment noting the need to address urinary incontinence. The quarterly MDS summary confirmed frequent incontinence, yet no interventions were included in the care plan. In an interview, the Director of Nursing confirmed the absence of documented interventions for the identified care areas in the residents' care plans. This deficiency was previously cited in March 2024, indicating a recurring issue with the facility's compliance in developing and implementing comprehensive care plans that address individual resident needs as identified in their comprehensive assessments.
Plan Of Correction
1. The care plans of Residents 112 and 115 were updated to reflect urinary incontinence. 2. Current residents identified with incontinence on the most recent MDS have been reviewed to verify incontinence needs are addressed in the care plan. 3. NPE or designee will reinservice licensed nursing staff on the process for developing care plans that address the individual resident needs as it relates to incontinence. 4. DON and/or designee will conduct weekly audits x 8, then monthly x 2 of residents identified with urinary incontinence to verify a care plan is in place. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Failure in Person-Centered Pain Management
Penalty
Summary
The facility failed to provide person-centered pain management consistent with professional standards of practice for a resident with chronic venous insufficiency, lymphedema, and Parkinson's disease. The facility's policy required that PRN (as needed) pain medications have defined parameters for use, but this was not adhered to. The resident had physician's orders for tramadol, ibuprofen, and acetaminophen, all as needed for pain, but the orders for tramadol and ibuprofen lacked specific parameters for administration. Despite this, the resident received tramadol for mild or moderate pain on numerous occasions over a three-month period, while no doses of acetaminophen or ibuprofen were administered during this time. The Director of Nursing confirmed that the necessary parameters for the administration of PRN pain medication were not ordered, which is a deviation from the facility's pain management policy. This oversight was identified during a review of the clinical records and an interview with the Director of Nursing, highlighting a failure in the facility's pain management practices for the resident in question.
Plan Of Correction
1. The PRN pain medication orders for Resident 20 were updated to include parameters of usage. 2. Current residents with orders for PRN pain medications have been reviewed to verify defined parameters are ordered. 3. NPE or designee will re-inservice licensed nurses on ensuring that PRN medications have proper defined parameters for administration. Residents with new orders for PRN pain medications will be reviewed during clinical meeting to verify pain parameters are ordered. 4. DON and/or designee will conduct random audits weekly x 8, then monthly x 2 for all residents with PRN pain medications to ensure defined parameters are stated. Audits will be reviewed with the QAPI committee for any further actions or recommendations that may be necessary.
Failure to Complete Pre-Dialysis Assessment for Resident
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident receiving dialysis, as required by professional standards of practice and the resident's care plan. The facility's policy, titled "Dialysis: Hemodialysis- Communication and Documentation," mandates that staff complete the pre-dialysis portion of the Hemodialysis Communication Record to assess the resident's status before sending them to dialysis. However, a review of clinical records revealed that for one resident with end-stage renal disease and a physician's order for dialysis three times a week, the pre-dialysis communication forms were not completed on five out of 14 occasions over a one-month period. This deficiency was confirmed by the Director of Nursing during an interview.
Plan Of Correction
1. The facility is unable to correct the cited deficient practice for Resident 70 due to documentation was for an appointment that happened in the past. 2. Current residents receiving dialysis have been reviewed to verify completion of the pre-dialysis portion of the Hemodialysis Communication form. 3. NPE or designee will re-educate licensed nursing staff on completion of dialysis communication forms. Residents receiving dialysis will be reviewed during clinical meeting to verify completion of the hemodialysis communication forms. 4. DON and/or designee will conduct audits weekly x 8, then monthly x 2 for residents on dialysis to ensure communication forms are being completed. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Failure to Document Specific Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were prescribed for specific diagnoses for two residents. Resident 82, who had diagnoses including Alzheimer's disease, anxiety, and stroke, was prescribed the antipsychotic medication Seroquel for agitation without evidence supporting its use for a specific diagnosis. This lack of documentation indicates a failure to comply with the requirement that psychotropic drugs be used only when necessary to treat a specific condition as diagnosed and documented in the clinical record. Similarly, Resident 116, with diagnoses of PTSD and depression, was prescribed antipsychotic medications haloperidol and quetiapine for psychosis. However, there was no evidence to support that these medications were used to treat a specific diagnosis. The Director of Nursing confirmed that the antipsychotic medication orders should have included specific diagnoses, highlighting a deficiency in the facility's adherence to regulatory requirements for psychotropic drug prescriptions.
Plan Of Correction
1. The psychotropic medication orders for Residents 82 and 116 were reviewed by the provider for proper diagnosis. 2. Current residents receiving antipsychotic medications was conducted to verify the medications were prescribed for a specific diagnosis. Residents with new orders for anti-psychotic medications will be reviewed during clinical meeting to verify that the medication was prescribed for a specific diagnosis. 3. NPE or designee will re-inservice licensed nursing staff on ensuring that psychotropic medications have specific diagnosis for administration and usage. 4. DON and/or designee will conduct audits weekly x 8, then monthly x 2 for residents with antipsychotic medications to verify a proper diagnosis has been ordered. Results of the audits will be presented at the QAPI committee for review and/or recommendations.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on multiple occasions over a 21-day period. Specifically, the facility did not maintain the minimum ratio of one NA per ten residents during the day shift on February 2, 2025. Additionally, the evening shift ratio of one NA per eleven residents was not met on December 24 and 25, 2024. Furthermore, the night shift ratio of one NA per fifteen residents was not adhered to on December 25, 2024, January 5, 6, 7, and 11, 2025, and February 1 and 2, 2025. These deficiencies were identified through a review of nursing schedules, indicating a pattern of non-compliance with staffing regulations.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three separate occasions. On February 2, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not have the mandated one LPN per 25 residents. Additionally, on the same day during the evening shift from 3:00 p.m. to 11:00 p.m., the facility did not meet the required one LPN per 30 residents. Furthermore, on December 22, 2024, during the night shift from 11:00 p.m. to 7:00 a.m., the facility failed to maintain the minimum ratio of one LPN per 40 residents. These deficiencies were identified through a review of nursing schedules over a 21-day period.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Deficiency in Meeting Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules over a 21-day period. Specifically, on December 25, 2024, February 1, 2025, and February 2, 2025, the facility provided only 2.97, 2.97, and 2.90 care hours per resident, respectively. These findings indicate that the facility did not consistently meet the mandated staffing levels on these days, resulting in a shortfall in the required direct care hours for residents.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
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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