Roosevelt Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 7800 Bustleton Avenue, Philadelphia, Pennsylvania 19152
- CMS Provider Number
- 395537
- Inspections on file
- 46
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Roosevelt Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including low back pain, end stage renal disease, chronic pancreatitis, and osteoarthritis, had an active PRN order for oxycodone 5 mg by mouth every 4 hours for pain. A nurse documented in a nursing note that the resident had pain and received one PRN oxycodone dose with positive effect, and the narcotic reconciliation log showed the drug was signed out during the night. However, the corresponding dose was not documented on the MAR. In an interview, the NHA and DON confirmed the missing MAR entry and stated that all narcotics are expected to be documented both in the narcotic log and on the MAR.
A resident with dementia and severe cognitive impairment, as shown by a low BIMS score, was able to leave a resident floor in the evening and enter the main kitchen unsupervised after kitchen staff had left. The kitchen had not been locked, contrary to the Administrator’s stated expectation, allowing the resident to access the area where a fire alarm pull switch was located beyond stoves and other kitchen equipment. Staff later found the resident in the kitchen in a wheelchair after a fire alarm was activated, and the resident reported looking for a snack and pulling something without knowing what it was.
A resident with an active PRN order for Cyclobenzaprine HCl 10 mg for muscle spasms did not receive the medication for several weeks because it was not available in the med cart, despite having previously received it routinely at bedtime. The resident reported not getting the muscle relaxant and being told by staff that the pharmacy did not have it, and staff confirmed the drug was unavailable for administration. Review of the MARs showed the last dose was given at the end of one month, with no further doses documented the following month, resulting in a deficiency related to pharmacy services and failure to provide necessary pharmaceutical care.
A resident with an elevated potassium level had physician orders for repeat lab tests, but staff failed to obtain the required laboratory studies on the specified dates. The DON confirmed that the ordered lab work was not completed, and clinical records lacked evidence of the tests being performed.
A resident with lower extremity wounds and a history of cellulitis did not receive timely podiatry follow-up as ordered after admission. The facility missed two scheduled appointments, failed to arrange transportation as promised, and did not document reasons for the missed services. Staff interviews confirmed the missed appointments and lack of explanation.
A resident with chronic kidney disease, urinary tract infection, and urinary retention had a new Foley catheter placed, but the facility did not develop a comprehensive, person-centered care plan for catheter care as required. This omission was confirmed by the ADON after review of the resident's records.
A resident with multiple urinary diagnoses had a Foley catheter placed without a corresponding physician order documented in the clinical record, despite facility policy requiring such documentation. Additionally, the same resident, who had an order for 1:1 supervision for safety, was left unsupervised when the assigned staff stepped away from the room, and this lapse was confirmed by facility leadership.
The facility did not display the required State Survey Agency contact information, including the Department of Health Hotline number, in the lobby or on any nursing floors. During a group interview, several alert and oriented residents reported not knowing how to contact the Department of Health, and observations with the Administrator confirmed the absence of the postings.
Pharmacist recommendations from monthly medication regimen reviews were not consistently reviewed or acted upon by physicians in a timely manner for three residents. In several cases, recommendations regarding medication timing, laboratory monitoring, and vital sign checks were either not implemented, not documented, or lacked proper physician signatures, despite facility policy requiring such actions.
Multiple residents reported that meals were consistently served cold, with specific complaints about cold pancakes, dry eggs, missing meal items, and insufficient accompaniments for beverages. Direct observation of a test tray with the Food Service Director confirmed that food and drink items were below the expected temperature for palatability and safety, and the Food Service Director acknowledged the deficiency.
Staff failed to consistently use required PPE and post enhanced barrier precaution signage for residents with indwelling devices or wounds, resulting in care being provided without gowns or gloves. Additionally, nurses used a blood pressure cuff on multiple residents without disinfecting it between uses. Staff interviews revealed confusion about PPE requirements and reliance on signage that was not always posted or accessible.
A resident with an indwelling urinary catheter was found to have a urine bag containing cloudy urine with sediment, and the bag was not dated. Nursing staff confirmed inconsistent bag changes and lack of adherence to facility policy. There was no documentation of urine output monitoring, physician notification, or follow-up after the cloudy urine was observed.
A resident with severe malnutrition and cognitive impairment did not receive a physician-ordered nutritional supplement, as confirmed by record review, meal observations, and staff interviews. The supplement was not documented as administered and was absent from the resident's meal trays, despite care plan and physician orders.
A resident with COPD and acute respiratory failure was observed receiving oxygen at a rate higher than the physician-ordered 2 liters per minute via nasal cannula. The nurse confirmed the administration of 5 liters per minute, which did not follow the documented order for respiratory care.
Two residents receiving hemodialysis had incomplete Hemodialysis Communication Records, with missing documentation such as new orders, shunt site observations, pain reports, lab values, and staff signatures on multiple occasions, as confirmed by an LPN.
A resident with acute congestive heart failure did not receive prescribed cardiac medications, including Carvedilol, Entresto, Rivaroxaban, and Spironolactone, in a timely manner after admission. The medications were not available as ordered, and administration was delayed until the following evening, with medication records inaccurately coded as 'held' without physician parameters.
Surveyors identified that the facility exceeded the acceptable medication error rate, with errors including a resident not rinsing after inhaled corticosteroid administration, another resident missing a scheduled inhalation medication due to unavailability, and a third resident receiving the wrong formulation of aspirin. These errors resulted in a medication error rate of 10.34%.
Surveyors found that several residents did not receive the food items they requested, with some reporting this happened multiple times a week. Residents and staff confirmed ongoing issues with meal accuracy, including a resident being served pasta despite a 'no pasta' order and another dependent resident not receiving a preferred sandwich provided by family. These incidents show the facility did not consistently accommodate resident dietary preferences.
Surveyors identified deficiencies in food storage and sanitation, including a foul odor and dirty walls in the dishwasher area, as well as improperly labeled food items in the walk-in cooler. Several meats were marked only with received dates and lacked required use-by or defrost dates, contrary to facility policy.
A resident at Roosevelt Rehabilitation and Healthcare did not receive a breakfast meal due to miscommunication among nurse aides. The resident had previously reported a nurse aide for refusing to change bed linens, which he believed led to retaliation. On the morning in question, the resident was asleep when the breakfast tray was delivered, and it was left because he did not like to be woken up. The facility's policy to deliver food trays to each resident's room was not followed, resulting in the resident missing his meal.
The facility failed to provide timely incontinence care for several residents, including one with chronic obstructive pulmonary disease and another with hypertension and diabetes. Residents reported being left soiled for extended periods, with call bells either unreachable or unanswered. This deficiency highlights a systemic issue in the facility's response to residents' toileting needs.
The facility failed to maintain sanitary conditions in food preparation and service, with observations of improper food storage, lack of labeling, and inadequate hand hygiene practices. A dietary aide was seen without proper hair restraints, and nursing aides did not perform hand hygiene after assisting residents, violating the facility's policies.
The facility failed to maintain an effective antibiotic stewardship program, as it did not consistently document necessary information such as symptoms, stop dates, total days of therapy, outcomes, and adverse events for antibiotic orders over a six-month period. Additionally, an Infection Report tool was not utilized after April 2024, as confirmed by the DON.
The facility failed to provide meals that were palatable, attractive, and served at safe temperatures during lunch observations. Meals were served at incorrect temperatures, lacked color, and were unappealing, leading to resident dissatisfaction and refusal to eat. The Regional Dietary Director and a unit manager confirmed these issues, and management acknowledged the problem.
The facility failed to implement enhanced barrier precautions and proper infection control practices for four residents. A resident with a feeding tube was cared for without the required gown, and two residents with feeding tubes lacked precaution signs outside their rooms. Additionally, a nurse aide did not follow hand hygiene protocols while preparing and feeding a resident.
The facility failed to maintain a clean and homelike environment on two nursing units. Issues included water leaks from the ceiling, missing ceiling tiles, sticky floors, missing baseboard molding, a hole in the wall, and a strong urine odor in a room and hallway. A resident reported the water leak had been ongoing for weeks without proper resolution, and these observations were confirmed by the facility administrator.
A facility failed to create a baseline care plan within 48 hours for a resident with a laryngectomy tube, who managed her own care. Despite the resident's preference for self-care, the facility did not develop a plan addressing her respiratory and communication needs, as confirmed by the DON.
A facility failed to create a smoking-related care plan for a resident with COPD and end-stage renal disease, despite identifying them as a smoker. The resident's MDS inaccurately reported no tobacco use, and no further assessment or care plan was developed. The DON confirmed the absence of a care plan, indicating a deficiency in policy adherence.
A resident with contractures due to a stroke did not receive necessary services to prevent further decline in range of motion. Observations showed the resident without positioning devices or splints, and clinical records indicated no restorative program was established. The Rehab Director confirmed the lack of services for the resident's condition.
A resident experienced significant weight loss, losing over 15 pounds in one month, which was not addressed by the facility until eight days later. The facility failed to adhere to its policy of reweighing residents with significant weight changes and did not evaluate the resident in a timely manner. The resident, who was on enteral nutrition and NPO, was found to have severe protein-calorie malnutrition with a BMI of 17.4.
A facility failed to maintain complete records of communication between the facility and a dialysis center for a resident with ESRD. The resident's dialysis binder lacked documentation on several occasions, indicating a failure to assess and monitor the resident after dialysis. A nurse confirmed the incomplete records and acknowledged the nursing staff's responsibility to complete the documentation.
A resident experienced a significant weight loss of over 26% without documented physician assessment or intervention, despite facility policy requiring such actions for significant weight changes. The resident's weight dropped from 178.2 lbs to 131.8 lbs, and although the dietitian was involved, the clinical record lacked evidence of a physician's assessment addressing the weight loss.
A facility failed to ensure a physician documented the rationale for rejecting pharmacist recommendations for a resident's medication regimen. The pharmacist suggested a dose reduction for Aripiprazole and a dosing schedule change for Midodrine, but the physician disagreed without providing a rationale. The Director of Nursing confirmed the documentation was incomplete, violating facility policy.
The facility failed to ensure proper labeling and storage of medications, as observed in four medication carts across different floors. Issues included missing opening dates on over-the-counter medications and eye drops, unidentifiable insulin pens, and loose pills in cart drawers. These deficiencies were confirmed by interviews with LPNs during observations.
The facility failed to maintain an effective pest control program, as evidenced by observations of fly traps with dead flies and reports of mice, rats, flies, and roaches in resident rooms. These issues were confirmed by the Administrator.
The facility failed to adequately train staff on Enhanced Barrier Precautions (EBPs), leading to inconsistent implementation of infection control measures. Observations and interviews revealed that staff misunderstood EBP requirements, with some equating them to isolation precautions. A nursing assistant was observed providing care to a resident with a feeding tube without wearing a gown, contrary to the facility's policy.
The facility failed to provide meals according to residents' dietary preferences, affecting four residents. Observations revealed discrepancies such as serving incorrect food items and undercooked meals. A resident received mashed potatoes instead of sweet potatoes, another was served a white bread sandwich despite a preference for wheat, and two residents received hard tortellini. Additionally, a resident with a colostomy bag was served pasta, which they avoid. These issues were confirmed by staff and resident interviews.
The facility failed to provide timely incontinence care for two residents, as evidenced by one resident reporting being wet from 5:00 a.m. to 11:00 a.m. and another resident experiencing delays during the night shift. Both residents have intact cognition and require two-person assistance for ADLs.
A resident experienced significant weight loss, and the facility failed to obtain physician orders for weekly weights despite a dietician's recommendation. The Director of Nursing confirmed the absence of the required orders, leading to the deficiency.
Failure to Accurately Document PRN Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident when documentation of a PRN narcotic dose was inconsistent across required records. The resident, who had diagnoses including low back pain, end stage renal disease, chronic pancreatitis, and osteoarthritis, had an active physician order for oxycodone 5 mg by mouth every 4 hours as needed for pain until it was discontinued following the resident’s death. A nursing note signed by employee E3 at 3:09 a.m. documented that the resident exhibited signs and symptoms of pain and that one PRN dose of oxycodone was given with a positive effect. The narcotic reconciliation log showed that an oxycodone dose was signed out at 1:38 a.m. the same date. However, review of the MAR revealed that this oxycodone dose was not documented there. In an interview, the Nursing Home Administrator and the Director of Nursing confirmed that the oxycodone dose was not signed out on the MAR and that facility expectations require all narcotics to be documented both in the narcotics log and on the MAR.
Failure to Secure Kitchen Allows Cognitively Impaired Resident Unsupervised Access
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and to provide adequate supervision when a resident with severe cognitive impairment accessed the main kitchen unattended during nighttime hours. The resident had diagnoses including dementia and anxiety, and an MDS dated August 22, 2025, documented a BIMS score of 3, indicating severely impaired cognition. On the evening of August 27, 2025, the resident, who was on the third floor at 8:30 p.m., was later found missing at 8:45 p.m. when staff could not locate her and a fire alarm sounded. According to the facility’s investigation, staff responding to the fire alarm found the resident in the first-floor kitchen, seated in her wheelchair, stating she had been looking for a snack and that she had pulled something without knowing what it was. The investigation determined that the resident had accessed the kitchen after hours when kitchen staff had left but failed to lock the kitchen. Observation of the first-floor kitchen showed that the fire alarm pull switch was located in the middle of the kitchen, beyond the stove and other kitchen equipment, with two fire doors and one regular door next to the switch leading to the exterior of the building. The Administrator confirmed that the kitchen should have been locked after kitchen staff left and that it was not locked on the night of the incident, allowing the resident to enter the kitchen and activate the fire alarm pull switch.
Failure to Provide Ordered PRN Muscle Relaxant Due to Medication Unavailability
Penalty
Summary
Surveyors determined that the facility failed to provide necessary pharmaceutical services when a resident did not receive a prescribed PRN muscle relaxant for an extended period. The resident reported during an interview that she had routinely taken Cyclobenzaprine HCl 10 mg at bedtime to relieve muscle spasms but had not received it for the past two weeks, and staff told her the medication was not available from the pharmacy. A staff member confirmed that the medication was not available in the medication cart to administer to the resident. Review of the physician’s order dated November 10, 2025, showed an active order for Cyclobenzaprine HCl 10 mg, 1 tablet by mouth every 8 hours as needed for muscle spasms. Review of the December 2025 MAR showed the medication was administered 15 times, with 11 of those doses given at bedtime between 8 p.m. and 10 p.m., and the last recorded administration on December 28, 2025. Further review of the January 2026 MAR through January 26, 2026, revealed that the resident did not receive any doses of Cyclobenzaprine HCl for the entire month, indicating that the ordered PRN medication was not provided after December 28, 2025. This lack of availability and administration of the ordered medication, despite an ongoing physician order and prior routine use by the resident, formed the basis of the cited deficiency under 28 Pa. Code 201.14(a) and 211.9(a)(1)(f)(2)(4)(k) related to pharmacy services.
Failure to Obtain Physician-Ordered Laboratory Studies
Penalty
Summary
The facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one resident. Clinical record review showed that a resident had an elevated potassium level, and the physician ordered a repeat Basic Metabolic Panel (BMP) to be done on a specific date. However, documentation revealed that the repeat BMP was not completed as ordered, and a subsequent order for a Comprehensive Metabolic Panel (CMP) was also not carried out. An interview with the Director of Nursing confirmed that staff did not obtain the required lab work on the dates specified by the medical practitioner. There was no evidence in the clinical records that the laboratory tests ordered by the physician were completed as required.
Failure to Arrange Timely Outside Professional Services for Wound Care
Penalty
Summary
The facility failed to provide timely access to outside professional services for a resident who required follow-up care for wounds on the lower extremity. The resident, who had a history of cellulitis and a chronic venous hypertension ulcer of the right lower extremity, was admitted with a hospital discharge order for a podiatry follow-up. Clinical record review showed that the resident was not seen by podiatry as ordered on two separate occasions, and there was no documentation explaining the missed appointments or cancellations. The resident reported that staff had informed him transportation was arranged for his appointments, but at the time of the scheduled visits, he was told there was no transportation and the appointments were not completed. Interviews with staff, including the DON, confirmed that the facility missed both scheduled podiatry appointments and could not provide a reason for the failure to send the resident. There was no evidence in the clinical record that the required services were furnished or that the missed appointments were documented.
Failure to Develop Comprehensive Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing urinary catheter care for a resident with multiple urinary diagnoses, including chronic kidney disease, urinary tract infection, prostatic hyperplasia with lower urinary tract symptoms, urinary urgency, and urinary retention. The resident was admitted with these conditions and had a new Foley catheter placed at a recent urology appointment. Review of the resident's clinical record and care plan revealed that, despite the presence of the catheter and related diagnoses, no care plan for catheter care was documented. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the absence of a comprehensive care plan for the urinary catheter.
Failure to Follow Physician Orders for Catheter Care and 1:1 Supervision
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician's orders for urinary catheter care and for required 1:1 staff supervision. For one resident with chronic kidney disease, urinary tract infection, prostatic hyperplasia, urinary urgency, and urinary retention, a Foley catheter was placed at a urology appointment. However, there was no physician order for the urinary Foley catheter documented in the resident's clinical record since the date of placement, despite the presence of a hard copy urology consultation indicating the catheter. The facility's policy required specific documentation for catheter care, but the necessary physician order was missing. Additionally, the same resident had a physician order for 1:1 supervision every shift for safety, but this was not consistently implemented. During an observation, the resident was found in their room without 1:1 staff present, and the assigned nurse aide confirmed she had stepped away from the resident's room for approximately five minutes. Interviews with facility leadership confirmed the lack of a physician order for the Foley catheter and the lapse in required supervision.
Failure to Post State Survey Agency Contact Information
Penalty
Summary
The facility failed to display the required contact information for the State Survey Agency, including the Department of Health (DOH) Hotline number, in the lobby and on all three nursing floors. During a resident council interview with nine alert and oriented residents, none of the residents knew how to contact the DOH with a complaint, and all confirmed they had not seen the contact information posted. One resident specifically stated that the number was not posted and suggested that pamphlets should be distributed. Observations conducted with the Administrator confirmed that the required contact information was not posted in the designated areas. The Administrator acknowledged this omission during an interview.
Failure to Ensure Timely Physician Review of Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist recommendations from monthly medication regimen reviews were reviewed and acted upon by physicians in a timely manner for three of five residents reviewed. For one resident, the pharmacist recommended adjusting the timing of insulin lispro administration to align with meal times, and although the physician indicated agreement and signed the recommendation, the clinical record and medication administration record did not reflect any change to the order. For another resident, the pharmacist recommended ordering specific laboratory tests to monitor medication safety and efficacy, and while the physician wrote that the labs were ordered and signed the document, there was no corresponding physician order for the labs in the clinical record. Additionally, the pharmacist suggested changing the administration time of tamsulosin to after dinner for better absorption, but the physician disagreed with the recommendation, and the document was not signed or dated by the physician. For a third resident, the pharmacist recommended adding weekly blood pressure and pulse monitoring due to ongoing antihypertensive therapy. The document had an "OK" written on it, but lacked a physician signature or date, and there was no evidence in the clinical record that the recommendation was reviewed or acted upon. An interview with the Director of Nursing confirmed that there was no documentation showing that these recommendations were noted and completed. These findings indicate a failure to follow facility policy and regulatory requirements for timely physician review and documentation of pharmacist recommendations.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
Surveyors identified that the facility failed to provide food and drink that was palatable and served at the proper temperature for all six residents interviewed. Multiple residents reported that their food was consistently cold, with specific complaints about cold pancakes, lack of cold cereal, dry eggs, missing meal items, and insufficient accompaniments for beverages. One resident noted that a rib sandwich was served cold, and another stated that the food was always cold and unappetizing. These concerns were echoed during a group interview, where all participating residents agreed there were ongoing problems with the food. Direct observation of a test tray with the Food Service Director confirmed these complaints, as food and drink items were measured at temperatures below the expected standard for palatability and safety. For example, apple juice was 46.5°F, canned pineapple was 65°F, mashed potatoes were 126°F, and a pork riblet was 111°F. The Food Service Director acknowledged that foods should reach 140°F and confirmed that the tested items were too cool to be considered palatable. These findings were supported by facility documentation, resident interviews, and direct observation.
Failure to Implement Enhanced Barrier Precautions and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the use of enhanced barrier precautions (EBP) and proper cleaning of medical equipment. Observations revealed that staff did not consistently use required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents with indwelling medical devices or wounds. For example, nurse aides provided bathing and incontinence care to a resident dependent on tube feeding without wearing gowns, despite care plan interventions specifying EBP. Additionally, there was no signage indicating EBP outside the rooms of residents requiring such precautions, and staff reported relying on signage to know when PPE was necessary. Further deficiencies were observed in the cleaning and disinfection of medical equipment. Multiple licensed nurses and registered nurses used a sphygmomanometer to check blood pressure on several residents without disinfecting the device between uses. This occurred even for residents on EBP, and staff confirmed at the time of observation that the equipment was not cleaned as required. The lack of proper disinfection was noted during medication administration and routine care activities. Interviews with staff, including nurse aides, licensed nurses, and the Assistant Director of Nursing (ADON), revealed gaps in knowledge and adherence to infection control protocols. Some staff were unaware of the need for PPE in the absence of signage, and EBP signage was found to be inaccessible, locked in the ADON's office. The infection preventionist indicated that unit managers were responsible for posting EBP signage, but this was not consistently done, leading to staff not following established infection control procedures.
Failure to Monitor Catheter Care and Urine Output
Penalty
Summary
A deficiency was identified regarding the care of a resident with an indwelling urinary catheter. The resident, who had diagnoses including Multiple Sclerosis, Spastic Hemiplegia, and the presence of urogenital implants, had a physician's order for a urinary catheter with a drainage bag. During observation, the urine bag was found to contain 50 cc of very cloudy liquid with sediment, and neither the bag nor the tubing was dated. The nurse interviewed confirmed the cloudiness of the urine and stated that the bag is sometimes changed only once a week, and that PRN staff do not always change the bags as required by facility policy. The nurse was unable to state when the urine bag was last replaced. Review of the clinical record revealed no documentation that the resident's urine output was being monitored, nor was there evidence that the physician had been notified about the cloudy urine. Additionally, there was no documentation of any monitoring or observation of the resident's status after the cloudy urine was observed. These findings indicate a failure to provide appropriate catheter care and monitoring as required.
Failure to Provide Ordered Nutritional Supplement to Resident with Malnutrition
Penalty
Summary
A resident with diagnoses including malnutrition, metabolic encephalopathy, muscle weakness, and cachexia was admitted to the facility with a BMI of 13, indicating extreme underweight status. The resident's care plan, initiated in early March, specified that nutritional supplements should be provided during meals according to the resident's preference. A physician order was in place for Ensure Plus to be administered three times daily as a supplement. Clinical record reviews, medication administration documentation, and direct meal observations revealed that the ordered supplement was not provided to the resident as prescribed. Specifically, there was no documented evidence that Ensure Plus was given from the date of the physician order through subsequent days, and the supplement was not present on the resident's meal trays during observed lunches. These findings were confirmed by staff interviews, including the nurse manager, registered dietitian, and director of nursing, all of whom acknowledged the lack of documentation and administration of the supplement as ordered.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Acute Respiratory Failure was not provided respiratory care in accordance with physician orders. The resident had a documented order for oxygen administration at 2 liters per minute via nasal cannula to maintain a pulse oximetry reading above 92%. However, during an observation, the resident was found to be receiving oxygen at 5 liters per minute via nasal cannula, which was not consistent with the physician's order. This discrepancy was confirmed by a licensed nurse at the time of the observation. The facility's policy requires nurses to follow physician orders when administering oxygen, but this was not adhered to in this instance.
Incomplete Dialysis Communication Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for two residents who required hemodialysis. For one resident, physician orders indicated scheduled dialysis treatments three times per week. However, review of the Hemodialysis Communication Record revealed missing required information on multiple dates, including documentation of new orders received and sent with the patient, comments, shunt site observation, whether ports were capped and completed, whether the patient reported pain, lab values, pertinent observations, staff signature and title, and time. A licensed nurse confirmed the lack of this information in the resident's record. Similarly, another resident with physician orders for dialysis on the same schedule had incomplete documentation in the Hemodialysis Communication Record on at least one occasion. The missing information included the same required elements as above. This deficiency was confirmed through staff interview, indicating a pattern of incomplete record-keeping for residents receiving dialysis services.
Failure to Timely Provide and Administer Cardiac Medications for New Admission
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of essential cardiac medications for a newly admitted resident diagnosed with acute congestive heart failure. Upon admission, the resident had physician orders for Carvedilol and Entresto to be administered starting the evening of admission, but these medications were not available and were not given as scheduled. The medication administration record showed that both medications were not administered at the prescribed times, and the first doses were delayed until the following evening. Additionally, Rivaroxaban and Spironolactone, which were part of the resident's hospital regimen and recommended for continued use, were not ordered until the day after admission, further delaying their administration. Interviews with the resident, the resident's wife, the DON, and the Administrator confirmed that the medications were not available on the day of admission and that the medication administration record was inaccurately coded as 'held' without physician parameters for holding the medications. The facility's policy required medications to be administered in a safe and timely manner as prescribed, but this was not followed, resulting in the resident not receiving critical heart medications as ordered.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by errors observed during medication administration for three of seven residents. One resident was administered Breo Ellipta Aerosol Powder by a licensed nurse, but the nurse did not ensure the resident rinsed and spit after inhalation, contrary to the physician's order. This step is necessary to comply with the prescribed administration method. The nurse confirmed the omission during an interview at the time of the finding. Another resident did not receive a scheduled dose of Ipratropium-Albuterol Inhalation Solution because the medication was not available in the facility, and the nurse was waiting for it to arrive from the pharmacy. Additionally, a third resident was given Aspirin Tablet Enteric Coated 81 mg instead of the prescribed Aspirin Tablet Chewable 81 mg, as per the physician's order. The nurse administering the medication confirmed this discrepancy during the observation. These incidents resulted in a calculated medication error rate of 10.34%.
Failure to Honor Resident Food Preferences and Requests
Penalty
Summary
Surveyors identified that the facility failed to honor resident food and drink preferences for six residents. Multiple residents reported not receiving the food items they selected on their menus, with some stating this occurred several times a week. During a group interview, all residents present agreed there were ongoing problems with the kitchen, and several residents specifically mentioned not receiving their requested meals or having items missing from their trays. One resident's lunch ticket specifically stated 'no pasta,' yet the resident was served spaghetti and meatballs, a fact confirmed by both the resident and a nursing aide who reviewed the ticket. Another resident, who is dependent on staff for all activities of daily living and is on a mechanically altered and therapeutic diet due to multiple sclerosis, did not receive the specific sandwich requested by her family. The family had provided bologna, apple sauce, and cranberry juice to ensure the resident received preferred items, but the resident was served a turkey sandwich instead of the requested bologna. A licensed nurse confirmed awareness of the resident's dietary preferences but was unable to explain why the correct item was not provided. These findings demonstrate that the facility did not consistently provide food that accommodated resident preferences and requests as required.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the Food Service Department, surveyors observed a foul smell caused by food debris in the dishwasher area and noted that the walls in this area had streaks of black dirt. In the walk-in cooler, several food items, including a 10-pound turkey, beef bologna, and two 10-pound ground beef packages, were labeled only with the received date and not with use-by or discard dates as required by facility policy. Additionally, a top round of meat was found with only a received date and no indication of when it was removed from the freezer to defrost, contrary to policy requirements for labeling and dating refrigerated foods.
Miscommunication Leads to Missed Meal for Resident
Penalty
Summary
Roosevelt Rehabilitation and Healthcare was found to be non-compliant with the requirement to provide meals at regular times, as evidenced by an incident involving Resident R3. On January 8, 2025, Resident R3 did not receive his breakfast meal due to a miscommunication among nurse aides. The facility's policy requires nursing staff to deliver food trays to each resident's room, but this was not followed for Resident R3. The resident had previously reported his assigned nurse aide, Employee E3, for refusing to change his bed linens, which he believed led to retaliation when he did not receive his breakfast. Further investigation revealed that Employee E3 was reassigned on the morning of January 8, 2025, and was not responsible for Resident R3's care at that time. However, a grievance report indicated that the meal was offered, but Resident R3 declined it, stating he was heading to lunch. The unit manager confirmed the miscommunication among staff, which resulted in the resident not receiving his breakfast tray. The facility's grievance investigation included a statement from Employee E3, noting that Resident R3 was asleep when the breakfast tray was delivered, and the tray was left because the resident did not like to be woken up.
Plan Of Correction
1. Facility cannot retroactively provide resident 3 with a missed meal. 2. Facility conducted full house audit on each meal to ensure every resident received a meal tray. Facility conducted full house audit to ensure all residents had meal tickets. 3. NHA/designee will re-educate all nursing department to ensure staff will remove food trays from the food cart and deliver the trays to each resident room when eating meals on the unit. 4. NHA/designee will conduct random audits on one cart to ensure all residents receive a meal daily x4 weeks, weekly x4 and monthly x2. Facility will conduct audits to ensure all residents have a meal ticket 3x a week for 4 weeks, weekly x4 and monthly x2. Results will be submitted to QAPI for review and recommendations as needed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for four out of six residents reviewed, leading to a deficiency in nursing services. Resident R1, who was admitted with chronic obstructive pulmonary disease, anemia, and coronary artery disease, was found soiled and unable to reach the call bell, which was wrapped around the back of the bed. Despite having an intact cognition as indicated by a BIMS score of 14, Resident R1 reported being left soiled for an hour without assistance. This was corroborated by Resident R1's roommate, who confirmed that staff frequently did not assist Resident R1 in a timely manner. Similarly, Resident R2, with diagnoses of hypertension, diabetes mellitus, and arthritis, reported pressing the call bell overnight for toileting assistance but remained soiled for several hours as staff did not respond. Residents R3 and R4, who require extensive assistance with toileting hygiene, also reported not being changed in a timely manner. Resident R3's family further confirmed that Resident R3 was often found soiled during visits. These findings indicate a systemic issue in the facility's response to residents' incontinence care needs.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served under sanitary conditions, as required by professional standards for food service safety. Observations during a kitchen tour revealed several violations of the facility's food storage and handling policies. These included a broom and dustpan left on the kitchen floor, improperly stored cleaning equipment, and trash containers with dirty gloves in the dock area. In the dry storage area, several food items such as dressings, bread, sesame seeds, and brown sugar were found without proper labeling or expiration dates. The main refrigerator contained prepared yellow cakes without preparation or expiration dates, and the main freezer had open chicken fingers and frozen meatballs without labels indicating when they were opened or their expiration dates. Additionally, a dietary aide was observed handling food without a beard covering or hair net, contrary to the facility's policy. Further observations in the dining area revealed that nursing aides failed to perform hand hygiene after assisting residents with their meals. Specifically, two nursing aides were seen delivering food and assisting residents without washing their hands after touching potentially contaminated surfaces. One aide was observed touching a resident's wheelchair footrest and picking up an item from the floor with a napkin before directly assisting a resident with their meal. These actions were confirmed by the unit manager, indicating a breach in the facility's hand hygiene policy, which is intended to prevent the spread of healthcare-associated infections.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a six-month period, as evidenced by a lack of adherence to its own policies and procedures. The facility's policy, dated December 2016, required the collection and documentation of antibiotic usage and outcomes using a facility-approved tracking form. However, the review of facility documentation revealed that the facility did not consistently document necessary information such as symptoms, stop dates, total days of therapy, outcomes, and adverse events for antibiotic orders. Specifically, in April, May, and June 2024, numerous infections were recorded without symptoms documented, and most antibiotic orders lacked critical information as per the facility's policy. Additionally, the facility's antibiotic stewardship data indicated that an Infection Report tool, which was supposed to be completed by a licensed nurse at the onset of infection symptoms, was not utilized after April 2024. This tool was intended to determine if infections met the criteria for reporting. The Director of Nursing confirmed these findings during an interview on July 2, 2024. The facility's failure to adhere to its antibiotic stewardship program and documentation requirements resulted in a deficiency under 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(5).
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and served at safe and appetizing temperatures during lunch observations on two consecutive days. On June 30, 2024, a test tray revealed that the hot meal items, including glazed pork loin, steamed cauliflower, and sweet potatoes, were served at temperatures below the safe threshold, while apple juice was served above the recommended cold temperature. Residents reported the food as unappealing, cold, and difficult to eat, with some refusing to eat their meals. The Regional Dietary Director confirmed the lack of color and attractiveness of the meals served. On July 1, 2024, further issues were observed with the lunch service. A resident received a lunch tray with hard tortellini pasta and burned garlic bread, which was confirmed by a unit manager to be unpalatable. The resident's meal preferences were not met, and the food was described as having no flavor or appearance. A group interview with residents revealed dissatisfaction with the taste and temperature of the food, with reports of it being undercooked or overcooked and not seasoned. The facility's management acknowledged the issues with the lunch service during a meeting.
Failure to Implement Enhanced Barrier Precautions and Infection Control
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) and proper infection control practices for four residents. Resident R52, who has a feeding tube due to conditions such as a stroke and dementia, was observed receiving care from a nursing assistant without the required gown, despite a sign indicating the need for EBPs. The nursing assistant misunderstood the EBP requirements, thinking they pertained to skin care rather than infection control. Additionally, residents R101 and R194, both with feeding tubes, did not have signs outside their rooms to alert staff and visitors about the need for EBPs, despite physician orders indicating such precautions every shift. In the dining room, infection control practices were not followed as a nurse aide was observed preparing and feeding a resident without washing or sanitizing her hands. This lack of adherence to hand hygiene protocols, as outlined in the facility's policy, further contributed to the deficiency. These observations indicate a failure in the facility's implementation of its infection prevention and control program, particularly in the use of EBPs and hand hygiene practices.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean and homelike environment in two of its three nursing units, specifically on the third and fourth floors. Observations revealed several issues, including water dripping from the ceiling in one room, with a missing ceiling tile and water being collected in a nearly full trash can. A resident reported that the leak had been ongoing for weeks since the air conditioner was turned on, and despite staff being aware, the issue was not resolved. The resident further stated that a ceiling tile was replaced without properly fixing the leak, leading to its collapse. Another room had water on the floor, making it sticky, and a different room had missing baseboard molding and a hole in the wall. Additionally, a strong odor consistent with urine was detected in a room and the hallway outside it. These observations were confirmed by the facility administrator.
Failure to Develop Baseline Care Plan for Resident with Laryngectomy
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with specific respiratory care needs. The resident, identified as having a laryngectomy tube due to the surgical removal of the larynx, expressed that nursing staff did not consistently offer assistance with the care of her laryngectomy tube, which she managed herself. Despite the resident's ability to care for her tube, the facility's policy required a baseline care plan to be developed to address immediate health and safety needs, which was not done in this case. Interviews and record reviews revealed that the respiratory therapist assessed the resident upon admission and noted her preference for self-care. However, no baseline care plan was created to address the resident's laryngectomy tube care, impaired communication, or respiratory needs, including suctioning and assessment. The Director of Nursing confirmed the absence of a baseline care plan for these needs, indicating a lapse in adhering to the facility's care policies and state regulations.
Failure to Develop Smoking-Related Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan related to smoking for a resident identified as a smoker. The facility's policy requires that a comprehensive care plan with measurable objectives and timetables be developed for each resident, including those who smoke. However, despite the resident being identified as a smoker in the facility's documentation, no care plan was developed to address the resident's smoking habits and ensure their safety. The resident, who has chronic obstructive pulmonary disease and end-stage renal disease, was observed smoking in the designated area, yet their Minimum Data Set assessment inaccurately indicated that they did not use tobacco. The facility's smoking policy mandates that residents' smoking status be evaluated upon admission and re-evaluated quarterly or upon significant changes. Despite this, the resident's smoking evaluation conducted by a licensed nurse inaccurately reported that the resident did not smoke, leading to a lack of further assessment or care planning. The Director of Nursing confirmed the absence of a smoking-related care plan for the resident, highlighting a deficiency in adhering to the facility's policies and ensuring resident safety.
Failure to Provide ROM Services for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, resulting in a deficiency. The resident, who had contractures in his hands due to a stroke, reported not receiving any services such as exercise or splinting to prevent further worsening of the contracture. Observations confirmed that the resident was lying in bed without any positioning devices or splints, and both hands appeared contracted. Clinical records revealed that the resident had hemiplegia and hemiparesis, with impaired range of motion in the upper extremities. An occupational therapy evaluation noted limited range of motion and decreased strength, but no restorative or functional maintenance program was established. The active care plan and physician orders did not include a restorative nursing program or services for the resident's limited range of motion. The Rehab Director confirmed that the resident was not receiving any services for his condition.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to provide acceptable nutritional parameters for a resident, identified as R194, who experienced significant weight loss. According to the facility's Weight Policy, residents should be weighed on admission, weekly for four weeks, and then monthly unless otherwise ordered. Any significant weight change, defined as a 5% gain or loss in one month, should be reported to the Registered Dietitian and reweighed. However, the facility did not adhere to this policy. Resident R194 lost over 15 pounds in one month, with a total weight loss of 26.04% from January to June 2024. Despite this significant weight loss, the staff did not address the issue until June 18, 2024, and no reweight was completed as per the policy. The resident was on enteral nutrition and NPO (Nothing by Mouth), and the weight loss was attributed to severe protein-calorie malnutrition, with a BMI of 17.4 indicating underweight status. The dietician confirmed that a reweight was not obtained after the significant weight loss was noted on June 10, 2024, and the resident was not evaluated until June 18, 2024. The delay in addressing the weight loss and the lack of adherence to the facility's policy contributed to the deficiency identified in the report.
Incomplete Dialysis Communication for Resident with ESRD
Penalty
Summary
The facility failed to ensure ongoing records of communication between the facility and the dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis services. The facility's policy, revised in September 2010, mandates that residents with ESRD be cared for according to recognized standards, and that staff be trained in the care and special needs of these residents. However, a review of Resident R58's dialysis communication binder revealed incomplete documentation on several dates, indicating a lack of assessment and monitoring after the resident returned from dialysis. Resident R58, who was admitted with a diagnosis of ESRD and dependence on renal dialysis, had missing documentation in their dialysis binder on multiple occasions. The binder is supposed to include vital information such as vitals, weight, vascular access, and any new acute problems since the last treatment. An interview with a licensed nurse confirmed the incomplete documentation and acknowledged that it is the nursing staff's responsibility to complete the dialysis communication pages for all residents receiving dialysis.
Failure to Document Physician Assessment for Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a physician assessment was completed for a resident experiencing significant unplanned weight loss. According to the facility's Weight Policy, residents should be weighed upon admission, weekly for four weeks, and monthly thereafter unless otherwise ordered. Any significant weight change, defined as a 5% gain or loss in one month, should be reported to the Registered Dietitian and the physician. The policy also requires that interventions be documented in the care plan and discussed in the interdisciplinary team meeting. However, for Resident R194, who experienced a weight loss of over 15 pounds in one month, there was no documented evidence of a physician assessment addressing this significant weight change. Resident R194's weight records showed a decrease from 178.2 pounds to 131.8 pounds, a 26.04% loss, between January and June 2024. Despite the resident appearing cachectic and the dietitian being involved, the clinical record lacked documentation of a physician's assessment or intervention regarding the weight loss noted on June 10, 2024. This deficiency was confirmed during an interview with the Director of Nursing. The failure to document a physician's assessment and address the nutritional and medical issues related to the resident's weight change constitutes a violation of the facility's policies and state regulations.
Physician Fails to Document Rationale for Rejecting Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the physician documented the review of pharmacy recommendations and provided a rationale for rejecting these recommendations for a resident. The consultant pharmacist conducted a medication regimen review for a resident, who had been prescribed Aripiprazole and Midodrine. The pharmacist recommended a gradual dose reduction for Aripiprazole and suggested that Midodrine should not be dosed after 5:00 p.m. However, the physician disagreed with both recommendations without documenting any rationale for the rejection. The deficiency was identified through a review of the clinical records, interviews with staff, and examination of the facility's policy on medication regimen reviews. The Director of Nursing confirmed that the medication regimen review documents for the resident were inadequately completed, as the physician failed to provide documentation for the rejection of the pharmacist's recommendations. This lack of documentation is inconsistent with the facility's policy, which requires the attending physician to document the review of any irregularities and the actions taken to address them.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards of practice. This deficiency was observed in four out of six medication carts across different floors. The facility's policy on medication storage and labeling, revised in February 2023, requires that medications be labeled with specific information, including the medication name, prescribed dose, strength, expiration date, resident's name, route of administration, and appropriate instructions. However, during observations, it was found that multiple bottles of over-the-counter medications and eye drops lacked a marked date of opening, and there were loose pills and capsules in the drawers of the medication carts. On the Third-floor center's medication cart, multiple bottles of over-the-counter medications and eye drops were found without a marked date of opening. Similarly, the Second-floor center's medication cart had an unidentifiable insulin pen and multiple bottles of eye drops without a marked date of opening. The Third-floor south's medication cart contained a substantial number of loose pills and capsules, along with over-the-counter medication bottles not dated for opening. Lastly, the Fourth-floor center's medication cart also had loose pills in the drawers. These findings were confirmed by interviews with licensed nurses present during the observations.
Pest Control Deficiency in Resident Care Areas
Penalty
Summary
The facility failed to maintain an effective pest control program in the resident care areas, as evidenced by observations and resident interviews. In Resident room [ROOM NUMBER], a sticky fly trap with dead flies was observed hanging from the ceiling. A resident in this room reported the presence of flies and mentioned using the trap for some time. Another resident in a different room reported the presence of mice, rats, flies, and roaches, pointing out roaches behind the door and inside the bathroom. These observations were confirmed by the Administrator.
Inadequate Training on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide adequate training on infection control procedures related to Enhanced Barrier Precautions (EBPs) for seven out of eight employees interviewed. The facility's policy on EBPs, dated August 2022, requires the use of gowns and gloves during high-contact resident care activities to prevent the spread of multi-drug resistant organisms (MDROs). Despite a documented in-service training session held in May and June 2024, observations and interviews revealed that staff members were not properly implementing these precautions. For instance, a nursing assistant was observed providing care to a resident with a feeding tube without wearing a gown, contrary to the facility's EBP policy. Interviews with various staff members, including nursing assistants and licensed nurses, indicated a lack of understanding and inconsistent interpretations of the EBP requirements. Some staff equated EBPs with isolation precautions, while others misunderstood the purpose of the barrier precaution signs posted on residents' doors. This confusion among staff members highlights a significant gap in the facility's training and communication regarding infection control measures, particularly in the context of EBPs.
Failure to Adhere to Residents' Dietary Preferences
Penalty
Summary
The facility failed to provide food products based on the residents' food preferences for four out of 36 residents. The facility's policy, last revised in July 2017, requires that individual food preferences be assessed upon admission and communicated to the interdisciplinary team. However, observations and staff interviews revealed discrepancies in meal preparation and delivery. Resident R22 received mashed potatoes instead of the preferred mashed sweet potatoes and was missing bread or a roll with butter. Resident R23 was served a white bread sandwich despite a preference for wheat bread and received no tea or substitute vegetable, even though they disliked cauliflower. Further issues were observed on the third floor, where Resident R155 and Resident R98 received undercooked tortellini, which was too hard to chew. Resident R98's meal did not match their preference ticket, which included baked ziti with cheese and marinara sauce, Italian blend vegetables, and a sandwich. Additionally, Resident R57, who does not eat pasta due to having a colostomy bag, was served tortellini instead of the requested sandwich. These incidents indicate a failure to adhere to residents' dietary preferences and needs, as confirmed by staff and resident interviews.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, R1 and R2, as determined through clinical record review, observations, and staff interviews. Resident R1, who has a diagnosis of a disorder of the skin and subcutaneous tissue, rash, and other nonspecific skin eruptions, is care planned to be checked approximately every 2 hours and provided incontinence care as needed. Despite this, Resident R1 reported being wet and not changed from 5:00 a.m. until 11:00 a.m. on the day of the interview. The resident's call bell request for assistance was also ignored, and a nursing assistant suggested delaying the change until after lunch, which the resident declined due to the prolonged wait time. Resident R1's MDS indicated a BIMS score of 15, showing intact cognition, and required two-person assistance for ADLs. Similarly, Resident R2, who also has a BIMS score of 15 and requires two-person assistance for ADLs, reported experiencing delays in being changed, particularly during the 11-7 shift the previous night. The deficiency was observed during an interview with Resident R1, who expressed frustration over the lack of timely incontinence care. The resident's roommate, Resident R2, corroborated these concerns, indicating that staff sometimes failed to change her in a timely manner. The failure to provide timely incontinence care for these residents violates their rights and the facility's nursing services regulations, as outlined in 28 Pa Code 201.29(j) and 28 Pa Code 211.11(d)(1)(5).
Failure to Obtain Physician Orders for Weekly Weights
Penalty
Summary
The facility failed to obtain physician orders for weekly weights for a resident, despite a recommendation from the registered dietician. The facility's policy required weekly weights for the first four weeks after admission and monthly thereafter unless otherwise ordered by a physician or the IDT team. The resident, who was admitted with diagnoses including rhabdomyolysis, acute kidney failure, and pneumonitis, experienced significant weight loss over a period of time. The resident's weight dropped from 160 pounds at admission to 139.8 pounds by February 7, 2024, representing a 12.63% weight loss since admission. The registered dietician recommended weekly weights on January 24, 2024, but this recommendation was not reflected in the physician orders for January and February 2024. Consequently, no weekly weights were taken between January 24, 2024, and February 7, 2024. The Director of Nursing confirmed the absence of a physician order for weekly weights. This failure to follow the dietician's recommendation and obtain the necessary physician orders led to the deficiency noted in the report.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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