Rosemont Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rosemont, Pennsylvania.
- Location
- 35 Rosemont Avenue, Rosemont, Pennsylvania 19010
- CMS Provider Number
- 395193
- Inspections on file
- 31
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Rosemont Center during CMS and state inspections, most recent first.
A resident with dementia, mood disturbance, depression, cognitive communication deficit, anxiety, and conduct disorder had been assessed as high risk for elopement, but no elopement prevention care plan was in place. The resident was able to activate a fire door alarm on an upper floor, exit via the stairs, and then pass through emergency fire doors near the main entrance across from the receptionist area, resulting in an elopement. This occurred despite the facility’s existing policy intended to prevent unsafe wandering in residents at risk for elopement.
A resident's request for medical records was delayed due to a miscommunication regarding payment, resulting in a failure to provide timely access as required by regulations. The facility's policy mandates access within 24 hours and copies within two business days, but the records were not sent until nearly two months later.
The facility did not meet the required nurse aide (NA) to resident ratios on six out of seven days reviewed. The day shift was understaffed from December 23 to December 25, failing to maintain one NA per 10 residents. The night shift was understaffed on December 20, 21, and from December 23 to December 26, not meeting the one NA per 15 residents ratio. This was confirmed by the Administrator.
The facility did not meet the required LPN to resident ratio of one LPN per 25 residents during the night shift for seven consecutive days. This deficiency was confirmed by the facility's administrator after a review of nursing time schedules.
The facility failed to create comprehensive care plans for several residents with complex medical needs, including those requiring oxygen therapy, seizure management, catheter care, splinting, and post-amputation care. These deficiencies were confirmed through staff interviews and record reviews, indicating a lack of timely and person-centered care planning.
A facility failed to protect a resident's privacy when a medication cart with an open laptop displaying resident information was left unattended. Additionally, a wall-mounted computer was found open, revealing resident details without staff supervision. These actions violated HIPAA regulations and compromised the confidentiality of resident health information.
The facility failed to notify residents and their representatives of transfers or discharges, as required by regulations. A resident was transferred to a hospital after a seizure, another due to suicidal ideations, and a third for unspecified reasons, without documented notification. The DON confirmed that discharge notification letters were not sent.
A resident who underwent a right below the knee amputation was readmitted to the facility, but the required significant change MDS assessment was not completed within the mandated timeframe. Despite receiving skilled therapy services and having specific physician orders, the facility failed to comply with federal regulations for resident assessments.
A facility failed to ensure a resident with limited ROM received appropriate treatment, as there was no documented evidence of the use of a prescribed splint. Despite recommendations from occupational therapy and a physician's order for a right upper extremity splint to be worn daily, records from March to October 2024 lacked documentation of its use. This deficiency was confirmed by the DON.
The facility failed to provide appropriate respiratory care for two residents. A resident with respiratory failure was given oxygen at 3 L/min instead of the ordered 2 L/min, and another resident with asthma received oxygen at 5 L/min instead of the ordered 2 L/min. These discrepancies were confirmed by an LPN.
A facility failed to maintain effective infection control during wound care for a resident. An LPN did not follow proper wound cleansing techniques and exited the resident's room wearing contaminated PPE, despite the room being marked for Enhanced Barrier Precaution.
A facility failed to maintain a safe and sanitary environment in a resident room, where two residents' areas were cluttered with personal items, snacks, and unauthorized power strips provided by the facility. The clutter included grocery bags, hygiene items, and respiratory equipment, obstructing access and creating potential hazards.
A resident with epilepsy experienced a seizure, but the physician was not notified during the morning shift as required by facility policy. The incident was only reported during the evening shift when the resident appeared unwell, leading to hospital transport. The lapse in communication was confirmed by the DON.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
Facility staff failed to provide adequate supervision and accident prevention measures to protect a resident at high risk for elopement, resulting in an elopement incident. The facility’s policy on “Wandering, Unsafe Resident” was intended to prevent unsafe wandering for residents at risk of elopement, yet the resident, who had dementia with mood disturbance and agitation, depression, cognitive communication deficit, adjustment disorder with anxiety, and conduct disorder, was assessed on December 31, 2025, as being at high risk for elopement. Despite this high-risk status, the resident did not have an elopement prevention care plan in place prior to the incident. On February 12, 2026, at approximately 9:00 a.m., the resident, who resided on the second-floor unit, was able to press on the fire doors for more than 15 seconds, activating the alarm, and then used the stairs to leave the unit. The resident subsequently passed through emergency fire doors on the first floor located next to the entrance doors and across from the receptionist’s desk area. Review of the clinical record and facility investigation confirmed that an elopement prevention care plan for this resident was not developed until after this elopement event occurred.
Delayed Access to Medical Records for a Resident
Penalty
Summary
The facility failed to comply with the requirement to provide timely access to medical records for a resident, as outlined in 42 CFR Part 483.10(g)(2)(i)(ii)(3). The deficiency was identified during an abbreviated survey conducted in response to complaints. The facility's policy states that residents have the right to access their personal and medical records within 24 hours of a request, excluding weekends and holidays, and to obtain copies within two business days. However, the facility did not meet these timelines for Resident R1, who requested a copy of their medical records. The delay occurred because the Medical Records Department was unaware that payment for the records had been received, as the check was made out to the facility rather than directly to the department. This oversight led to a delay in processing the request. The facility administrator confirmed that the records were not released immediately, and the social worker did not send an electronic copy of the records to the resident until nearly two months after the initial request. This failure to provide timely access to medical records resulted in a deficiency under the resident rights regulations.
Plan Of Correction
I hereby acknowledge the CMS 2567-A, issued to ROSEMONT CENTER for the survey ending 12/26/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements. Resident R1 was sent the requested medical records. NHA/Designee will audit medical record requests for the last 30 days to ensure timely release of records. RDO will reeducate administrative staff on the regulation of releasing records timely. NHA/Designee will audit the release of medical records from requests weekly x 3 and then monthly x 3. Results will be shared at QAPI monthly until substantial compliance is met.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified by the regulation effective July 1, 2024. During the review period from December 20, 2024, to December 26, 2024, the facility did not meet the required staffing levels on six out of seven days. Specifically, the facility was understaffed on the day shift from December 23 to December 25, 2024, where the ratio of one NA per 10 residents was not maintained. Additionally, the night shift was understaffed on December 20, 21, and from December 23 to December 26, 2024, failing to meet the ratio of one NA per 15 residents. This deficiency was confirmed by Employee E1, the Administrator, on December 26, 2024, at approximately 12:45 p.m.
Plan Of Correction
Preparation and/or execution of his plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements. Nursing schedules were reviewed to ensure the proper nursing assistant ratio on the day and overnight shifts. NHA/designee will reeducate the scheduler, Nurse Supervisors and Nursing Management on the correct Nursing Assistant ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure nursing assistants are being staffed at the proper ratio. Results will be shared at QA monthly until substantial compliance is met.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to comply with the regulation requiring a minimum number of Licensed Practical Nurses (LPNs) per resident during the night shift. Specifically, the facility did not meet the required ratio of one LPN per 25 residents for seven consecutive days, from December 20, 2024, through December 26, 2024. This deficiency was identified through a review of nursing time schedules, which revealed the shortfall in staffing levels. The issue was confirmed by the facility's administrator, Employee E1, on December 26, 2024, at approximately 12:45 p.m.
Plan Of Correction
Preparation and/or execution of his plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements. Nursing schedules were reviewed to ensure the proper LPN ratio on the evening shifts. NHA/designee will reeducate the scheduler, Nurse Supervisors, and Nursing Management on the correct LPN ratios. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure LPN's are being staffed at the proper ratio. Results will be shared at QA monthly until substantial compliance is met.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, as identified during a review of clinical records and staff interviews. Resident R17, diagnosed with acute and chronic respiratory failure with hypoxia, was observed receiving oxygen therapy without a corresponding care plan for oxygen administration. This deficiency was confirmed by a licensed nurse, indicating a lack of timely care planning for the resident's oxygen needs. Resident R41, who has epilepsy and is on Keppra to prevent seizures, experienced seizure activity, prompting a physician to order blood work. However, there was no evidence of a care plan addressing the resident's epilepsy diagnosis. The Director of Nursing confirmed the absence of a care plan for this condition. Similarly, Resident R44, with a diagnosis of rhabdomyolysis and an order for urinary catheter management, was found to have no care plan for the catheter's administration, as confirmed by licensed staff. Additional deficiencies were noted for Resident R48, who had a urinary catheter but no care plan for its use, and Resident R49, who required splinting and range of motion exercises but lacked a corresponding care plan. Resident R59, with a recent below-the-knee amputation, also did not have a care plan addressing this significant medical condition. These omissions were confirmed through interviews with the Director of Nursing, highlighting a systemic issue in care planning for residents with complex medical needs.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records, specifically for one resident, identified as Resident R28. During an observation on the second-floor unit, a medication cart was found unattended in the hallway, with a laptop computer open and displaying resident information visible to passersby. This lapse in security allowed unauthorized individuals to potentially view sensitive health information, violating the resident's rights to privacy and confidentiality. Additionally, during a medication administration observation, a computer mounted on the wall was left open, revealing names of residents and clinical documentation without any staff member present to monitor it. A registered nurse, identified as Employee E6, explained that these computers are used by aides to document resident information. This incident further highlights the facility's failure to ensure that protected health information is secured and only accessible to authorized personnel, as required by HIPAA regulations.
Failure to Notify Residents and Representatives of Transfers
Penalty
Summary
The facility failed to ensure timely notification to residents, their representatives, and the ombudsman regarding transfers or discharges, including their appeal rights. This deficiency was identified for three residents during a review of clinical records and facility documentation, as well as interviews with staff. The facility was unable to produce a policy on notifying residents and their representatives about transfers or discharges. Resident R11 was transferred to a local hospital after a seizure episode resulting in a fall, but there was no documented evidence of notification to the resident or their representative. Similarly, Resident R41, who was admitted with epilepsy, depression, anxiety, and a history of suicide attempts, was sent to the hospital for evaluation after expressing suicidal ideations, yet no notification was documented. Resident R42 was also transferred to a hospital without documented notification to the resident or their representative. Interviews with the Director of Nursing (DON) confirmed that the facility did not send written notifications to the residents or their representatives regarding their transfers to the hospital. The DON admitted that discharge notification letters were not sent to the residents or their families. This lack of communication and documentation was a violation of the facility's responsibility to inform residents and their representatives about transfers or discharges, as required by regulations.
Failure to Conduct Significant Change MDS Assessment for Amputee Resident
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who underwent a right below the knee amputation (RBKA). The resident, identified as R59, was readmitted to the facility from a local hospital with a diagnosis of RBKA related to osteomyelitis of the right foot. Despite the significant change in the resident's condition, which included a new diagnosis of acquired absence of the right leg below the knee, the facility did not complete the required significant change MDS assessment within the mandated timeframe. The resident's clinical record showed that they were receiving skilled physical and occupational therapy services and had specific physician orders for wound care and non-weight bearing status on the right lower extremity. An interview with the Regional Registered Nurse Assessment Coordinator (RNAC) confirmed that the resident's status post BKA should have triggered a significant change MDS assessment. However, the assessment was not completed as required, indicating a deficiency in the facility's compliance with federal regulations for resident assessments.
Failure to Document Splint Use for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion (ROM), specifically in ensuring the use of a splint as recommended by occupational therapy and ordered by the physician. The resident, identified as R49, had a discharge recommendation from occupational therapy for the use of a splint/brace and active and passive range of motion exercises. A physician's order specified the use of a right upper extremity resting hand splint to be worn after lunch daily, with the resident allowed to remove it independently. However, a review of the resident's treatment administration record from March to October 2024 showed no documented evidence that the splint was donned and doffed as required. This lack of documentation was confirmed by the Director of Nursing during an interview, indicating a failure to follow through with the prescribed treatment and services to maintain or improve the resident's ROM.
Inappropriate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents. Resident R17, diagnosed with acute and chronic respiratory failure with hypoxia, was ordered to receive oxygen at 2 liters per minute via nasal cannula continuously. However, on October 10, 2024, it was observed that the resident was administered oxygen at 3 liters per minute, contrary to the physician's order. This discrepancy was confirmed by a licensed nurse, Employee E5. Similarly, Resident R38, diagnosed with asthma, was ordered to receive oxygen at 2 liters per minute via nasal cannula as needed. On October 8, 2024, it was observed that the resident was administered oxygen at 5 liters per minute, which was not in accordance with the physician's order. This was also confirmed by the same licensed nurse, Employee E5.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program during wound treatment for a resident. A Licensed Practical Nurse (LPN) was observed administering wound care to a resident with a physician's order for specific wound care procedures. The LPN transported the entire treatment cart into the resident's room, which was marked for Enhanced Barrier Precaution. During the wound cleansing process, the LPN did not follow the proper technique of cleansing from the center to the outer side of the wound. Additionally, the LPN exited the resident's room wearing contaminated Personal Protective Equipment (PPE), specifically a gown. These actions were confirmed during the observation with the LPN.
Cluttered Resident Rooms and Unauthorized Power Strips
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment in a resident room on the first floor, specifically in room 105. Observations revealed that Resident R1's area was cluttered with open and closed boxes, random items such as spices, hygiene products, snacks, and clothing, as well as grocery bags containing snacks and other items. A power strip outlet was found amidst the clutter, powering a nebulizer and Bi-pap respiratory machines. The resident reported that the facility provided the power strip. The tray table was also cluttered with breakfast items, a fan, headphones, and a full urinal. In the same room, Resident R2's bed was positioned away from the headboard wall, with a chair and bariatric wheelchair blocking access to the closet. The resident's area was similarly cluttered with Walmart bags containing snacks, plastic boxes, and a nebulizer placed on top of an electric mixer. The dresser was covered with hygiene items, leaving no space for the nebulizer treatment machine. The floor was cluttered with power strips, grocery bags containing oranges, clothing, and snacks. Resident R2 confirmed ownership of the items and mentioned ordering them online. The maintenance director confirmed these observations and made some adjustments, but the administrator was unaware of the power strips' origin.
Failure to Notify Physician of Resident's Seizure
Penalty
Summary
The facility failed to notify the physician of a change in a resident's medical status, specifically for a resident diagnosed with epilepsy who experienced a seizure. According to the facility's policy, any significant change in a resident's condition, such as a seizure, should prompt immediate notification to the attending physician. However, on the morning shift, a licensed nurse, Employee E4, was informed by a CNA that the resident had a seizure lasting at least one minute. Despite this, Employee E4 did not notify the physician or any supervisory nursing staff about the incident during her shift. Later, during the evening shift, another employee, Employee E5, noticed the resident did not look well during dinner and reported this to Employee E4. It was only at this point that the physician was notified, and the resident was subsequently transported to the hospital. The resident was admitted with a diagnosis of a breakthrough seizure, indicating a significant lapse in communication and adherence to the facility's policy regarding changes in a resident's condition. The Director of Nursing confirmed that there was no notification of the seizure during the morning shift until the evening when the resident was sent to the hospital.
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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