River's Edge Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 9501 State Road, Philadelphia, Pennsylvania 19114
- CMS Provider Number
- 395843
- Inspections on file
- 31
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at River's Edge Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
The facility was found to have deficiencies in food storage and sanitation practices. Observations revealed unlabeled and undated ground beef, outdated deli meats, and improperly sanitized equipment in the kitchen. The Food Service Director confirmed these findings during a tour.
The facility did not ensure proper disposal of garbage and refuse, as observed during a kitchen tour with the FSD. Cigarette butts were found in the receiving area and loading dock, and the garbage was not covered. These issues were confirmed by the FSD.
A facility failed to conduct timely care plan meetings for a resident with dementia and hearing deficits. The last documented meeting was in June 2024, attended by the resident's daughter-in-law via phone, with no evidence of subsequent meetings. Interviews confirmed missed meetings in September and December 2024.
The facility did not provide timely written notification to residents and their representatives about hospital transfers and the reasons for these transfers. Two residents were transferred to the hospital without their representatives being informed in writing, in a language and manner they understood. The facility lacked a system for notifying residents' representatives in writing prior to transfers or discharges, as confirmed by the Nursing Home Administrator and DON.
A facility failed to follow a physician's order for a resident's catheter care. The order specified a Foley Catheter with a 16fr/10ml balloon, but the resident was found with a 16fr/5ml balloon. This discrepancy was confirmed by a licensed nurse, highlighting a lapse in adhering to the prescribed catheter care.
A resident with multiple health issues experienced a significant weight loss, which the facility failed to address appropriately. Despite policies requiring reweighing and nutritional evaluation, there was no documented reweight or physician evaluation. The dietitian did not implement timely nutritional interventions, and the food-first approach was deemed inappropriate by the physician.
A facility failed to create an individualized care plan for a resident with dementia, as required by their policy. The care plan lacked measurable goals and interventions for the resident's dementia care needs. This was confirmed by the DON, highlighting a deficiency in compliance with state regulations.
A resident's bed was found to have a mattress six inches smaller than the bed frame, exposing slats and increasing entrapment risks. The resident, with neurological and physical impairments, had been using this setup since admission. Staff interviews confirmed the mismatch, and it was noted that mattresses are purchased separately from bed frames, leading to this oversight.
The facility failed to follow physician orders for two residents, resulting in deficiencies. One resident experienced delays in insulin administration, with a nurse leaving the resident unsupervised with medication. Another resident did not receive ordered showers, with documentation not supporting a claimed refusal. Staff confirmed these deficiencies, acknowledging policy violations.
The facility did not ensure that residents and/or their responsible parties were notified or participated in care plan meetings, as required by policy. This was confirmed for four residents, with no documentation of notification or participation since their last meetings. An interview with a social worker confirmed the absence of such documentation.
A resident with diabetes continuously refused Lantus insulin injections for three months, but the facility failed to notify the physician. Despite the refusals, the physician's notes inaccurately stated that the resident's diabetes was controlled with Lantus. The Unit Manager confirmed the lack of communication, leading to a deficiency in resident care.
A resident with cognitive impairment and multiple health issues was found with bruises of unknown origin. The facility's investigation was incomplete, lacking interviews with staff and failing to confirm the resident's report of a therapy session. The Director of Rehabilitation noted the resident had been discharged from therapy months earlier, and the Director of Nursing acknowledged the investigation's shortcomings.
The facility failed to notify the State LTC Ombudsman of emergency transfers for four residents who required hospital care due to significant medical issues. Despite transferring 56 residents over three months, the facility did not provide the required notifications for these specific cases, as confirmed by the Nursing Home Administrator.
The facility did not develop care plans for three residents requiring oxygen therapy, despite physician orders for oxygen administration and maintenance. Observations revealed uncleaned oxygen concentrator filters, confirmed by staff, indicating non-compliance with care plan policy and nursing service regulations.
A facility failed to follow a physician's order for a neurology follow-up for a resident who was transferred to the hospital for right arm weakness. Hospital discharge instructions required a neurology appointment within two weeks, but no evidence of scheduling was found in the resident's records. This was confirmed with the Unit Manager.
The facility failed to maintain clean oxygen concentrator filters for three residents, as required by their physician orders and facility policy. Despite instructions to clean the filters weekly, it was observed that the filters were covered with thick dust, indicating non-compliance with the established standards of practice for respiratory care.
The facility failed to administer medications as ordered for two residents due to unavailability. One resident did not receive Betamethasone cream for eczema over several days, and another did not receive Oxycodone and Methocarbamol for pain management. The facility's policy requires notifying the physician and providing alternatives when medications are unavailable, which was not followed.
A facility failed to obtain timely laboratory services for a resident's digoxin levels as per physician orders. The resident, diagnosed with Atrial Fibrillation and prescribed Digoxin, had a care plan requiring serum digoxin level checks every six months. However, the last documented test was in April 2023, which was confirmed by the Unit Manager.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a kitchen tour. The main refrigerator contained two 10-pound ground beef links that were unlabeled and undated, opened ham deli meat dated March 10, 2025, two 10-pound ready-to-eat roast beef labeled with a received date of March 17, 2025, and opened mozzarella cheese labeled with a received date of December 10, 2024. Additionally, the three-compartment sink was found to be improperly sanitized, as the pH test of the sanitation solution showed no change in the pH test strip, indicating the sanitizer was outside the acceptable pH range. These findings were confirmed by the Food Service Director during the kitchen tour.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a tour of the main kitchen conducted with the Food Service Director (FSD), Employee E6. During the inspection, hundreds of cigarette butts were found in the receiving area and loading dock, which are used by the facility to transport clean food. Additionally, it was observed that the garbage was not covered. These observations were confirmed by the FSD during the tour.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were held for a resident, identified as Resident R55, who was reviewed among 24 residents. Resident R55 had a decline in communication due to a hearing deficit and impaired cognition related to dementia. The clinical records showed that a care conference meeting was last documented in June 2024, attended by the resident's daughter-in-law via phone. However, there was no documented evidence of subsequent care conference meetings occurring after June 2024. Interviews with the facility Administrator and Social Worker confirmed that care conferences were not conducted in September 2024 and December 2024, as required.
Failure to Notify Residents' Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding hospital transfers and the reasons for these transfers. Specifically, two residents, identified as R31 and R102, were transferred to the hospital without their representatives being notified in writing, in a language and manner they understood. Resident R31 was admitted to the hospital with a diagnosis of hematoma of the left kidney and abdominal pain, while Resident R102 was transferred for evaluation of a gastrointestinal bleed. The clinical records lacked evidence of written notification to the residents' representatives. An interview with the Nursing Home Administrator and Director of Nursing confirmed the absence of a system for notifying residents' representatives in writing prior to transfers or discharges.
Failure to Implement Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to implement appropriate treatment and services for incontinence management for one resident. A physician's order for the resident, dated March 24, 2025, specified the use of a urinary Foley Catheter with a size 16fr/10ml balloon, to be changed monthly and as needed based on clinical indications. However, on March 27, 2025, it was observed that the resident had a Foley Catheter with a 16fr/5ml balloon instead of the ordered 16fr/10ml balloon. This discrepancy was confirmed by a licensed nurse, indicating a failure to adhere to the physician's order for catheter care.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately monitor and modify nutritional interventions for a resident, leading to a significant weight loss that was not addressed in a timely manner. The resident, who was admitted with conditions such as muscle wasting, high blood pressure, hyperlipidemia, depression, and dysphasia, experienced a clinically significant weight loss of 6.3% in one month. Despite the facility's policy requiring reweighing and nutritional evaluation for significant weight changes, there was no documented reweight or evidence of a physician's evaluation to address the resident's medical and nutritional issues related to the weight loss. Additionally, the Registered Dietitian failed to implement and monitor appropriate nutritional interventions, such as therapeutic supplements, to address the resident's impaired nutrition. Instead, the dietitian notified the Food Service Director, a non-medical professional, about the weight loss, and the resident was placed on a select menu with updated preferences. The physician acknowledged that the food-first approach was not suitable for the resident's condition, as the resident was very sick, had a dry mouth, and lacked appetite. The facility's documentation was also inconsistent, with a progress note indicating an evaluation for weight loss occurring after the fact.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia, identified as Resident R84. The facility's dementia care policy, dated September 2024, mandates that care plans be individualized based on the assessment and diagnosis of each resident. However, upon reviewing Resident R84's care plan dated April 21, 2022, it was found that there were no measurable goals or interventions addressing the resident's dementia care needs. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that residents diagnosed with dementia should have a care plan in place. The deficiency was identified under the regulations 28 Pa Code 211.11(d) and 28 Pa Code 211.12 (d)(1)(3)(5).
Incompatible Mattress and Bed Frame Leads to Entrapment Concerns
Penalty
Summary
The facility failed to ensure compatibility between mattresses and bed frames for a resident, leading to a deficiency. Observations conducted on two consecutive days revealed that the mattress used by a resident was six inches smaller than the metal bed frame, exposing the bedframe slats on each side and increasing entrapment concerns. The resident, who was admitted with neurological conditions, a cerebrovascular accident, cognitive communication deficit, muscle weakness, and atrophy, had been using the mismatched bed frame and mattress since admission. Interviews with staff, including a nurse assistant and the maintenance director, confirmed the mismatch. The maintenance director acknowledged that the mattress applied was a 36-inch size, while the bed frame required a 42-inch mattress. It was revealed that bed audits were last conducted in the first week of February, and the incorrect mattress size was likely reapplied by housekeeping. The facility's practice of purchasing mattresses separately from bed frames contributed to the oversight.
Medication and Care Deficiencies
Penalty
Summary
The facility failed to adhere to physician orders regarding medication administration for two residents, resulting in deficiencies. Resident R3, diagnosed with type 2 diabetes mellitus and other conditions, was prescribed NovoLin R insulin at specific times. However, there were multiple instances where the insulin was administered late, including significant delays on several days. On one occasion, Resident R3 expressed symptoms of hypoglycemia due to the delay, and the nurse, Employee E5, left the resident unsupervised with medication, contrary to the facility's policy. Additionally, the facility did not follow physician orders for Closed Record CR2, who was supposed to receive showers twice a week. The documentation did not indicate that the resident refused a shower, yet the shower was not provided as ordered. A family member later inquired about the missed shower, prompting a late entry in the progress notes claiming the resident refused, which was not supported by the initial documentation. Interviews with the Director of Nursing and other staff confirmed these deficiencies, acknowledging the delays in insulin administration and the failure to provide a shower as ordered. The facility's policies on medication administration and resident care were not followed, leading to these documented deficiencies.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were provided with the opportunity to participate in their care plan meetings. This deficiency was identified for four residents, specifically Residents R64, R54, R85, and R69. The facility's policy, revised in August 2023, mandates that residents and their families or legal representatives be part of the interdisciplinary team and participate in the development and ongoing review of the care plan. However, the clinical records for these residents showed no evidence of notification or participation in care plan meetings since their last documented meetings, which were held on various dates in 2023. During an interview with the social worker, Employee E14, it was confirmed that there was no documentation to prove that the facility had notified the residents or their responsible parties about the care plan meetings, provided them with the opportunity to participate, or given them a copy of their care plan. This lack of documentation and involvement is a violation of the facility's policy and the relevant Pennsylvania Code sections regarding clinical records and nursing services.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify a physician about a resident's continuous refusal to take prescribed medication, Lantus, for diabetes management. The resident, who has a history of falling, hypertension, seizures, and diabetes, was prescribed 12 units of Lantus to be administered subcutaneously at bedtime. However, the Medication Administration Records (MAR) for March, April, and May 2024 indicated that the resident refused the majority of the scheduled injections, with refusals recorded for 28 out of 31 days in March, 28 out of 30 days in April, and 28 out of 31 days in May. Despite these refusals, the physician's progress notes for the same months documented that the resident's diabetes was being controlled with Lantus insulin and glipizide. Interviews and reviews of the clinical records revealed that the nursing staff did not notify the physician about the resident's refusal to take the Lantus insulin. The Unit Manager confirmed that there was no evidence to show that the physician was informed of the refusals, even though the physician continued to document that the resident's diabetes was being managed with the medication. This lack of communication between the nursing staff and the physician led to a deficiency in ensuring proper resident care and adherence to prescribed medication orders.
Incomplete Investigation of Resident's Bruising
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into bruises of unknown origin found on a resident, identified as Resident R69. The resident, who was cognitively impaired and had a history of pain, delusional disorder, hypertension, and peripheral vascular disease, was observed with purplish areas on the left hand towards the wrist. The facility's policy on abuse, neglect, and exploitation requires considering factors such as physical injury of unknown source, but the investigation into the resident's bruising was inadequate. The investigation only included an interview with the resident, who reported having physical therapy exercises the day before noticing the bruises. However, the Director of Rehabilitation confirmed that the resident had been discharged from therapy months prior, and no evidence was found to confirm any therapy session on the day in question. The investigation lacked interviews with staff who might have interacted with the resident or witnessed the incident, and there was no documentation to rule out abuse or neglect. The Director of Nursing confirmed that no additional information was available to demonstrate a thorough investigation.
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 for four residents. This deficiency was identified through a review of facility documentation, clinical records, and staff interviews. Specifically, the facility did not provide the required notification for emergency hospital transfers of four residents, each of whom experienced significant medical issues necessitating immediate hospital care. These issues included a swollen tongue, low blood sugar, signs of gastrointestinal bleeding, and altered mental status with intractable pain. The facility's documentation revealed that a total of 56 residents were transferred to the hospital over a three-month period, yet there was no indication that the Ombudsman was notified for the emergency transfers of the four residents in question. The Nursing Home Administrator confirmed during an interview that the required notifications were not made in a timely manner, as mandated by the regulations. This oversight highlights a failure in the facility's process for ensuring compliance with notification requirements for emergency transfers.
Failure to Develop Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for three residents, which was identified during a review of 27 resident records. Specifically, Residents R40, R62, and R65 did not have care plans addressing their use and maintenance of oxygen therapy, despite having physician orders for oxygen administration. Resident R40 had an order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, while Residents R62 and R65 had orders for continuous oxygen at the same rate. Additionally, all three residents had orders to clean their oxygen concentrator filters weekly and as needed. On observation, it was found that the oxygen concentrator filters for these residents were covered with thick dust, indicating they had not been cleaned as required. This was confirmed by a registered nurse, Employee E7. Further interviews with Unit Manager Employee E29 confirmed the absence of care plans related to the residents' oxygen use. This deficiency violates the facility's care plan policy, which mandates timely and adequate person-centered care plans for all residents, and contravenes specific nursing service regulations.
Failure to Schedule Neurology Follow-Up
Penalty
Summary
The facility failed to ensure that a physician's order for a neurology follow-up was followed for a resident. The resident, identified as R62, was transferred to the hospital due to right arm weakness. Upon discharge from the hospital, the instructions dated April 30, 2024, specified that a follow-up appointment with neurology should be scheduled within two weeks. However, a review of the resident's clinical records showed no documented evidence that this neurology appointment was scheduled. This deficiency was confirmed with the Unit Manager on June 3, 2024, at approximately 2:15 p.m.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards of practice for three residents. The facility's policy for oxygen administration, revised in January 2024, requires nursing staff to administer oxygen correctly and clean the oxygen concentrator filters weekly. Resident R40 had a physician's order to administer oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, with instructions to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed. Resident R62 had a similar order for continuous oxygen administration, and Resident R65 had an order for continuous oxygen administration with the same filter cleaning instructions. On May 29, 2024, it was observed and confirmed by a registered nurse that the O2 concentrator filters for these residents were covered with thick dust and had not been cleaned, indicating non-compliance with the facility's policy and physician orders.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, and administration of medications for residents, as evidenced by the case of Resident R56. The facility's policy requires that medications be administered as ordered, and if unavailable, the physician should be notified, and an alternative should be provided. However, Resident R56 did not receive the prescribed Betamethasone Dipropionate Augmented cream for eczema over several days because the medication was on back order, and there were no corresponding nurse notes for several days to document this issue. Additionally, Resident R31, who was admitted for aftercare following a fracture and malignant neoplasm, did not receive the prescribed Oxycodone and Methocarbamol for pain management on a specific date because the medications were not available. This lack of medication availability and administration indicates a failure to meet the residents' needs as per the facility's policies and procedures.
Failure to Monitor Digoxin Levels
Penalty
Summary
The facility failed to obtain laboratory services to meet the needs of a resident's digoxin levels as per physician orders. Resident R55, who was admitted with a diagnosis of Atrial Fibrillation, was prescribed Digoxin to manage this condition. The resident's care plan included monitoring serum digoxin levels monthly or as ordered by the physician, with specific instructions to check these levels every six months as of October 2020. However, the last documented digoxin serum levels were completed in April 2023, indicating a failure to adhere to the physician's orders. This deficiency was confirmed by the Unit Manager, Employee E29, on June 3, 2024.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
