Saunders Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wynnewood, Pennsylvania.
- Location
- 100 Lancaster Avenue, Wynnewood, Pennsylvania 19096
- CMS Provider Number
- 395380
- Inspections on file
- 35
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Saunders Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not obtain direct verification from the Pennsylvania Nurse Aide Registry before allowing an agency nurse aide to work, despite a policy requiring verification of active licenses and certifications. Instead, the facility relied on a staffing agency that accepted an uploaded, falsified nurse aide license without independently verifying it. This led to an unlicensed nurse aide working multiple shifts in the facility before the issue was identified by the state Attorney General's Office and the aide was removed from the schedule.
A resident with multiple chronic conditions and intact cognition was discharged home, via a scheduled dialysis appointment, without receiving discharge instructions, prescriptions, or personal belongings, despite facility policy requiring a discharge transition packet for residents going to a private residence. Documentation showed that the RN signed the discharge summary and medication instructions later that evening, after the resident had already left, and there was no record that instructions or prescriptions were offered or refused. The administrator confirmed the resident should have received discharge instructions and prescription information, and the resident’s representative did not obtain the discharge paperwork until later that night, demonstrating a breakdown in the discharge process.
Surveyors found that several residents did not have accessible call bells to request staff assistance. During an observation with the DON, one resident’s call bell was behind a nightstand and covered by a pillow, another’s was on a dresser out of reach, and another’s was behind the bed. Two residents had call bells hanging down and out of reach, and a family member reported that one resident’s call bell was often on the floor. Another resident’s call bell was wrapped behind the bed and not accessible.
Two residents reported receiving cold meals, and a test tray conducted with the Dietary Director confirmed that several food items, including hot entrees and vegetables, were served below the required temperature for hot foods. The Food Service Director acknowledged that these items were not within the acceptable temperature range for palatability.
A resident who was fully dependent for bed mobility and transfers was left unattended by a single aide during care, despite the care plan requiring two staff and use of a Hoyer lift. The aide was distracted by a cellphone and earbuds, resulting in the resident sliding from the bed to the floor and experiencing minor knee pain. The incident was substantiated as neglect due to failure to follow the care plan and use of personal electronic devices during care.
A resident who was dependent on staff for bed mobility and required two-person assistance experienced a fall from bed while being cared for by a single CNA who was distracted by cellphone use. The incident was not reported to nursing staff during the shift, and the resident was not assessed until the following day when she reported pain. The facility failed to immediately report the allegation of neglect to the state health department as required.
A resident developed a blister on the left shoulder after receiving heat therapy when staff failed to follow facility protocols, including daily hydrocollator temperature checks and routine skin assessments during treatment. Documentation showed that required temperature monitoring was missed on multiple dates, and the resident's skin was not checked as per policy, leading to unrecognized injury.
Two residents experienced abuse and neglect when one was verbally threatened and physically mistreated by a nurse aide, while another was left in a soiled brief overnight and intimidated by their assigned aide. Both residents were cognitively intact and reported feeling unsafe or afraid to seek help due to staff behavior, with staff and documentation confirming the incidents.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson's disease, was not provided with care-planned safety interventions during bed mobility by hospice staff. The required use of bilateral 1/4 side rail enablers was not followed, and the hospice aide was unaware of this intervention, resulting in the resident falling from bed and sustaining head lacerations that required hospital treatment.
A resident receiving hospice care did not have a physician order or a comprehensive care plan for hospice services, including the use of enablers to support independence during morning care. Staff interviews and record reviews revealed confusion about responsibilities for entering orders and care plans, and hospice aides lacked access to the facility's electronic care plan. The facility's policies requiring coordination with the hospice provider and inclusion of hospice care details in the resident's plan were not followed.
Three residents experienced a lack of dignity and respect from staff, including rough handling of a hearing-impaired resident and dismissive or rude remarks made to two other cognitively intact residents. Staff actions did not align with facility policies on resident rights and effective communication.
The facility did not conduct complete or thorough investigations into multiple allegations of abuse and neglect, including delayed incontinence care, rough handling, and verbal abuse. In several cases, required interviews and documentation were missing, and some incidents were not reported to the Department of Health as required.
A deficiency was found when a resident with a new diagnosis of delusional disorder did not have their PASRR Level I form updated as required by facility policy. Staff confirmed that the necessary update was not completed after the new mental health diagnosis was identified.
Three residents did not receive care in accordance with physician orders and facility policy. One resident's family member applied a medicated cream without proper authorization or nurse supervision. Another resident's medications were left at the bedside without staff observing ingestion. A third resident continued to receive oxygen therapy after the order was discontinued in error, with documentation showing ongoing administration and a low oxygen saturation event.
A resident with significant immobility and multiple health conditions was identified as being at risk for pressure ulcers and had a wound consult recommending heel protection. However, surveyors found that staff did not implement the recommended intervention to float the resident's heels, and this was confirmed by the DON. The facility failed to have preventative measures in place to protect the resident's heels.
A resident with multiple medical conditions, including metabolic encephalopathy and type 2 diabetes, experienced a significant weight loss over a one-month period. Facility staff did not perform a timely reweigh or nutritional assessment as required by policy, and no interventions were documented until several days after the weight change was identified.
A resident with a fractured tibia and multiple surgical staples experienced moderate to severe pain that was not effectively managed, as only acetaminophen for mild pain was administered despite reports of higher pain levels. It took nearly two weeks before the physician was notified and a stronger pain medication was ordered, resulting in a failure to follow professional standards and facility policy for pain management.
Two residents with significant medical needs and intact cognition experienced prolonged wait times for call bell responses, with one waiting up to an hour for assistance and another observed waiting at least 30 minutes for a request to be answered.
The facility failed to serve food and drinks at safe temperatures on the third-floor unit. Residents reported ongoing issues with cold meals, which were discussed in meetings with the NHA but remained unresolved. A test tray confirmed the food was not at acceptable temperatures, and the issue was attributed to a broken heating device that had not been replaced.
The facility failed to investigate and resolve grievances for three residents, including issues with cold meals, unclean rooms, and missing food items. There was no documentation of investigations or resolutions, indicating a systemic issue in handling grievances.
The facility failed to address ongoing resident grievances about cold food, as reported during resident council meetings over three months. Despite residents arranging a meeting with the NHA to discuss these issues, no actions were taken to resolve the problem, and the NHA acknowledged the need for equipment replacement. The facility did not demonstrate any response to the residents' concerns.
A facility failed to create a person-centered care plan for a resident with COPD, neglecting to address sensitivities to irritants like perfumes and sprays. An incident occurred where a nurse aide's perfume affected the resident's breathing, highlighting the lack of specific interventions in the care plan. The DON was aware of the incident and provided staff education, but the care plan still did not include measures to prevent exposure to irritants.
A resident with cognitive impairment and multiple health conditions was left with medications unattended by a nurse, despite lacking authorization to self-administer. The DON confirmed the medications and identified the responsible nurse, revealing a failure in supervision and adherence to medication protocols.
The facility did not meet the required nurse aide staffing ratios for several shifts, failing to provide the mandated hours of care based on resident census. This deficiency was identified through a review of nursing schedules and census data, revealing shortfalls in care hours provided on specific dates. Discussions with the Nursing Home Administrator and DON confirmed the failure to meet state staffing requirements.
The facility did not meet the required LPN staffing ratios during an overnight shift, providing only 33.74 hours of care instead of the required 35.20 hours for 176 residents. This deficiency was identified through a review of nursing schedules and staff interviews.
The facility failed to provide the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period for 13 out of 21 days reviewed. Staffing documentation revealed multiple days where care hours fell short, with the lowest being 2.94 hours. This issue was discussed with the Nursing Home Administrator and DON.
A resident with cognitive and physical impairments sustained a second-degree burn after being served a hot beverage without proper temperature checks or supervision. The facility's failure to adhere to its hot liquid safety policy and inaccurate temperature logs contributed to the incident.
The facility failed to follow diabetes management protocols for three residents, resulting in unreported elevated blood sugar levels and missed insulin doses. The DON confirmed the lack of adherence to facility policies and physician orders.
The facility failed to conduct thorough investigations into incidents involving residents, including unexplained injuries, elopement, and burns. A resident's shoulder fracture was not investigated for potential abuse, another resident's elopement lacked proper documentation, and a resident's ankle injury was not fully assessed. Additionally, a resident suffered a burn from hot water, with the investigation revealing lapses in checking water temperature.
A facility failed to create a comprehensive care plan for a resident's chronic constipation. Despite medical interventions ordered by a CRNP, including Milk of Magnesia and Docusate, the facility did not develop a care plan as required by its policy. This was confirmed by the DON.
A facility failed to provide restorative nursing services for a resident with hemiplegia post-neurosurgery. Despite the resident's care plan including a Restorative Nursing Program for ambulation, there was no evidence of nursing staff providing the necessary therapy. The resident expressed a desire to walk again, but after physical therapy ended, no assistance was given. The DON confirmed the oversight in coordinating care.
A resident with Parkinson's disease and cognitive impairment was inadequately supervised and assessed, leading to a burn injury from a hot beverage. The facility's NHA and DON failed to implement necessary safety measures, such as serving beverages at safe temperatures and providing appropriate supervision, as outlined in their Hot Liquid Safety policy.
Failure to Verify Nurse Aide Certification Prior to Allowing Work
Penalty
Summary
The facility failed to ensure that a Pennsylvania Nurse Aide Registry check was obtained prior to allowing an agency nurse aide to work in the building. Facility policy, last revised July 7, 2023, required that all offers of employment be contingent upon a thorough criminal background check and verification that any required license or certification was active and in good standing. Despite this policy, one agency nurse aide (Employee E3) worked multiple shifts at the facility without the facility obtaining direct verification of her nurse aide certification status from the Pennsylvania Nurse Aide Registry. The deficiency was identified after the Pennsylvania Attorney General's Office notified the facility that the agency nurse aide did not possess a valid nurse aide certification during the time she provided services. The facility had relied on the staffing agency to obtain and verify the nurse aide’s credentials. The facility’s investigation file included an email from the staffing agency stating that the nurse aide had submitted a falsified license document that appeared legitimate, and that the agency’s onboarding team had been accepting uploaded licenses from clinicians rather than independently running verification checks. As a result, the unlicensed agency nurse aide worked several dates at the facility before being removed from the schedule.
Failure to Provide Discharge Instructions and Prescriptions at Time of Discharge
Penalty
Summary
The facility failed to provide a resident with discharge instructions and prescription medication at the time of discharge. The resident was admitted with multiple diagnoses, including cervical disc degeneration, lumbar radiculopathy, hemiplegia, end stage renal disease, muscle wasting/atrophy, difficulty in walking, need for assistance with personal care, chronic diastolic condition, and thrombocytopenia. The admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact. Facility policy required completion of discharge transition instructions for residents anticipating discharge to a private residence or similar setting to assist with a safe adjustment to their living environment. Clinical record review showed that on the day before discharge, the social worker communicated with the resident’s family about referrals for potential facility-to-facility transfers and, when no transfer was secured and Medicare benefits were exhausted, the facility planned discharge home with skilled home care referrals and a post-discharge primary care appointment. Transportation was arranged for the morning of the discharge date. A progress note documented that the resident was discharged to home, first going to dialysis and then home, and that all personal belongings remained at the facility awaiting family pickup and receipt of discharge instructions and prescriptions. The discharge summary, signed later that day by an RN, listed several medications with specific dosing schedules and times for the next doses, but there was no indication that these instructions or prescriptions were provided to the resident at the time of discharge. In an interview, the RN who signed the discharge summary confirmed that the resident had already left the facility when she signed the discharge packet around 9:00 p.m., and therefore she could not provide the packet to the resident. She stated that the usual practice is to complete the discharge before any scheduled appointment and to ensure the resident leaves with discharge instructions, prescriptions, and belongings, which did not occur in this case. The RN also confirmed she was not the nurse who discharged the resident and that discharge instructions were not provided at the time of discharge. The administrator confirmed that the resident was alert and oriented and should have received discharge instructions and prescription medication upon discharge, and that there was no documentation that the discharge summary and prescription information were offered or refused. The resident’s representative did not pick up the discharge instructions and prescription documentation until later that evening, confirming that the resident had been discharged without these materials, in violation of state regulatory requirements cited in the report.
Inaccessible Call Bells for Multiple Residents
Penalty
Summary
The facility failed to ensure that all residents had access to a functioning call system in their rooms and bathrooms, as required by policy and state regulations. During an observation conducted with the Director of Nursing, multiple residents were found without accessible call bells. One resident’s call bell was located behind a nightstand dresser, covered with a pillow, and not accessible. Another resident’s call bell was observed on top of a dresser and not within reach. A third resident’s call bell was behind the bed and not accessible. Two additional residents had call bells hanging down and out of reach, and a family member sitting with one of these residents reported that this resident’s call bell was often found on the floor and not accessible. Another resident’s call bell was wrapped behind the bed and not accessible. These observations showed that several residents did not have call bells within reach to request staff assistance. The deficiency was cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(b)(1) regarding management responsibilities.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food at the proper temperature as required by its Food Temperatures Policy, which mandates that hot foods be held and served at or above 135°F and cold foods at or below 41°F. During interviews, one resident reported receiving cold sausages and pancakes for breakfast, while another resident expressed grievances about receiving cold dinners on two separate occasions. A test tray conducted with the Dietary Director revealed that the temperatures of steamed broccoli, sweet potatoes, and honey garlic chicken were all below the required 135°F, and the juice was above the acceptable cold temperature. The Food Service Director confirmed that these foods were outside the acceptable temperature range for palatability.
Neglect Due to Failure to Follow Care Plan and Use of Personal Devices During Resident Care
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and dependent on staff for all bed mobility and transfers due to multiple sclerosis and other conditions, was not provided care according to her established care plan. The care plan specified that two staff members were required for bed mobility and transfers, and the use of a Hoyer lift was indicated for transfers in and out of bed. Despite these requirements, a certified nurse aide performed bed mobility alone, without a second staff member present, and was using her personal cellphone and wearing earbuds during the provision of care. During the incident, the resident was being turned to her side by the aide when she slid from the bed onto her knees and then to the floor. The resident reported experiencing minor knee pain following the fall, and an x-ray was ordered to rule out fractures, which later returned negative. The resident also stated that no nursing staff came to assess her immediately after the fall, and that the aide was alone, distracted by her phone, and wearing earbuds at the time of the incident. The facility's internal investigation confirmed that the aide failed to follow the resident's care plan by not having a second staff member present and by being distracted with personal electronic devices during care. The incident was substantiated as neglect, as the resident's safety and care needs were not met according to established protocols and policies.
Failure to Immediately Report and Investigate Alleged Neglect Following Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all allegations of neglect were reported immediately to the Pennsylvania Department of Health for one resident. The facility's policy requires that all incidents involving mistreatment, neglect, abuse, or injuries of unknown origin be reported immediately to the Director of Nursing (DON) and Administrator for further review and reporting as per state and federal regulations. However, in this case, a resident who was dependent on staff for bed mobility and transfers, and required the assistance of two staff members, experienced a fall from bed while being cared for by a single certified nurse aide who was also using a personal cellphone and wearing earbuds during the incident. The resident, who was cognitively intact and bedbound due to multiple medical conditions including muscle weakness and multiple sclerosis, reported that the aide was alone and distracted at the time of the fall. The aide did not report the incident to nursing staff during the shift, and the resident was not assessed by nursing staff until the following day, after she reported knee pain. Documentation shows that the facility only became aware of the fall when the resident informed a licensed nurse the next day, at which point an assessment and investigation were initiated. Interviews and internal investigation confirmed that the certified nurse aide failed to follow the resident's care plan, which required two-person assistance for bed mobility, and did not report the fall to nursing staff as required. The Director of Nursing confirmed that staff failed to notify nursing staff on both the evening and overnight shifts, resulting in a delay in reporting the incident and initiating appropriate follow-up.
Failure to Follow Heat Therapy Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice related to heat therapy. According to facility policy, hydrocollator temperatures should be checked daily, and specific procedures must be followed when applying heat packs, including wrapping the pack in layers of toweling, checking the resident's skin after application, and documenting the patient's response. Review of records revealed that a male resident developed a blister on his left shoulder after receiving heat therapy. The hydrocollator temperature was not checked daily as required, and the physical therapy associate did not routinely check the resident's skin during the application, only after the treatment was completed, which was not in accordance with facility protocol. Interviews and documentation indicated that redness was noted on the resident's shoulder after the heat therapy session, but no pain or discomfort was reported immediately post-treatment. The resident later experienced pain and was found to have a blister. There was no evidence that skin concerns were noted during the resident's scheduled bath/shower following the therapy. Additionally, facility records showed multiple dates where the hydrocollator temperature was not checked as per policy. The facility did not ensure daily temperature checks of the hydrocollator and did not accurately assess and report skin changes as required by their own procedures.
Failure to Prevent Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by two separate incidents involving two cognitively intact residents. In the first incident, a resident with anxiety and depression reported that a nurse aide intentionally struck their foot with a linen cart and then verbally abused and threatened them. The nurse aide was overheard yelling at the resident, making threatening statements, and using profane language. This behavior was witnessed by a registered nurse, who confirmed the verbal abuse and threats directed at the resident. In the second incident, another resident with depression, muscle weakness, and a need for assistance with personal care reported being afraid to use the call bell for help during a night shift due to intimidating comments made by their assigned nurse aide. The resident stated they were not changed throughout the shift and remained in a soiled brief until the following morning. The resident's bed was found soaked and required cleaning due to a strong urine odor. Documentation and interviews revealed that the nurse aide made disparaging remarks to the resident and other residents under their care, contributing to an environment of intimidation and neglect. Both incidents were substantiated through staff witness statements, resident interviews, and facility documentation. The facility's failure to prevent and address these actions resulted in residents being subjected to verbal abuse, threats, and neglect, contrary to facility policy and regulatory requirements for resident rights and safety.
Failure to Implement Care-Plan Interventions for Fall Risk Resident
Penalty
Summary
A deficiency occurred when hospice staff failed to implement care-planned interventions for a resident identified as a fall risk. The resident, who had diagnoses of dementia, Parkinson's disease, and anxiety, was assessed as having severe cognitive impairment and required extensive assistance with bed mobility. The resident's care plan and physician orders specified the use of bilateral 1/4 side rail enablers while in bed to assist with mobility and increase safety. During personal care, a hospice nurse aide turned the resident in bed to assist with dressing and, while moving to the other side of the bed, did not realize the resident was holding onto the aide's pocket. The resident subsequently fell from the bed to the floor, sustaining lacerations to the left eyebrow and the back of the head, which required sutures and staples at a hospital. Documentation and investigation revealed that the side rail enablers were not utilized at the time of the incident, and the hospice aide was unaware of the care plan interventions and physician's orders regarding the use of side rails. Facility records and staff interviews confirmed that the required safety interventions were not communicated or implemented by the hospice staff, resulting in actual harm to the resident. The incident report also indicated that proper tools or equipment were not being used during the event, and the hospice aide did not have knowledge of the resident's specific care plan requirements for fall prevention.
Failure to Obtain Physician Order and Develop Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to obtain a physician order and develop a comprehensive care plan for hospice services for one resident who was receiving hospice care. Review of the resident's clinical record showed that there was no physician order for hospice care and no comprehensive care plan addressing hospice services or the use of enablers to support the resident's independence during morning care. Staff interviews confirmed that the resident had been receiving hospice services, but there was confusion among staff regarding who was responsible for entering the necessary physician order and care plan. Additionally, the hospice contractor's care plan did not include instructions regarding the use of enablers, and hospice aides did not have access to the facility's electronic care plan. Documentation in the hospice communication binder indicated that the resident had been on hospice since the end of May, and the last documented hospice service was provided in early June. Interviews with facility staff and hospice aides revealed a lack of clarity about the resident's care needs, particularly regarding the use of enablers during morning care. The facility's policies required coordination with the hospice provider and inclusion of the hospice plan of care and physician orders in the resident's written care plan, but these requirements were not met for the resident in question.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Surveyors identified that the facility failed to maintain resident dignity and respect for three residents. One resident with hearing impairment and cognitive intactness was observed being approached from behind by a nursing aide, who pulled the resident's shoulders back roughly into a wheelchair and spoke in a loud tone, instructing the resident to sit back and pick up their feet. The resident's care plan specified the need for direct communication, including facing the resident and establishing eye contact, which was not followed during this interaction. Two other cognitively intact residents reported staff making disrespectful and dismissive remarks. One resident stated that when they required frequent assistance to the bathroom due to illness, staff questioned them with, "What's your problem," and responded, "That's not my job," when asked to change bedding. Another resident reported that staff were rude and rough during care, making comments such as, "What do you want, stop complaining." These actions and statements were inconsistent with the facility's policies on resident rights and communication, as well as the residents' care plans.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct complete and thorough investigations into allegations of abuse and neglect for six residents. Facility policy required staff to prevent, report, and investigate suspected or alleged abuse, neglect, or mistreatment, with specific steps for interviewing involved parties and documenting findings. However, in multiple cases, the facility did not follow these procedures, resulting in incomplete investigations and lack of proper documentation. For one resident with hemiplegia and incontinence, a family member reported neglect due to delayed incontinence care. The facility's documentation confirmed the delay but did not provide a complete investigation or documentation of the incident. Another resident, who was severely cognitively impaired and on hospice care, was found saturated in urine by a hospice nurse, but the facility did not document a thorough investigation or report the incident to the Department of Health as required. In another case, a cognitively intact resident was observed being handled roughly by a nurse aide, but the facility's report omitted key details of the incident. Additional deficiencies included a resident reporting rough handling, being hit, denied a snack, and experiencing verbal abuse from a nursing assistant. The facility did not investigate or document these allegations. Another resident reported being grabbed and thrown by a nurse, but there was no evidence that the facility interviewed other staff or residents as part of the investigation. These failures to investigate and document allegations of abuse and neglect were confirmed through interviews with facility leadership and staff, as well as review of facility records.
Failure to Update PASRR Documentation After New Mental Health Diagnosis
Penalty
Summary
A deficiency was identified when the facility failed to update the PASRR (Pre-admission Screening and Resident Review) Level I form for a resident who had a new diagnosis of delusional disorder during their stay. The facility's policy requires that any new diagnosis identified during a resident's stay be added to the Level I PASRR form. However, review of the clinical record showed that the resident was admitted with schizoaffective disorder and later diagnosed with delusional disorder, but the PASRR Level I form, initially completed at admission, was not updated to reflect the new diagnosis. Staff interviews confirmed that there was no evidence of the PASRR Level I form being updated after the new diagnosis was made. This failure to update the PASRR documentation was found during clinical record review and staff interviews, and it was determined that the facility did not coordinate assessments with the PASRR program as required by policy and regulation.
Failure to Follow Physician Orders for Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician orders for medication administration for three residents. For one resident with a history of stroke, aphasia, dysphagia, diabetes, and hemiplegia, the resident's grandson was observed applying hemorrhoidal cream without a physician's order or nurse supervision, contrary to facility policy and physician instructions. Documentation showed that the grandson applied the cream before an order was obtained, and after the order was in place, there was no evidence that a nurse was present during application as required. Another resident, who was cognitively intact but had functional impairments and required set-up assistance with eating, was found with her prescribed 9:00 a.m. medications left at her bedside. The resident reported difficulty taking all pills at once and preferred to take them throughout the day with pudding or applesauce. The nurse responsible for administering the medications confirmed that the medications were left at the bedside and that the resident was not observed ingesting them, which is against facility policy requiring staff to observe medication ingestion and document administration immediately. A third resident with a history of congestive heart failure and pulmonary hypertension continued to receive oxygen therapy after the physician's order for oxygen was discontinued. Nursing progress notes indicated ongoing oxygen administration, and hospice notes documented the resident being found with low oxygen saturation and the oxygen device disconnected. The discontinuation of the oxygen order was later confirmed to have been done in error during a review of physician orders by the Assistant Director of Nursing.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
A deficiency was identified when the facility failed to implement appropriate interventions to prevent pressure ulcers for one resident. The facility's policy requires early identification of at-risk residents and the use of preventative strategies. The resident in question had a history of stroke with resulting hemiplegia, aphasia, dysphagia, and diabetes, and was completely dependent on staff for all activities of daily living, including bed mobility and toileting. The resident was assessed as being at risk for developing pressure ulcers, and a wound consult specifically recommended floating the resident's heels with pillows while in bed to prevent skin breakdown. Despite these recommendations, both clinical record review and direct observation during the survey revealed that the resident's heels were not protected or off-loaded as directed by the wound healing specialist. This lack of preventative measures was confirmed by the DON during the survey. The facility did not have the required interventions in place to protect the resident's heels, resulting in noncompliance with resident care policies and nursing service regulations.
Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper monitoring and follow-up of a significant weight loss for one resident. According to the facility's policy, any weight change greater than or less than 5 pounds within 30 days requires a reweigh the next day, confirmed by a licensed nurse. A resident with diagnoses including metabolic encephalopathy, type 2 diabetes, and muscle wasting experienced a weight loss of 20.9 pounds (13.59%) between two monthly weigh-ins. There was no documented evidence that a reweigh or nutritional assessment was performed in response to this significant weight change, and no interventions were documented until several days after the weight loss was identified. Staff interviews confirmed the lack of timely assessment and intervention.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency was identified when a resident with a fractured right tibia and multiple surgical staples reported ongoing moderate to severe pain that was not effectively managed according to professional standards. Upon admission, the resident was alert, oriented, and able to communicate needs, but was only provided acetaminophen for pain, which was ordered for mild pain. Despite the resident reporting pain levels of 7/10 and 8/10, which indicate moderate to severe pain, acetaminophen continued to be administered, and there was no evidence of further action to address the resident's discomfort. The resident communicated to staff that the prescribed pain medication was not effective, but it took 13 days from admission before the physician was contacted and an order for Tramadol, appropriate for moderate to severe pain, was obtained. The DON confirmed that the pain management provided was not consistent with the resident's needs and that the physician should have been notified sooner. The facility failed to follow its own pain management policy and did not ensure timely and appropriate pain relief for the resident.
Failure to Timely Respond to Resident Call Bells
Penalty
Summary
The facility failed to ensure that call bells were answered in a timely manner for two residents. One resident, admitted with hemiplegia and hemiparesis following a stroke and assessed as cognitively intact, reported waiting up to an hour for assistance to get off the toilet, with call bell wait times sometimes reaching 30 minutes. Another resident, also cognitively intact and admitted with muscle wasting, atrophy, arthritis, and multiple rib fractures, stated that the call bell was never answered timely. Direct observation confirmed that this resident's call bell light remained on for at least 23 minutes, and the resident reported waiting at least 30 minutes for a cup of coffee. These findings were based on resident interviews, clinical record reviews, and direct observation.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food and drinks at safe and appetizing temperatures on the third-floor nursing unit. Multiple residents reported ongoing issues with cold food, which had been discussed in resident council meetings and a separate meeting with the Nursing Home Administrator (NHA). Despite these discussions, the problem persisted, and residents continued to receive cold meals. The NHA acknowledged the issue, attributing it to a broken heating device used to keep food warm during transport, which had not been replaced. Interviews with several residents revealed dissatisfaction with the temperature of their meals, including cold coffee, French fries, hamburgers, and eggs. These concerns were repeatedly raised in meetings, but residents reported no follow-up or resolution. The Food Service Director (FSD) confirmed that the heating device was broken and needed replacement, but no interim measures were implemented to ensure meals were served at appropriate temperatures. A test tray conducted on the third floor confirmed that food and beverages were not served at acceptable temperatures. The Food Service Director and the NHA were aware of the broken heating device but had not taken steps to address the issue. The facility's failure to maintain food at safe temperatures violated regulatory requirements, as evidenced by the test tray results and resident complaints.
Plan Of Correction
The facility cannot go back retroactively to correct this issue. Dietary staff members were educated on appropriate food temperatures. The Dietary Director/designee will conduct test tray audits on each floor weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were investigated and resolved for three residents. Resident R12 reported a grievance about receiving cold breakfast meals, but there was no documentation of any investigation or resolution provided by the facility. This indicates a lack of follow-through on the part of the grievance official or the designated department responsible for addressing such concerns. Resident R15 filed a grievance upon admission, reporting that her room was not clean and contained someone else's belongings. Additionally, she did not receive requested food items such as soup and tea. The facility did not document any investigation or resolution for these grievances, showing a failure to address the resident's immediate concerns and uphold the grievance policy. Resident R14's daughter submitted a grievance regarding multiple issues, including cold meals and missing food items. She detailed specific instances where her father received cold food and incomplete meals, which were not addressed by the facility. The lack of investigation and resolution for these grievances highlights a systemic issue in the facility's grievance handling process, as evidenced by the absence of documented actions or solutions for the residents' reported concerns.
Plan Of Correction
The facility cannot go back retroactively to correct this issue. The NHA/designee conducted an audit of the last 2 weeks of grievances to ensure grievances are investigated and resolved. The Interdisciplinary Team was educated on the grievance policy by the Regional Nurse. The NHA/designee will audit grievances to ensure grievances are investigated and resolved. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Failure to Address Resident Grievances on Cold Food
Penalty
Summary
The facility failed to act promptly upon resident grievances and recommendations during monthly resident group meetings, specifically concerning the dietary department. Over a period of three months, residents consistently reported issues with cold food during resident council meetings. Despite these repeated complaints, there was no evidence that the facility took action to address these concerns. The facility's policy on resident council meetings emphasizes the importance of addressing resident concerns, but the facility did not demonstrate any response or rationale for the lack of action. Interviews with residents revealed ongoing dissatisfaction with the food temperature, with multiple residents reporting that their meals were often served cold. Residents expressed their grievances during meetings and even arranged a separate meeting with the Nursing Home Administrator (NHA) to discuss these issues. However, the residents reported that they were not updated on any actions taken to resolve the problem, and the issue of cold food persisted. The NHA acknowledged awareness of the problem, specifically noting that a heating device used to keep food warm needed replacement but had not been addressed. Despite the residents' efforts to communicate their concerns through formal channels, the facility did not provide evidence of any steps taken to resolve the issues raised, leading to a deficiency in addressing resident grievances effectively.
Plan Of Correction
The facility cannot go back retroactively to correct this issue. A Resident Council meeting was held on 12/20/2024 and concerns voiced were documented and acted upon promptly with a resolution. Resolutions will be reported to the individuals voicing concerns. The Interdisciplinary Team was educated by the Regional Nurse on the Resident Council process and acting upon any concerns in a timely manner as well as communicating actions taken to resolve those concerns. The NHA/designee will audit Resident Council Meeting minutes monthly to ensure any concerns voiced are acted upon promptly. Audits will be done monthly x 3 months. Results of the audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Develop Person-Centered Care Plan for Resident with COPD
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with chronic obstructive pulmonary disease (COPD) and other health conditions, such as pulmonary hypertension, heart failure, and chronic kidney disease. The deficiency was identified when it was found that the resident's care plan did not address sensitivities to irritants like aerosol sprays and perfumes, which could adversely affect the resident's health. This oversight was discovered during a review of the resident's clinical records and facility policies. An incident was reported where a nurse aide wore perfume that had a suffocating effect on the resident, exacerbating her respiratory condition. The Director of Nursing (DON) acknowledged awareness of the incident and provided education to the staff member involved. However, the care plan still lacked specific interventions to prevent exposure to such irritants, despite the resident's known sensitivities and previous complaints about similar issues. The facility's policy on care planning requires that each resident's needs be addressed with specific goals and interventions, but this was not adhered to in the case of the resident with COPD. The absence of a comprehensive plan to manage the resident's exposure to irritants indicates a failure to ensure all staff were informed of the potential health impacts, as confirmed by the DON during an interview.
Plan Of Correction
R1 care plan was updated to include the resident's sensitivities to aerosol sprays and perfumes and the effects that the use of them could have on the residents health related to the diagnosis of COPD. The DON/designee audited residents with a diagnosis of COPD to ensure appropriate care plans are in place. The facility educated licensed staff on the development of person-centered plan of care for residents with COPD that addresses sensitivities to aerosol sprays, perfumes, and the effects that the use of them could have on a resident. The DON/designee will audit new admissions with a diagnosis of COPD to ensure care plans are developed that address sensitivities to aerosol sprays and perfumes. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Inadequate Supervision During Medication Administration
Penalty
Summary
The facility failed to ensure adequate supervision during medication administration for a resident, identified as Resident R2. The resident, who has a medical history of kidney failure, hypertension, diabetes, cerebral infarction, and senile degeneration of the brain, was observed with a plastic cup containing approximately four pills on her bedside table. The resident, who was assessed with moderate cognitive impairment and lacked the capacity to make general healthcare decisions, reported that the nurse left the pills for her to take. The Director of Nursing (DON) confirmed that the medications included nifedipine, Allegra, Farxiga, and aspirin, and identified the licensed nurse responsible for leaving the medications unattended. The review of the resident's physician orders indicated that there was no authorization for the resident to self-administer medication. The facility's policy on medication administration requires that medications be administered under the orders of the attending physician or their designees. The incident was discussed with the DON, who acknowledged that the resident's clinical record did not show evidence of authorization for self-administration of medication, highlighting a failure in supervision and adherence to medication administration protocols.
Plan Of Correction
E4 was educated by the DON on the medication administration policy. The DON/designee did an audit of the unit to ensure there were no other residents with medications left at the bedside. Licensed staff were inserviced on the Medication Administration/Disposition policy by the Facility Educator. The DON/designee will conduct random room audits of 10 rooms on each unit to ensure medications are not left at the bedside. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Failure to Maintain Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides across several shifts, as mandated by the regulation effective July 1, 2024. Specifically, the facility did not meet the minimum staffing requirements of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight for 6 out of the 63 shifts reviewed. This deficiency was identified through a review of nursing staff schedules and facility census data, which revealed discrepancies in the hours of care provided by nurse aides compared to the hours required based on the resident census. On multiple occasions, the facility's staffing levels fell short of the required hours of care. For instance, on October 20, 2024, the facility provided only 116.4 hours of care instead of the required 140 hours during the day shift. Similarly, on November 28, 2024, only 75.93 hours of care were provided overnight, falling short of the required 89.60 hours. These findings were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to meet state staffing requirements on specific dates.
Plan Of Correction
The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and Staffing Coordinator were educated by the Regional Nurse on the CNA staffing ratios for dayshift, evening shift, and nightshift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required CNA ratios are met. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Failure to Meet LPN Staffing Ratios Overnight
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) during the overnight shift on one of the 63 shifts reviewed. Specifically, on October 20, 2024, the facility had a census of 176 residents, necessitating 35.20 hours of care by LPNs for the 11:00 p.m. to 7:00 a.m. shift. However, the review of nursing time schedules revealed that only 33.74 hours of care were provided by LPNs, falling short of the required staffing ratio. This deficiency was identified during a review of nursing staff schedules and interviews with staff, and it was discussed with the Nursing Home Administrator and the Director of Nursing on December 3, 2024.
Plan Of Correction
The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and staffing coordinator were educated by the regional nurse on the LPN staffing ratios on the nightshift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required LPN ratios are met. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.
Deficiency in Meeting Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period for 13 out of 21 days reviewed. This deficiency was identified through a review of the facility's nursing staffing documentation for the periods between October 14, 2024, and December 1, 2024. Specific days were noted where the hours of direct care fell below the required threshold, with the lowest being 2.94 hours on October 20, 2024. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing on December 3, 2024. The review highlighted multiple instances where the facility's staffing levels did not meet the state-mandated requirement, indicating a pattern of insufficient staffing to provide the necessary level of care to residents. No corrective actions or follow-up measures were mentioned in the report.
Plan Of Correction
The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and Staffing Coordinator were educated by the Regional Nurse on the state required direct resident care hours of 3.2 per patient day (PPD). The NHA/designee will audit the daily PPD as well as the projected PPD for the upcoming day using the PA DOH grid to ensure the required PPD is being met. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.
Failure to Monitor Hot Beverage Temperatures Leads to Resident Burn
Penalty
Summary
The facility failed to monitor and serve hot beverages at a safe temperature, resulting in an Immediate Jeopardy situation for a resident who sustained a second-degree burn. The resident, identified as R371, was cognitively impaired with a BIMS score of 4, indicating significant cognitive impairment. The resident also had impairments in the range of motion in the upper extremity, Parkinson's disease, arthritis, and malnutrition, requiring substantial assistance with eating and drinking. Despite these conditions, the resident was served a hot beverage without adequate supervision or temperature checks. On the day of the incident, the resident was dining in the common room when a licensed nurse, Employee E10, provided a cup of hot water for tea, which was not temperature-checked. The resident spilled the hot beverage on their right thigh, resulting in a burn. The facility's policy on hot liquid safety, which required serving temperatures not to exceed 140 degrees Fahrenheit and the use of protective measures, was not followed. The beverage temperature logs revealed inconsistencies and inaccuracies, with some temperatures exceeding the safe limit. Interviews and documentation indicated that the dietary staff had not been accurately recording beverage temperatures, and the coffee machine had been malfunctioning, leading to incorrect temperature readings. The facility's failure to adhere to its hot liquid safety policy and provide appropriate supervision during meal service directly contributed to the resident's injury.
Removal Plan
- Licensed staff conducted a hot liquid safety evaluation for all residents in the facility. Any resident that triggers at risk will be evaluated further by occupational therapy to determine if the resident requires assistance during meals or adaptive equipment.
- All staff will be educated on the results of hot liquid safety assessment and intervention will be included in the resident care plan.
- To ensure that temperature of hot liquids is accurate, the facility developed a protocol and educated all staff.
- Prior to hot liquids leaving dietary, a temperature will be taken by two staff members in Dietary. One staff member will take the temperature and the supervisor/designee will verify the accuracy of the temperature.
- The temperature will be documented on the hot beverage form along with both staff members signing off on this form.
- Temperature on the unit should not exceed 140 degrees Fahrenheit.
- Any hot beverage temps over 140 degrees will be sent back to the dietary department for a replacement.
- The hot beverage monitoring form will be submitted daily to the NHA/designee for review to assure compliance. The Hot Liquid tools will be submitted to the Quality Assurance Committee for review.
Failure to Follow Diabetes Management Protocols
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, specifically in managing diabetes care. For Resident R57, the facility did not inform the physician of a missed insulin dose due to the medication not arriving from the pharmacy, as documented in the nursing note dated May 29, 2024. The Director of Nursing confirmed that the nursing staff did not follow the facility policy by failing to notify the physician about the missed medication. Resident R135's clinical records showed multiple instances of elevated blood sugar levels that were not reported to the physician as required by the physician's orders. Similarly, Resident R149 experienced both hypoglycemic and hyperglycemic episodes, with no documented evidence that the facility followed the prescribed protocols for managing these conditions. The Director of Nursing confirmed the lack of documentation and adherence to protocols for both residents.
Inadequate Investigations into Resident Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into several incidents involving residents, leading to deficiencies in addressing potential abuse, neglect, and injuries of unknown origin. For Resident R120, the facility did not investigate the new onset of shoulder pain, which was later diagnosed as a fracture, to rule out potential abuse. The Director of Nursing confirmed that no investigation was conducted, attributing the injury to an old fracture without further inquiry. In another case, Resident R51 eloped from the facility, and the investigation was incomplete. There was no documentation of interviews with the resident's roommate or the person who reported the incident. Additionally, the facility did not determine how the resident removed the alarm bracelet or the duration of time spent outside. The Director of Nursing acknowledged the lack of a thorough investigation into the elopement. Further deficiencies were noted with Resident R102, who complained of ankle pain after being left unattended. The investigation did not include a comprehensive assessment or interviews to determine the source of the injury. Similarly, Resident R371 suffered a burn from hot water, and the investigation revealed that the water temperature was not checked. The facility's documentation and interviews with staff confirmed these lapses in investigation and documentation.
Failure to Develop Comprehensive Care Plan for Constipation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident's chronic condition of constipation. The facility's policy, revised in July 2023, mandates the creation of a comprehensive care plan for each resident, addressing their specific needs with goals and interventions. However, for one resident, identified as R57, the facility did not adhere to this policy. The resident had a history of constipation, with a progress note from a Certified Registered Nurse Practitioner (CRNP) on April 15, 2024, indicating no bowel movement for 96 hours. The CRNP ordered Milk of Magnesia (MOM) and, if ineffective, a suppository. On May 6, 2024, the CRNP noted another instance of no bowel movement for 48 hours and ordered the initiation of a bowel protocol and daily Docusate. Despite these medical interventions, the facility did not develop a care plan for the resident's constipation, as confirmed by the Director of Nursing on July 19, 2024.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services for a resident who was admitted following neurosurgery for a brain tumor and was diagnosed with seizures and hemiplegia. The resident, who was alert and oriented, expressed a desire to walk again and reported that after physical therapy ended, no one assisted her with walking. Her care plan included a Restorative Nursing Program to maintain skills learned in physical therapy, specifically ambulating 200 feet using a quad cane with contact guard assistance. However, there was no documented evidence that nursing staff provided the restorative therapy as outlined in her care plan. The deficiency was confirmed by the Director of Nursing, who acknowledged that the resident should have been on the restorative program, but the facility failed to coordinate this care with therapy. The resident's progress notes and care conference records indicated she was on a physical therapy maintenance program, yet the necessary restorative nursing services were not implemented, leading to a lapse in the resident's care as per her needs and care plan.
Failure to Manage Hot Beverage Safety for Resident with Parkinson's
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, leading to an immediate jeopardy situation involving a resident, identified as R371. This resident, who had Parkinson's disease with associated tremors, was not adequately assessed and supervised. Despite being cognitively impaired with a BIMS score of 4 and requiring substantial, maximal assistance for eating, the resident was provided a hot beverage, which resulted in a serious burn injury when it spilled. The facility's documentation and policies indicated that the resident had multiple risk factors, including visual impairment, weakened upper extremity strength, and balance issues, which should have triggered additional precautions. The facility's Hot Liquid Safety policy, last revised in February 2023, was not adhered to, as evidenced by the incident where a licensed nurse provided the resident with a hot beverage without ensuring the temperature was safe. Observations revealed that hot beverages were served at temperatures exceeding the policy's maximum of 140 degrees Fahrenheit, with one instance recorded at 152 degrees Fahrenheit. The failure to implement necessary interventions, such as serving beverages at safe temperatures and providing appropriate supervision, contributed to the deficiency. The NHA and DON did not fulfill their responsibilities to ensure the safety and well-being of the residents, as required by federal, state, and local guidelines.
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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