Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River's Edge Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that an oxygen storage room on the second floor lacked the required precautionary signage stating, "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING," as mandated for gas cylinder storage areas. This deficiency was confirmed by facility leadership during the initial survey and again during a subsequent revisit, when the same room was still missing the required sign.
A cognitively intact resident with osteoarthritis, low back pain, and major depressive disorder was assisted out of bed and placed in a Geri-chair in the dayroom for breakfast and to await therapy. The resident became verbally agitated and repeatedly requested to return to their room, but staff, including a nurse aide and unit staff, attempted to redirect the resident and delayed honoring the request for approximately 30–40 minutes so the resident would remain up for therapy, despite the resident’s known preference for in-room therapy. The resident ultimately called the police, reporting they were being forced to stay in the dayroom, and was only taken back to their room when police arrived, demonstrating a failure to respect the resident’s right to make choices about daily activities.
The facility failed to keep its dish machine in safe working order, resulting in staff manually pushing dishware through a machine with a broken conveyor belt and missing curtains and jet caps. The Dietary Director reported the malfunction and requested repair approval from the Administrator, who approved the request, but the machine remained in disrepair while quotes for repair and replacement were obtained over several weeks.
Advance directive and POLST orders were not followed for two residents. One resident with cerebral infarction and dementia had a POLST for DNR, comfort measures only, no antibiotics, and no tube feeding, but the care plan, face sheet, and MD order listed full code. Another resident with COPD and HF had a POLST for DNR and limited interventions, but the care plan had no code status, the face sheet listed DNI, and the MD order did not match the POLST. The DON and UM confirmed the mismatches.
Grievance forms were not readily available on the first and second floors, and residents had to request a form from the front desk or nursing station filing cabinet. The Administrator confirmed there was no method for residents to file anonymous grievances.
The facility failed to document either a 14-day stop date or a clinical rationale for continued PRN psychotropic use for two residents. One resident with dementia, traumatic subdural hemorrhage, and severe protein-calorie malnutrition had an Ativan PRN order for anxiety without the required stop date or justification beyond 14 days, and the DON confirmed the missing documentation during interview.
The facility failed to develop person-centered care plans for two residents. One resident with cerebral infarction and dementia had severe cognitive impairment, no activities care plan, and no activity documentation despite staff noting limited engagement and frequent time spent in the room. Another resident with cerebral infarction and dementia had moderate cognitive impairment, and the DON confirmed there was no dementia care plan in place.
Failure to provide ADL assistance for a resident with CVA-related weakness and limited mobility. The resident’s care plan and MDS showed a need for partial/moderate help with showering, and physician orders directed showers twice weekly with documentation of refusals. During observation, the resident had greasy hair and facial hair and stated it had been a couple of weeks since the last shower and shave; the DON later confirmed the resident still needed grooming assistance.
Unlabeled Enteral Feeding Bag: A resident with muscle wasting, protein-calorie malnutrition, cerebrovascular disease, and immunodeficiency was receiving enteral feeding under an order for Jevity 1.5 at 65 mL/hr for 16 hours with every-shift monitoring. During observation, the feeding bag had no label, and an LPN acknowledged it was not labeled and should have been labeled on both the internal feed bag and flushes.
A resident with local skin/subcutaneous infection, polyneuropathy, and an anxiety disorder had an order for PRN oxycodone 5 mg for pain rated 6-10, but the MAR showed the medication was given when documented pain scores were 5, 4, 3, and even 0. The DON confirmed the PRN pain med was not administered in accordance with the physician’s order.
A resident with parkinsonism, PTSD, anxiety disorder, and a history of OCD had a care plan that identified mood problems, but it did not address possible triggers that could cause re-traumatization. The DON confirmed the care plan lacked this information.
Facility Assessment Lacked Required Input: The facility failed to include direct care staff and input from residents, resident representatives, and/or family members when completing the facility assessment. Review of the assessment showed no indication that these individuals were involved, and the Administrator confirmed that no direct care staff, resident representatives, and/or family members were included.
Residents with Severe Cognitive Impairment Signed Arbitration Agreements: The facility failed to ensure that residents with severe cognitive impairment had the capacity to understand a binding arbitration agreement. Three residents with diagnoses including cerebrovascular disease, Alzheimer's disease, encephalopathy, dementia, and traumatic subdural hemorrhage had BIMS scores indicating severe impairment, yet each signed an arbitration agreement during admission. The admission Director confirmed the residents lacked capacity to understand the agreement terms.
Failure to use enhanced barrier precautions and required masking: The facility did not ensure that enhanced barrier precautions were used for three residents with an enteral feeding tube, wounds, or an indwelling catheter, as staff provided direct care while wearing only gloves despite signs and orders indicating enhanced precautions. The facility also did not ensure that an LPN who refused the flu vaccine wore a mask during flu season, and the LPN was observed unmasked during medication pass.
Food was not consistently served at palatable temperatures and several residents reported that meals did not taste good, were cold, or did not match the menu. During a tray observation, the FSD found a hamburger, broccoli, and potatoes below the facility's acceptable temperature range, and the kitchen was short on heat plates and covers, with meals delivered wrapped in plastic wrap.
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.
Failure to Post Required Oxygen Storage Room Cautionary Signage
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During an observation on the second floor, they found that the Oxygen Storage Room did not have the required precautionary signage on the door. Specifically, the room lacked a sign readable from 5 feet that stated: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING," as required for oxygen cylinder storage areas. This absence was directly observed by surveyors during the inspection. In an exit interview conducted with the Administrator and the Maintenance Director following the initial observation, facility leadership confirmed the lack of required signage. During a subsequent onsite revisit, surveyors again observed that the same second-floor Oxygen Storage Room still lacked the mandated cautionary sign. In a second exit interview with the Administrator and a Maintenance Representative, they again confirmed that the signage remained absent at the time of the revisit.
Plan Of Correction
1. The facility immediately purchased and installed the required signage at the Oxygen Storage Room on the second floor. The signage was updated to include "Oxygen Storage No Smoking" in accordance with NFPA 99 requirements for compressed gas storage areas. 2. All residents have the potential to be affected by this issue. 3. The Director of Maintenance and facility leadership were in-serviced on the requirements for proper labeling and signage of medical gas storage areas, including oxygen storage rooms, in accordance with NFPA 99 and CMS Life Safety Code requirements. 4. The Director of Maintenance or designee will conduct routine environmental rounds to ensure all medical gas storage areas are properly labeled and compliant with NFPA 99 signage requirements. Audits will be conducted monthly for three months, with immediate correction of any identified deficiencies. Findings will be documented and reported to the Quality Assurance and Performance Improvement (QAPI) Committee as appropriate.
Failure to Honor Resident’s Choice to Return to Room Before Therapy
Penalty
Summary
The facility failed to honor a cognitively intact resident’s right to make choices regarding daily activities, specifically the resident’s repeated requests to return to their room. The resident, admitted with diagnoses including primary osteoarthritis, low back pain, and major depressive disorder, had a BIMS score of 15 on the March 20, 2026 MDS, indicating intact cognition. On the morning in question, staff assisted the resident out of bed around 7:30 a.m. in preparation for scheduled therapy and placed the resident in a Geri-chair in the dayroom for breakfast and to wait for therapy. The resident became verbally agitated in the dayroom and repeatedly shouted that they wanted to go back to their room. Staff attempted to redirect and reassure the resident, explaining that therapy was scheduled and that they should remain out of bed to attend. Despite the resident’s clear and repeated requests—reported as approximately four times after breakfast—to return to their room, staff did not immediately comply, instead keeping the resident in the dayroom for an estimated 30–40 minutes while waiting for therapy. During this time, the resident contacted the police, stating they were being forced to remain in the dayroom and not allowed to return to bed. When the police arrived, the resident was still in the Geri-chair, continuing to request to return to bed. The DON confirmed that the resident preferred to have therapy in their room, but staff encouraged the resident to remain out of bed for therapy and did not take the resident back to the room immediately, despite multiple requests, resulting in a failure to respect the resident’s right to self-determination and choice of daily activities.
Dish Machine Not Maintained in Safe and Functional Condition
Penalty
Summary
The facility failed to maintain the dish machine in safe and functional operating condition, resulting in staff having to manually operate malfunctioning equipment. On April 15, 2026, observation of the dish machine showed that the conveyor belt was broken, requiring staff to manually push dishware through the machine to initiate the wash cycle. The Director of Dietary confirmed that the dish machine was not functioning properly and that there were missing curtains and caps on the jets. Review of email communication dated March 12, 2026, showed that the Director of Dietary had requested approval from the Administrator for dish machine repair, stating it needed to be fixed as soon as possible, and that the Administrator approved the repair the same day. Further review revealed that the Administrator did not receive a quote from the repair company until April 2, 2026, and that a new quote for a replacement dish machine was submitted on April 13, 2026. Interview with the Administrator on April 15, 2026, confirmed that the dish machine remained in this condition while the facility was in the process of obtaining a new machine. No residents or specific patient conditions were mentioned in relation to this deficiency.
Advance Directive and POLST Orders Not Followed
Penalty
Summary
The facility failed to ensure residents' advance directives and POLST orders were followed according to their expressed wishes for 2 of 24 residents reviewed. Facility policy stated that resident wishes were to be communicated through the care plan and to the resident physician, and that POLST orders were to reflect treatment preferences and be followed across care settings. The report identified that the facility did not keep the care plan, physician orders, and face sheet aligned with the POLST information for the affected residents. Resident R5 had diagnoses of cerebral infarction and dementia, and the MDS showed a BIMS score of 0, indicating severe cognitive impairment. R5's POLST, signed by the physician and responsible party, indicated DNR, comfort measures only, no antibiotics, and no artificial hydration or nutrition by tube. Despite this, the care plan documented full code status, the face sheet listed full code, and a physician order revised on June 21, 2025 also listed full code. The Unit Manager confirmed that the POLST indicated DNR, but the care plan, orders, and face sheet did not reflect it, and the DON confirmed the resident's son did not want any change from the POLST. Resident R13 had diagnoses of COPD and heart failure, and the MDS showed a BIMS score of 9, indicating moderate cognitive impairment. R13's POLST, signed by the physician and resident, indicated DNR, limited additional interventions, and no artificial hydration or nutrition by tube. However, the comprehensive care plan had no documented code status, the face sheet listed DNI, and there was no documented evidence of the requested CPR interventions. The Unit Manager confirmed that the POLST indicated DNR, but the care plan, physician orders, and face sheet did not reflect it.
Grievance Forms Not Readily Available and No Anonymous Filing Method
Penalty
Summary
The facility failed to ensure that grievance forms were available to residents and failed to provide a method for residents to file anonymous grievances on two nursing units, the first floor and second floor. During observations on March 24, 2026, with the Administrator, Employee E1 confirmed that grievance forms were only available at the front desk and that residents would need to request a form to receive one. The Administrator also confirmed that no method had been established for residents to file anonymous grievances. On the second floor, observations showed that no grievance forms were readily available to residents, and the forms could only be obtained upon request from a filing cabinet behind the nursing stations.
Missing Stop Date and Justification for PRN Psychotropic Orders
Penalty
Summary
The facility failed to ensure that the physician documented either a 14-day stop date or a clinical justification for continued use of PRN psychotropic medication for two residents reviewed. Facility policy stated that PRN psychotropic drug orders are limited to 14 days unless the attending physician or prescribing practitioner documents a rationale for extending the order beyond 14 days and indicates the duration for the PRN order. Resident R7 was admitted with diagnoses including dementia, traumatic subdural hemorrhage, and severe protein-calorie malnutrition. The clinical record showed a physician order dated February 4, 2026 for Ativan 1 mg by mouth every 24 hours as needed for anxiety, but the order did not include a documented stop date or clinical justification for continued use beyond 14 days. During an interview on March 25, 2026, the DON confirmed that Resident R4 lacked the required stop date within 14 days and a rationale for continued use beyond 14 days.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for two residents reviewed. Resident R5 was admitted with diagnoses of cerebral infarction and dementia, and the MDS dated June 26, 2025 showed a BIMS score of 0, indicating severe cognitive impairment. Review of the clinical record found no care plan addressing R5’s activities. The resident’s responsible party reported concerns that the resident slept too much during the day and was not engaging in activities. The activities task record showed no data for the last 30 days, although the Activities Director stated the resident was visited by activities staff three times a week for about 15 minutes and was not always interested in activities and spent a lot of time in the room. Resident R25 was admitted with diagnoses of cerebral infarction and dementia, and the MDS dated February 2, 2026 showed a BIMS score of 9, indicating moderate cognitive impairment. Review of the clinical record found no care plan developed to address R25’s dementia care. The DON confirmed that no care plan was in place for dementia care for this resident.
Failure to Provide ADL Assistance for a Resident Needing Showering and Grooming Support
Penalty
Summary
The facility failed to provide ADL assistance for Resident R9, who was admitted with diagnoses including hemiparesis following a cerebral infarction affecting the right dominant side and muscle wasting and atrophy. The physician orders dated October 26, 2025, directed showers on Monday and Thursday on the 3-11 shift and required documentation if the resident refused a shower. The quarterly MDS indicated a BIMS score of 15 and showed that Resident R9 required partial/moderate assistance with showering tasks. The comprehensive care plan dated September 17, 2024, identified an ADL self-care performance deficit related to limited mobility and left-side weakness related to CVA. During an observation and interview on March 23, 2026, Resident R9 was noted to have greasy hair and facial hair. When asked when they last received a shower and shave, the resident stated it had been a couple of weeks. The resident also stated a preference for bed baths and a desire to be shaved daily and have hair washed. This was communicated to an LPN, who responded that the resident would be given a shower. On March 25, 2026, the DON observed that Resident R9 still had greasy hair and required a facial shave.
Unlabeled Enteral Feeding Bag
Penalty
Summary
Enteral feedings were not administered and monitored according to professional standards of practice for one resident receiving tube feeding. The resident was admitted with diagnoses including muscle wasting and atrophy, protein calorie malnutrition, cerebrovascular disease with long-term weakness after a stroke, and immunodeficiency. A physician order dated March 20, 2026 directed Jevity 1.5 at 65 mL/hour for 16 hours, with a total volume of 1040 mL, to be started at 2 p.m. and stopped at 6 a.m. or when the total volume was infused, with every-shift monitoring and signing to confirm the feeding was infusing as ordered. During an observation on March 25, 2026 at 8:39 p.m., the resident was seen in bed receiving enteral feeding, and the feeding bag was not labeled with any information. A nurse acknowledged that the bag was not labeled and stated it should have been labeled on both the internal feed bag and flushes.
PRN Pain Medication Given Outside Ordered Parameters
Penalty
Summary
Safe, appropriate pain management was not provided for one resident who required pain services. The resident was admitted with diagnoses including local infection of the skin and subcutaneous tissue, polyneuropathy, and an anxiety disorder. A physician’s order dated February 16, 2026 directed Oxycodone 5 mg by mouth every 4 hours as needed for pain rated 6-10. Review of the March 2026 MAR showed the medication was administered when the resident’s documented pain scores were below the ordered range, including pain levels of 5, 4, 3, and 0 on multiple occasions. During an interview on March 25, 2026, the DON confirmed the resident’s pain medication was not administered in accordance with the physician’s order.
Failure to Address PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for one resident with PTSD. Resident R14 was admitted with parkinsonism, PTSD, and an anxiety disorder, and the clinical record showed a care plan dated February 15, 2026, identifying a mood problem related to disease processes and a past medical history of obsessive-compulsive disorder and PTSD. However, the care plan did not address possible triggers that could cause re-traumatization of the resident. During an interview on March 25, 2026, the DON confirmed that Resident R14's care plan did not include possible triggers that may cause re-traumatization.
Facility Assessment Lacked Required Input
Penalty
Summary
The facility failed to ensure that direct care staff and input from residents, resident representatives, and/or family members were included when conducting the facility assessment. Review of the facility assessment dated January 29, 2026, showed no indication that direct care staff, resident representatives, or family members were involved in the assessment process. During an interview with the Administrator, Employee E1, on March 25, 2026, at 12:00 p.m., it was confirmed that no direct care staff, resident representatives, and/or family members were included in the facility assessment.
Residents with Severe Cognitive Impairment Signed Arbitration Agreements
Penalty
Summary
The facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement for three of five residents reviewed. Resident R135 was admitted with diagnoses including disorder of the kidney and ureter, cerebrovascular disease, and anxiety disorder. A BIMS dated March 18, 2026, showed a score of 7, indicating severe cognitive impairment, yet the admission paperwork showed the resident signed an Arbitration Agreement on March 17, 2026. Resident R126 was admitted with cerebral infarction, Alzheimer's disease, and encephalopathy. A BIMS dated March 13, 2026, showed a score of 0, indicating severe cognitive impairment, and the admission paperwork showed the resident signed an Arbitration Agreement on March 13, 2026. Resident R7 was admitted with dementia, traumatic subdural hemorrhage, and severe protein-calorie malnutrition. A BIMS dated February 03, 2026, showed a score of 7, indicating severe cognitive impairment, and the admission paperwork showed the resident signed an Arbitration Agreement on February 02, 2026. During interview on March 25, 2026, the admission Director confirmed that Residents R135, R126, and R7 had severe cognitive impairment based on their BIMS scores and did not have the capacity to understand the terms of a binding arbitration agreement.
Failure to Use Enhanced Barrier Precautions and Required Masking
Penalty
Summary
The facility failed to implement enhanced barrier precautions for three residents who had indwelling medical devices or wounds. Resident R6 had diagnoses including muscle wasting and atrophy, protein calorie malnutrition, cerebrovascular disease, and immunodeficiency, and had a physician order for enteral feeding via tube. On March 23, 2026, a nursing aide provided direct care to R6 while only wearing gloves, and when asked about enhanced barrier precautions, stated that R6 was not on them even though a sign outside the room indicated otherwise. Resident R108 had diagnoses including dysphagia, chronic respiratory failure with hypoxia, Alzheimer's disease, and nutritional deficiencies, and had a physician order for enhanced barrier precautions related to wounds. On March 24, 2026, a nurse aide provided direct care to R108 while only wearing gloves and acknowledged in the hallway that the appropriate PPE was not being worn despite the sign outside the room indicating enhanced precautions. Resident R91 had a care plan stating enhanced barrier precautions were required related to an indwelling catheter. On March 23, 2026, a licensed nurse provided catheter care while only wearing gloves, and an assisting DON confirmed that R91 was on enhanced barrier precautions and that the required PPE was not being worn. The facility also failed to ensure that an LPN who refused the influenza vaccine wore a mask during flu season; the LPN was observed not wearing a mask during medication pass, and the Infection Preventionist and DON confirmed that unvaccinated healthcare workers must wear a mask during flu season.
Food Served Cold and Not Palatable
Penalty
Summary
Food and drink were not consistently served at palatable temperatures and were described by residents as not tasting good or not matching the menu. A facility policy on food temperatures stated that foods were to be served at proper temperatures, with acceptable serving temperatures for meat and entrees greater than 135 degrees Fahrenheit, potatoes greater than 135 degrees Fahrenheit, and vegetables greater than 135 degrees Fahrenheit. During a test tray observation, the last tray was passed at 12:45 p.m., and temperatures taken by the Food Service Director showed the hamburger at 130 degrees Fahrenheit, broccoli at 119 degrees Fahrenheit, and potatoes at 124 degrees Fahrenheit, all below the facility's acceptable range for palatability. The Food Service Director confirmed these items were outside the acceptable temperature range and therefore not palatable. Resident and family interviews also identified concerns with the quality and presentation of meals. One resident reported that food was always cold when served and that it sat on the carts too long. A family member reported that meals included too many carbohydrates, such as pizza served with mashed potatoes. Other residents stated that the food did not taste good, was cold, and did not match the menu. The kitchen was also short on heat plates and covers during observed service, and resident meals were delivered wrapped in plastic wrap.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Immaculatemarycenter For Rehabilitation&healthcare | 2.3 mi | ★★★★★ | 26 | 1 |
| Transitional Care Unit At Nazareth Hospital | 3.1 mi | ★★★★★ | 0 | 0 |
| Deer Meadows Rehabilitation Center | 3.1 mi | ★★★★★ | 21 | 0 |
| Wesley Enhanced Living Pennypack Park | 3.1 mi | ★★★★★ | 11 | 0 |
| The Pines At Philadelphia Rehab And Healthcare Ctr | 3.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.