Rittenhouse Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- Penn Med Rittenhouse Campus 1800 Lombard St 5th Fl, Philadelphia, Pennsylvania 19104
- CMS Provider Number
- 395749
- Inspections on file
- 18
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Rittenhouse Post Acute during CMS and state inspections, most recent first.
A resident with diagnoses including convulsions and a prescription for seizure medication did not have a care plan addressing seizure management. Review of clinical records and staff interview confirmed that the care plan lacked goals and interventions for seizures, despite the resident's documented need.
A resident with a seizure disorder did not receive prescribed doses of Lamotrigine and Lacosamide because the facility's pharmacy failed to deliver the medications as ordered. The MAR and nursing documentation confirmed the missed doses, and the DON verified that the medications were unavailable due to pharmacy delivery issues, despite facility policy requiring 24/7 pharmacy services.
A resident with documented muscle weakness, abnormal gait, and a need for standby assist during ambulation was sent to an outside medical appointment without an escort, despite facility policy and care plan requirements. The resident, using a rolling walker, was left unsupervised after ambulance drop-off, tripped over a mat in the building lobby, and sustained a nasal fracture.
A resident who requested and was approved for an earlier discharge from Medicare Part A services was not provided with the required Notification of Medicare Non-Coverage. The staff member responsible confirmed that the notice was not given, despite being aware of the resident's change in discharge plans.
A resident with multiple chronic conditions and moderate cognitive impairment experienced significant weight loss, but the facility did not develop or implement a comprehensive care plan with measurable goals or interventions to address the weight loss or the resident's pescatarian dietary preferences. The care plan lacked individualized strategies and did not reflect the resident's nutritional needs, as confirmed by staff and policy review.
Two residents experienced significant unaddressed weight loss due to the facility's failure to monitor, reweigh, and update care plans or implement timely dietary interventions, despite clear indications of nutritional risk and documented weight changes.
Two residents with PTSD did not receive trauma-informed or culturally competent care as required. There was no documented assessment or care planning related to their PTSD, and no evidence that services were provided to address their diagnoses. A psychiatric evaluation for one resident also failed to mention or address PTSD.
A resident was found to be self-administering a magnesium supplement without a physician's order or assessment for self-administration. An LPN was unaware of the supplement use, and facility policy requiring prescriber orders for all medications was not followed, resulting in a significant medication error.
A resident's inhaler was found unsecured on an overbed table instead of in a locked compartment, and an open vial of tuberculin purified protein derivative in the medication room refrigerator was not dated. The DON confirmed both deficiencies, which were not in accordance with facility policy for medication storage and labeling.
The facility did not employ a qualified registered dietitian, as the individual in the role had not completed the required licensure exam and was working under supervision without proper credentials. This unlicensed dietitian was solely responsible for assessing and documenting a resident's significant weight loss, with no evidence of review or consultation by a licensed dietitian.
The facility's activities program was directed by a social worker who lacked the necessary qualifications. The social worker, responsible for overseeing the program, did not possess a license or registration as a qualified therapeutic recreation specialist or activity professional. Additionally, she lacked the required experience and training, and was unaware of the qualification requirements.
The facility failed to adhere to professional standards for food service safety. Observations revealed that the high temperature dishwasher had incorrect wash and rinse cycle temperatures, and expired food products were found in the dry storage area. The Dietary Director confirmed these issues and stated that the facility was addressing the inaccurate dishwasher readings.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for several residents with conditions requiring such measures, including open wounds and urinary catheters. Observations showed a lack of PPE use by staff during care, despite signs indicating EBPs were needed. Delays in ordering EBPs and interviews with staff confirmed the deficiency in infection control practices.
The facility did not notify the Office of the State LTC Ombudsman of emergency transfers as required. A resident was transferred to a hospital due to medical conditions, but the facility failed to provide evidence of notification. An employee confirmed that no notifications were made for any hospital transfers.
A facility failed to conduct a comprehensive pain assessment with direct observation and communication for a resident who had knee surgery. The MDS coordinator completed the assessment remotely, relying on documentation from other staff, leading to inaccuracies in the recorded pain levels and the resident's reported experience. This resulted in a failure to accurately reflect the resident's condition in the care plan.
A resident's pain assessment was inaccurately documented in the MDS, showing discrepancies between reported pain levels and actual documented pain. The assessment was completed remotely by an employee who did not directly interview the resident, leading to inaccurate documentation of the resident's pain experience.
The facility failed to provide a written summary of the baseline care plan to three residents, as required by policy. Interviews and record reviews confirmed that the residents did not receive documentation outlining their initial care goals, medications, dietary instructions, and services. The DON acknowledged this oversight, indicating a lapse in compliance with resident care policies.
A resident admitted after back surgery did not receive the ordered wound care, leading to an infection. The facility failed to clean and monitor the surgical incision as instructed by the hospital, resulting in the resident requiring antibiotics. The DON confirmed the lapse in care.
A resident did not receive prescribed medications due to unavailability from the pharmacy, as confirmed by the Director of Nursing. This failure to provide necessary pharmaceutical services was identified through a review of records and interviews.
The facility did not ensure the attendance of an Infection Preventionist at the quarterly QAPI meetings for four consecutive quarters. A review of meeting attendees lists for October 2023, January 2024, and April 2024 showed the absence of an Infection Preventionist, and no documentation was available for July 2024. This was confirmed by an interview with a clinical administrative staff member.
Failure to Develop Seizure Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing the diagnosis of seizures for one resident. Clinical record review showed that the resident had multiple diagnoses, including depression, back pain, convulsions, and cerebral infarction, and was prescribed medication for seizure management. Despite these documented conditions and treatments, the resident's person-centered care plan did not include any goals or interventions related to seizure care. This omission was confirmed by the Director of Nursing during an interview, who acknowledged that no care plan for seizures was in place for the resident.
Failure to Provide Timely Pharmacy Services for Seizure Medications
Penalty
Summary
The facility failed to ensure timely delivery and administration of prescribed seizure medications for a resident, as required by physician orders and facility policy. The resident had documented orders for Lamotrigine and Lacosamide to be administered at specific times for seizure management. On the evening of August 9, 2025, the resident did not receive the 9:00 p.m. doses of both Lamotrigine and Lacosamide because the medications were not delivered by the facility's pharmacy. This omission was confirmed by review of the Medication Administration Record (MAR) and a nursing note, which documented that the resident did not receive the prescribed seizure medications during the overnight shift. Facility policy, revised in April 2019, requires that pharmacy services be available 24/7 to ensure residents have a sufficient supply of prescribed medications and receive them in a timely manner. Despite this policy, the resident's seizure medications were not available for administration as ordered, and the DON confirmed the failure was due to the pharmacy not delivering the medications. The physician was notified of the missed doses, as documented in the nursing note.
Failure to Provide Required Supervision During Resident Transport Results in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who required supervision and assistance with ambulation was sent to an outside medical appointment without an escort, contrary to facility policy. The resident had a history of muscle weakness, abnormal gait, and impaired balance, as documented in clinical records and therapy assessments. The care plan and therapy evaluations consistently indicated the need for standby assistance during ambulation, especially on uneven surfaces and in community settings. On the day of the incident, the resident was transported by ambulance to a medical appointment. Upon arrival, the resident was dropped off in front of the building and proceeded to walk into the building unassisted, using a rolling walker. There was no staff member or family escort present to provide the required supervision. The resident subsequently tripped over a thick mat in the lobby, resulting in a fall and a fractured nasal bone. Facility policies reviewed in the report specified that residents requiring supervision should be accompanied by staff if family is unavailable, and that individualized safety interventions must be communicated and implemented. Despite these policies and the resident's documented need for supervision, the facility failed to provide an escort, leading to actual harm. Staff interviews confirmed the resident's ongoing need for standby assistance and the lack of supervision at the time of the fall.
Failure to Provide Notification of Medicare Non-Coverage Upon Early Discharge
Penalty
Summary
The facility failed to provide a Notification of Medicare Non-Coverage (NOMNC) to a resident who was being discharged from Medicare Part A services. Documentation review showed no evidence that the NOMNC was given to the resident. The Director of Social Services, who was responsible for sending the NOMNC, confirmed during an interview that the resident was originally scheduled to leave on a later date but requested to leave earlier. The resident communicated this request a few days prior to the new discharge date, and after being cleared by the rehab department, was discharged. The Director of Social Services acknowledged that the NOMNC should have been provided but was not.
Failure to Develop and Implement Comprehensive Care Plan for Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's nutritional needs and significant weight loss. Despite the resident being admitted with multiple diagnoses including coronary artery disease, hypertension, diabetes, aphasia, malnutrition, and depression, and having a moderate cognitive impairment, the care plan did not include measurable objectives, timetables, or specific interventions related to the resident's documented weight loss. The resident experienced a notable weight loss from 118.0 pounds at admission to 102.8 pounds within a short period, yet the care plan lacked focus areas, goals, or interventions to address this decline. Additionally, the care plan did not reflect the resident's dietary preferences or supplemental needs associated with a pescatarian diet, even though the dietitian and kitchen staff had worked to accommodate these preferences. There was no documentation of menu choices for pescatarian diets, and the care plan did not address the resident's need for oral nutrition supplements or other individualized interventions. These omissions were confirmed by staff interviews and review of facility policies, which require ongoing assessment and multidisciplinary care planning for weight loss and nutritional risk.
Failure to Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor, implement, and modify nutritional interventions for two residents, resulting in unaddressed significant weight loss. For one resident with a history of lumbosacral and pelvic fractures, weight records showed a loss of 9.2 lbs (5.14%) over ten days, but there was no evidence of a required reweigh or timely dietary intervention. The resident's care plan, which already identified risk for malnutrition, was not updated to reflect the significant weight loss, and the dietitian did not assess the resident until after the weight loss had occurred. Another resident, admitted with multiple diagnoses including coronary artery disease, diabetes, malnutrition, and moderate cognitive impairment, experienced a weight loss of 15.2 lbs (12.7%) within one month. Despite repeated weight warnings and documentation indicating the need for a reweigh, there was no evidence that a reweigh was performed. The resident's dietary preferences were not met, and the care plan to provide oral nutritional supplements was not fully implemented. The dietitian was aware of the weight loss but had not completed a comprehensive assessment or documented interdisciplinary team notification. Both cases demonstrated a lack of adherence to the facility's own policies regarding weight monitoring, timely reweighs, and prompt dietary interventions. Documentation and staff interviews confirmed that significant weight changes were not properly addressed, and care plans were not updated to reflect the residents' changing nutritional needs.
Failure to Provide Trauma-Informed, Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice for two residents diagnosed with PTSD. Review of the clinical records for both residents revealed that there was no documented evidence of an assessment related to PTSD being conducted. Additionally, there was no documentation indicating that either resident received services to address their PTSD diagnoses. The facility's policy requires universal screening and assessment for trauma, as well as individualized care planning to address trauma-related needs, but these steps were not followed for the residents in question. Further review showed that for one resident, a psychiatric evaluation was performed, but the PTSD diagnosis was not mentioned or addressed in the evaluation. Neither resident had a care plan that addressed their PTSD diagnosis, despite this being a requirement under the facility's trauma-informed care policy. These omissions indicate that the facility did not account for the residents' past experiences and preferences, nor did it take steps to eliminate or mitigate potential triggers that could cause re-traumatization.
Resident Self-Administers Magnesium Supplement Without Physician Order
Penalty
Summary
A deficiency was identified when a resident was found to be self-administering a magnesium supplement without a physician's order. Facility policy requires that all medications, including supplements, be administered according to prescriber orders, and that residents may only self-administer medications if the attending physician and the interdisciplinary care planning team have determined the resident has the capacity to do so safely. Review of the resident's clinical record showed no order for magnesium, and there was no documentation that the resident had been assessed or approved to self-administer this supplement. During a medication pass observation, a licensed nurse was seen administering morning medications to the resident, and a bottle of magnesium gummies was observed on the resident's table. The resident stated she takes the gummies twice daily, and the nurse confirmed there was no order for this supplement and was unaware the resident was consuming it. This failure to ensure medications and supplements were administered according to policy and prescriber orders resulted in a significant medication error for the resident.
Failure to Securely Store and Properly Label Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely and in accordance with professional standards. During an observation, a Fluticasone inhaler labeled with a resident's name was found on top of the resident's overbed table, rather than being stored in a locked compartment as required by facility policy. The resident, who had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and a physician's order for the inhaler, confirmed that nurses had given her the medication but could not recall which nurse provided it. The inhaler remained unsecured during a follow-up observation with the Director of Nursing. Additionally, an inspection of the medication refrigerator in the medication room revealed an open vial of tuberculin purified protein derivative that was not dated. The Director of Nursing confirmed that the vial was not labeled with the date it was opened, which is contrary to facility policy requiring multi-dose vials to be dated upon opening. These findings demonstrate lapses in the secure storage and proper labeling of medications and biologicals within the facility.
Failure to Employ Qualified Registered Dietitian
Penalty
Summary
The facility failed to employ a qualified registered dietitian as required by regulations. Review of the dietitian's job description outlined responsibilities such as assessing nutritional needs, developing individualized nutrition care plans, conducting nutrition-focused physical exams, and collaborating with the interdisciplinary team. However, the individual serving as the registered dietitian had not completed the mandatory LDN licensure exam and was working under the direct supervision of a regional dietitian. Interviews with facility staff confirmed that the dietitian had not obtained the required licensure. Further review of resident records showed that the unlicensed dietitian was the only staff member documenting and reviewing clinical notes related to significant weight loss for a resident. There was no evidence that a licensed dietitian reviewed or consulted on any clinical documents, nor was there a cosignature or indication of oversight by the regional dietitian. This lack of qualified oversight and documentation directly contributed to the deficiency cited.
Unqualified Staff Directing Activities Program
Penalty
Summary
The facility's activities program was not directed by a qualified professional as required by regulations. During an interview, the nursing home administrator and regional staff member confirmed that the social worker, Employee E8, was overseeing the facility's activity program, including programs and assessments, despite not having the necessary qualifications. Employee E8 admitted to lacking a license or registration as a qualified therapeutic recreation specialist or activity professional. She also did not have two years of experience in a social or recreational program within the last five years, with at least one year in a therapeutic activities program. Furthermore, she was not a qualified occupational therapist or occupational therapy assistant and had not completed a state-approved training course. Employee E8 acknowledged her lack of qualifications and was unaware of the requirement to be a qualified activity professional or director.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations in the main kitchen dish room area revealed that the high temperature dishwasher machine had a wash cycle temperature of 172°F and a final rinse cycle temperature of 515°F, which were not in accordance with the manufacturer's instructions. A follow-up observation showed a wash cycle temperature of 170°F and a final rinse cycle temperature of 210°F. The Dietary Director confirmed these temperatures and stated that the facility was in contact with the manufacturer to address the inaccurate readings on the digital thermostat. Additionally, during an observation in the main kitchen dry storage area, it was found that there were four boxes of cornbread mix dated June 2024, one container of molasses with an expired date, one container of cooking wine dated February 1, 2024, and loaves of bread that were not dated. The Dietary Director confirmed that the facility failed to dispose of expired food products.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish Enhanced Barrier Precautions (EBPs) for five out of six residents reviewed, which is necessary to prevent the spread of multi-drug resistant organisms (MDROs). Observations revealed that signs for EBPs were posted at the doors of certain resident rooms, but there were no isolation carts or supplies available nearby. Interviews with residents indicated that staff were not wearing gowns during care activities that required EBPs, such as incontinence care. Clinical records showed that residents with conditions like open wounds, urinary catheters, and recent surgeries were not placed on EBPs in a timely manner, with orders for EBPs being delayed until after the residents were admitted. Specific cases included residents admitted with spinal surgery, open wounds, urinary catheters, and positive cultures for Group A hemolytic strep, all of whom required EBPs. However, the necessary precautions were not implemented promptly, as evidenced by the lack of PPE use by staff during direct care. Interviews with staff confirmed that EBPs should have been in place for these residents due to their medical conditions, but the facility did not ensure that the appropriate measures were taken to protect both residents and staff from potential infection risks.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required. This deficiency was identified through a review of facility documentation, clinical records, and staff interviews. Specifically, the progress notes for a resident indicated that the resident was transferred to a local hospital emergency department due to medical conditions. However, the facility did not provide evidence of notification to the Ombudsman regarding this transfer. An interview with an employee confirmed that the required notification was not made for this resident or any other hospital transfers.
Failure to Conduct Direct Pain Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment with direct observation and communication for a resident, as required by regulations. The deficiency was identified during a review of facility documentation, clinical records, and staff interviews. Specifically, the Resident Assessment Instrument (RAI) manual guidelines for pain assessment were not followed. The guidelines emphasize the importance of obtaining pain information directly from the resident to ensure accurate and individualized care planning. However, the assessment for the resident in question was completed remotely by an MDS coordinator without direct interaction with the resident. The resident, who had undergone knee surgery, reported experiencing severe pain that affected her sleep, therapy, and daily activities. Despite this, the Minimum Data Set (MDS) assessment documented inaccurate responses regarding the resident's pain levels and its impact on her activities. The MDS coordinator relied on documentation from other staff rather than conducting a direct interview with the resident. This lack of direct assessment led to discrepancies in the recorded pain levels and the resident's reported experience, resulting in a failure to accurately reflect the resident's condition in the care plan.
Inaccurate Pain Assessment for Resident
Penalty
Summary
The facility failed to complete comprehensive assessments that accurately reflected the resident's status for one of the eight residents reviewed. Specifically, for Resident R62, the Minimum Data Set (MDS) assessment conducted on August 13, 2024, included a pain assessment that was found to be inaccurate. The MDS documented that the resident experienced pain frequently, with a worst pain rating of 7 on a scale of zero to ten. However, a review of the pain assessment for the same period revealed that the resident had a highest documented pain level of 10 from August 9 to August 13, 2024. An interview with the Regional MDS coordinator, Employee E6, revealed that the assessment was completed by Employee E7, who worked remotely and did not conduct a direct interview with the resident. Instead, the information was obtained from documentation completed by other staff. Employee E6 confirmed that there was no source documented in the clinical record for responses related to the effect of pain on sleep, therapy, and day-to-day activities, as documented in the MDS. This discrepancy led to the conclusion that the responses and pain scale documented in the record were inaccurate.
Failure to Provide Baseline Care Plan to Residents
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to three residents, which is a requirement under the facility's policies and regulations. Interviews with the residents revealed that they did not receive a copy of the baseline care plan, which should have included the initial goals for the resident, a summary of medications, dietary instructions, and the services and treatments to be administered by the facility. This deficiency was confirmed through interviews with the residents and a review of their clinical records, which showed no evidence of the baseline care plan being provided. The Director of Nursing confirmed that the facility did not provide the required written summary of the baseline care plan to the residents or their representatives. This oversight affected the residents' understanding of their care plan and the services they were to receive upon admission. The deficiency was identified during a review of facility policies, clinical records, and staff interviews, highlighting a lapse in the facility's adherence to its resident care policies as outlined in 28 Pa Code 211.10(d).
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide care and services to a surgical wound according to professional standards of practice and as ordered by the physician for a resident who had undergone back surgery. The resident, identified as R65, was admitted to the facility from the hospital with a surgical incision on her back. The hospital records indicated an order to clean the incision with soap and water daily and to monitor for changes or signs of infection. However, the facility did not adhere to these instructions, as there was no evidence of the wound being cleaned or monitored from August 14 to August 20, 2024. The resident reported that the facility staff did not monitor or clean the incision for several days after her admission, leading her to contact her physician and complain to the staff. As a result of this neglect, the incision became infected, and the resident required antibiotics. The Director of Nursing confirmed that the facility did not provide the appropriate treatment as ordered by the hospital and failed to monitor the incision as recommended.
Failure to Provide Necessary Pharmaceutical Services
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for a resident, identified as R64, as determined through a review of facility documentation, clinical records, and interviews. The physician had ordered several medications for the resident, including Amlodipine, Atorvastatin, Ezetimibe, Repatha, Venlafaxine, Metoprolol, and Ramipril, all of which were to be administered on August 18, 2024. However, the Medication Administration Record indicated that these medications were not administered at the scheduled times. An interview with the Director of Nursing confirmed that the medications were not available from the pharmacy to be administered as ordered. This lack of availability led to the resident not receiving their prescribed medications, which constitutes a failure in providing necessary pharmaceutical services. The deficiency was noted under the Pennsylvania Code sections related to the responsibility of the licensee and pharmacy services.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist or their designee attended the quarterly Quality Assurance Process Improvement (QAPI) committee meetings for all four quarters reviewed, from October 2023 through July 2024. A review of the QAPI committee meeting attendees list for October 2023, January 2024, and April 2024 revealed the absence of an Infection Preventionist. Additionally, there was no sign-in sheet or QAPI information available for July 2024. An interview with Clinical Administrative staff, Employee E5, confirmed that no Infection Preventionist attended the QAPI meetings during the specified period.
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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