Rydal Park Of Philadelphia Presbytery Homes, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Rydal, Pennsylvania.
- Location
- 1515 The Fairway, Rydal, Pennsylvania 19046
- CMS Provider Number
- 395321
- Inspections on file
- 19
- Latest survey
- March 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rydal Park Of Philadelphia Presbytery Homes, Inc during CMS and state inspections, most recent first.
The facility failed to store and label food items properly in the kitchen, as observed during a tour with the FSD. A foul odor was detected in the refrigerator, and several food items, including ground beef, pastrami, beef hunks, briskets, pork loins, and lamb hunks, were found with expired dates or were undated and unlabeled. These issues were confirmed by the FSD.
The facility did not properly dispose of trash and recyclables in the receiving and dumpster area. Observations revealed exposed trash in two grey trash cans and one blue dumpster. Additionally, broken wooden pallets, cabinets, and a bathroom vanity were found near the receiving door. These findings were confirmed by the Food Service Director.
The facility failed to maintain effective infection control during medication administration for two residents. A nurse did not wash hands or wear gloves before administering eye drops, contrary to the facility's guidelines. The nurse touched a bedside table and administered oral medications and eye drops without performing hand hygiene.
A facility failed to inform a resident or their representative about the addition of Seroquel, a psychotropic medication, including its risks, benefits, and alternative treatment options. The resident, who was moderately cognitively impaired and had Parkinson's disease, received the medication without documented informed consent. The Nursing Supervisor confirmed the absence of necessary documentation, violating resident rights.
A facility failed to assess a resident's ability to self-administer medications safely, as required by their policy. The resident, who had a physician's order for Timolol Maleate Ophthalmic Solution for glaucoma, was observed keeping the medication on her over-the-bed table. Despite self-administering the eye drops, there was no documented assessment for medication self-administration, as confirmed by two registered nurses. This oversight violates the facility's policies and state regulations.
The facility failed to notify residents and their representatives of hospital transfers and the reasons for these transfers in a timely manner, in writing, and in a language and manner they understood. This deficiency was identified for three residents who were reviewed for hospitalizations, with reasons including shortness of breath, diabetic ketoacidosis, and hypoxia. An interview with the Nursing Home Administrator and DON confirmed the absence of a system to notify residents' representatives in writing prior to transfers.
The facility failed to provide written notice of the bed-hold policy to residents and their representatives during hospital transfers. This affected three residents who were transferred for medical reasons such as shortness of breath and diabetes ketoacidosis. The facility lacked a system to ensure compliance with this requirement, as confirmed by the Nursing Home Administrator and DON.
A resident, who was cognitively intact and required assistance for bed mobility, was not transferred into bed in a timely manner according to her preferences. After requesting assistance to be put to bed after lunch, the resident was told to wait for the next shift and later to wait until after dinner. The facility's failure to provide timely assistance violated its policy on activities of daily living.
The facility failed to maintain accurate and complete clinical records for all sampled residents. A review of the 'Arbitration Agreement' document revealed that resident signatures were present without any indication of their choice regarding arbitration. An interview with the Facility Administrator confirmed that staff did not direct residents to mark their preferred option, resulting in incomplete documentation for 204 residents.
The facility did not send timely discharge notifications to the State Ombudsman for emergency transfers in June and July 2024. Notifications were delayed until the survey date, confirmed by the Executive Director, violating 28 Pa. Code 201.18(b)(3).
The facility failed to include a nebulizer treatment in a resident's comprehensive care plan despite a physician's order and active treatment being observed. This omission was confirmed by the DON during an observation.
The facility failed to follow physician orders for a resident with chronic diastolic heart failure by not monitoring and documenting daily weights as required. The Director of Nursing confirmed the lack of documentation, and the facility could not provide the necessary records.
The facility failed to ensure a resident's wander guard was functioning and did not monitor hot beverage temperatures on one nursing unit. A resident with Alzheimer's had a non-functional wander guard, and a dietary aide did not check the temperature of a heated beverage before giving it to a nurse aide.
A resident with dementia and malnutrition experienced a significant weight loss shortly after admission, but the facility failed to notify the Registered Dietitian or reassess and modify interventions as required by policy.
A resident with multiple diagnoses, including anxiety, was prescribed Alprazolam on a PRN basis. The facility failed to document the rationale and duration for the PRN order when it was continued beyond 14 days, as required by CMS regulations, leading to a deficiency.
The facility failed to ensure proper labeling and discarding of medications. Several opened eye medication vials on the Middle Cart of the Second Floor were found without marking the opened date, contrary to the facility's policy. An RN confirmed the oversight during an interview.
The facility failed to maintain effective infection control in the laundry room, where clean linens were observed dragging on the floor and touching employees' personal clothing, leading to potential contamination.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage, labeling, and dating of food items in the main kitchen. During a tour with the Food Service Director, a foul sulfur odor was detected in the refrigerator. An open package of ground beef was found with an expiration date that had already passed, and two cooked, ready-to-eat pastrami packages were labeled with a date from over a month prior. Additionally, several beef hunks, beef briskets, pork loins, and top round roast beef were found undated and unlabeled. Lamb hunks were labeled with an expired date and were submerged in a red-colored liquid. These findings were confirmed by the Food Service Director during the inspection.
Improper Disposal of Trash and Recyclables
Penalty
Summary
The facility failed to ensure proper disposal of trash and recyclables in the receiving and dumpster area, as observed during a tour of the Food Service Department. Two grey trash cans and one blue dumpster were found with trash exposed. Additionally, near the receiving door, there were four wooden pallet stacks with broken pieces lying on the ground, approximately five feet high, along with three broken wooden cabinets and a broken bathroom vanity. These observations were confirmed in an interview with the Food Service Director.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program during medication administration and wound treatment for two residents. Specifically, during a medication administration observation, a Registered Nurse, identified as Employee E9, did not wash hands or wear gloves before administering eye drops to a resident. The nurse touched the resident's bedside table and proceeded to administer oral medications and eye drops without performing hand hygiene or donning gloves, which is contrary to the facility's Medication Administration General Guidelines dated May 2016. These guidelines require hands to be washed with soap and water and gloves to be applied before administering various types of medications, including topical and ophthalmic medications.
Failure to Inform Resident of Psychotropic Medication Risks and Alternatives
Penalty
Summary
The facility failed to ensure that a resident or their representative was informed of treatment options, as well as the risks and benefits of the proposed care, specifically regarding the administration of psychotropic medication. Resident R396, who was moderately cognitively impaired with a BIMS score of 12 and had diagnoses including progressive neurological conditions and Parkinson's disease, was administered Seroquel, an antipsychotic medication, without documented evidence of informed consent. The resident's Medication Administration Records indicated that Seroquel was given daily, starting at 12.5 mg and later increased to 25 mg, without any record of the resident or their responsible party being informed about the medication, its risks, benefits, or alternative treatment options. The deficiency was further highlighted by the absence of documentation in the psychiatric progress notes, which failed to show that the resident or their representative was informed about the addition of Seroquel. An interview with the Nursing Supervisor confirmed the lack of documentation regarding the communication of this information to the resident or their responsible party. This oversight is a violation of resident rights as per the cited Pennsylvania codes.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications safely, as required by their policy. The policy, dated November 2017, states that residents who wish to self-administer medications must have a prescriber's order and be assessed by the interdisciplinary team to ensure the practice is safe. However, for one resident, identified as R80, there was no documented assessment for self-administration of medications, despite the resident having a physician's order for Timolol Maleate Ophthalmic Solution 0.5% to be instilled in both eyes every morning and at bedtime for glaucoma. During an observation, it was noted that the resident kept the eye drops on her over-the-bed table, which was confirmed by the resident and a registered nurse, Employee E9. The nurse acknowledged that the resident self-administers the eye drops and that an assessment for medication administration safety should have been conducted. Another registered nurse, Employee E6, confirmed the absence of a medication self-administration assessment for the resident. This oversight is a violation of the facility's policies and state regulations regarding resident care and pharmacy services.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives of hospital transfers and the reasons for these transfers in a timely manner, in writing, and in a language and manner they understood. This deficiency was identified for three residents who were reviewed for hospitalizations. Resident R1 was discharged to the hospital for shortness of breath, while Resident R59 was discharged multiple times for various reasons including shortness of breath, evaluation and treatment, diabetic ketoacidosis, and hypoxia. Resident R246 was sent to the hospital for evaluation. There was no evidence in the clinical records that the residents' representatives were informed of these transfers and the reasons behind them. An interview with the Nursing Home Administrator and Director of Nursing confirmed that the facility did not have a system in place to notify residents' representatives in writing, including the reasons for the transfers, prior to the residents' transfer or discharge. This lack of notification is a violation of the residents' rights as outlined in the applicable state code, which requires timely and understandable communication regarding transfers or discharges.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to residents and their representatives at the time of a facility-initiated transfer to a hospital. This deficiency was identified for three residents who were transferred to the hospital for various medical reasons, including shortness of breath, diabetes ketoacidosis, and hypoxia. The clinical records for these residents did not contain any documented evidence that the residents or their representatives received the required written notice explaining the duration of the bed-hold, bed-hold reserve payment, and the conditions for returning to a bed at the facility. An interview with the Nursing Home Administrator and the Director of Nursing confirmed that the facility did not provide the necessary bed-hold policy information to the residents and their representatives. Additionally, it was acknowledged that there was no system in place to ensure compliance with this requirement. This oversight was in violation of the Pennsylvania Code, specifically sections 201.14(a) regarding the responsibility of the licensee and 201.29(f) concerning resident rights.
Failure to Timely Assist Resident with Bed Transfer
Penalty
Summary
The facility failed to ensure that a resident, identified as R246, was transferred into bed in a timely manner according to her preferences. The resident, who was cognitively intact with a BIMS score of 14, required partial to moderate assistance for bed mobility. On January 7, 2025, after lunch, the resident requested assistance to be transferred to bed from a team member who had helped her to the bathroom. However, the team member refused the request, asking the resident to wait for the next shift. Further investigation revealed that the resident reiterated her request to another staff member later in the day, but was again told to wait until after dinner. The resident was eventually assisted to the bathroom by an agency aide around 6:27 p.m. The facility's failure to assist the resident into bed in a timely manner was a violation of the facility's policy on activities of daily living, which mandates providing care and services to maintain or improve residents' ability to carry out such activities.
Incomplete Arbitration Records for Residents
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for all 21 sampled residents. The deficiency was identified through a review of the facility's document titled 'Arbitration Agreement,' which included a designated signature area and two blank check boxes for residents to indicate their consent or refusal to arbitrate. However, the records showed that resident signatures were present without any indication of their choice regarding arbitration. An interview with the Facility Administrator confirmed that staff did not direct residents to mark their preferred option, resulting in incomplete documentation. This issue affected a total of 204 residents' arbitration records, as confirmed by the administrator.
Failure to Timely Notify Ombudsman of Discharges
Penalty
Summary
The facility failed to provide timely discharge notifications to the State Office of the Long-Term Care Ombudsman for emergency transfers and discharges that occurred in June and July 2024. This deficiency was identified through a review of emailed notifications for the months of April, May, June, July, and August 2024. It was found that the notifications for June and July were not sent until the date of the survey on September 24, 2024. An interview with the Executive Director confirmed the delay in sending these notifications, which is a requirement under 28 Pa. Code 201.18(b)(3) Management.
Failure to Include Nebulizer Treatment in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan related to respiratory care for one resident. The resident, admitted with diagnoses including respiratory tuberculosis and nasal congestion, had a physician order for Ipratropium-Albuterol Solution to be inhaled twice daily for wheezing and chest congestion. Despite the presence of a nebulizer machine at the resident's bedside and active treatment being observed, the comprehensive care plan dated April 18, 2024, did not include the nebulizer treatment. This omission was confirmed by the Director of Nursing during an observation on May 3, 2024.
Failure to Follow CHF Protocol and Document Daily Weights
Penalty
Summary
The facility failed to follow physician orders related to the congestive heart failure (CHF) protocol for one of eight sampled residents. Specifically, the facility did not monitor and document the daily weights of Resident R72, who had a diagnosis of chronic diastolic heart failure, among other conditions. The physician's orders required daily weighing before breakfast and notification of the medical doctor if there was a weight gain of two pounds in twenty-four hours or five pounds in one week. However, a review of the resident's clinical record revealed no documented evidence that these daily weights were taken as ordered. During an interview, the Director of Nursing confirmed that the weights were not documented in the resident's clinical record, although they believed there might be documentation elsewhere. Despite this belief, the facility was unable to provide any documentation related to the daily weights for Resident R72. This failure to follow the physician's orders and document the required daily weights constitutes a deficiency in nursing services as per the facility's heart failure clinical protocol and relevant regulations.
Failure to Ensure Functioning Wander Guard and Monitor Hot Beverage Temperatures
Penalty
Summary
The facility failed to ensure that a resident's wander guard was functioning properly for a resident at risk for elopement. Resident R89, diagnosed with Alzheimer's disease and unspecified dementia, had a physician order to check the wander guard every shift. However, during an observation, the wander guard was found to be non-functional, and it did not alert staff when the resident approached the exit doors. This deficiency was confirmed by a registered nurse, unit manager Employee E5, who acknowledged that the wander guard needed replacement. Additionally, the facility did not monitor hot beverage temperatures on one of the three nursing units. In the 3rd floor dining room, Dietary Aide Employee E13 was observed heating a beverage in the microwave and handing it back to a nurse aide without checking its temperature. This action was against the facility's policy, which requires maintaining hot liquid serving temperatures below 180 degrees Fahrenheit to prevent scalding. Employee E13 confirmed that the temperature was not checked before distribution to the resident.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and modify interventions consistent with a resident's needs to maintain acceptable parameters of nutritional status. Specifically, Resident R39, who had diagnoses of dementia and malnutrition, experienced a significant weight loss of 6.7% (7.2 pounds) over nine days shortly after admission. Despite the facility's policy requiring the treatment team to evaluate undesirable weight changes, there was no documented evidence that the Registered Dietitian was made aware of the significant weight loss or that the resident's needs were reassessed and interventions modified accordingly. Resident R39's weight history showed a drop from 107 pounds on admission to between 99.8 and 100.4 pounds over a period of several weeks. The Registered Dietitian confirmed during an interview that the significant weight loss was not assessed. This failure to monitor and address the resident's nutritional status is a clear deficiency in the facility's care practices, as outlined by the relevant state codes.
Failure to Document Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure a resident's medication regimen was free from potential unnecessary medications. Resident R72, who has multiple diagnoses including anxiety, was prescribed Alprazolam, a psychotropic medication, on a PRN basis. The resident received this medication on several occasions in April 2024. However, the clinical records did not contain evidence that the physician documented the rationale and indicated the duration of the PRN order when it was continued beyond the 14-day limit as required by CMS regulations. A pharmacy consultant review in November 2023 recommended that PRN anxiolytic orders need a 14-day stop date unless a longer duration is justified with a clinical rationale. Despite this recommendation, the PRN order for Alprazolam was continued without the necessary documentation. The medication was discontinued and restarted multiple times, but the required documentation was still not provided, leading to the deficiency noted in the report.
Failure to Label and Discard Medications Properly
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards and to discard expired medications as required. During an observation of the Middle Cart on the Second Floor, several opened eye medication vials were found without any marking of the opened date. These included a 5 ML bottle of Tobramycin Ophthalmic Solution, two 15 ML bottles of Tears Lubricant Eye Drop, a 5 ML bottle of Polymyxin B Sulfate and Trimethoprim Ophthalmic Solution, a 5 ML bottle of Latanoprost Ophthalmic Solution, an opened box of Systane Lubricant Eye Drops, and a 5 ML bottle of Brimonidine Tartrate/Timolol Maleate Ophthalmic Solution. All these medications had future expiry dates but were not labeled with the date they were opened, which is against the facility's policy revised in February 2023 that requires multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer. An interview with Registered Nurse (RN), Employee E9, confirmed that the eye drop bottles should have been discarded as they were not marked with the opened dates per the facility policy. This deficiency was identified during a review of the facility policy, observation, and staff interview, indicating a failure to comply with the professional standards for medication labeling and storage. The relevant state codes cited include 28 Pa Code 201.14(a), 28 Pa Code 211.9(g)(h), and 28 Pa Code 211.12(c)(d)(1)(5).
Infection Control Deficiency in Linen Processing
Penalty
Summary
The facility failed to maintain an effective infection control program related to the processing of linens. During an observation in the laundry room, it was noted that a Laundry Aide, Employee E10, allowed clean linens to drag on the floor while folding them. Employee E10 confirmed that this practice was incorrect and could lead to contamination. Additionally, another Laundry Aide, Employee E12, was observed allowing clean linens to touch their personal clothing while folding them. Employee E12 also confirmed that this practice was improper and could result in contamination. These actions were in violation of infection control protocols designed to prevent contamination and maintain hygiene standards.
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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