Sinking Spring Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Sinking Spring, Pennsylvania.
- Location
- 3000 Windmill Road, Sinking Spring, Pennsylvania 19608
- CMS Provider Number
- 395541
- Inspections on file
- 28
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Sinking Spring Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow physician orders and its own medication administration policy for a resident with Hodgkin’s lymphoma and anxiety. An LPN gave only one lorazepam tablet hours before the ordered bedtime dose of three tablets, and on another occasion a different LPN administered only one lorazepam tablet instead of three at bedtime. The same resident also missed a scheduled oxycodone HCL (IR) 10 mg dose for pain because no medication was available, with the last dose on hand given earlier in the day and the next dose not provided until several hours later. The Administrator acknowledged there was no documentation showing that staff followed the physician’s orders in these instances.
A resident with chronic pain, major depressive disorder, and anxiety, who depended on staff for personal hygiene and had a care plan directing staff to postpone care when she refused, had her hair cut and shaved against her wishes. Despite facility policies prohibiting abuse and requiring respect for grooming preferences, the DON instructed staff to cut the resident’s hair using scissors and an electric razor. The resident repeatedly screamed no, stating she wanted to keep her ponytail, but staff proceeded, did not discuss or attempt alternatives, and then took her to the shower. The resident was later observed with unevenly shaved hair and was reported by her roommate to have been crying afterward, with no documentation of medical necessity, alternative options, or acknowledgment of her refusal.
A resident with depression, anxiety, and chronic pain, who was alert, oriented, and dependent on staff for hygiene, had a care plan stating she often refused care, that staff should postpone activities when she refused, and that she should be allowed to choose between a shower or bed bath. Despite this, staff provided a shower instead of the planned bed bath after the resident stated she did not want a shower, and, on the DON’s instruction, staff cut the resident’s hair using scissors and an electric razor while she repeatedly refused and became distressed. The resident was later observed with short, uneven hair, reporting that her ponytail had been shaved off against her wishes, and her roommate reported that she cried afterward.
A resident with chronic pain syndrome, major depressive disorder, and anxiety, who was alert, oriented, and dependent on staff for personal hygiene, had a care plan stating that staff should postpone personal care activities if she refused them. Despite this, staff proceeded to cut the resident’s hair and provide a shower after she refused, and the DON confirmed these actions. There was no documentation that the care was postponed as directed in the care plan.
A review of staffing schedules showed that the facility did not meet the required minimum NA-to-resident ratio during one night shift, failing to provide at least one NA for every 15 residents as required by regulation.
The facility did not meet the required minimum LPN-to-resident ratios on several day and evening shifts, as shown by a review of nursing schedules. On multiple occasions, there were not enough LPNs scheduled to meet the mandated ratios for the number of residents present.
A review of nursing schedules showed that the facility did not provide the required minimum of 3.2 hours of direct nursing care per resident on three days within a 21-day period, with care hours falling below the mandated threshold on each of those days.
Surveyors observed unsanitary conditions in the kitchen, including a black substance on ceiling tiles near exhaust vents, missing ceiling tiles, and a central air vent dripping water onto the floor.
Three residents with significant medical conditions who required staff assistance for hygiene were observed with long, dirty nails and reported that staff had not provided nail care as outlined in their care plans. Despite needing help with activities of daily living, these residents stated that nail care was not offered during showers or as needed.
Surveyors observed peeling wallpaper in the Chapel and damaged walls and linoleum in two resident rooms on one nursing unit. The Administrator confirmed these environmental issues should have been addressed, resulting in a deficiency for failing to maintain a safe, sanitary, and comfortable environment.
A resident's personal funds were not conveyed to their estate nor was a final accounting provided to the appropriate party within 30 days of death, as required. Instead, the facility issued a check to the Social Security Administration, and the Administrator confirmed that the necessary documentation and transfer to the estate did not occur.
Two residents were involved in incidents of ongoing harassment, sexual threats, and physical altercations, with one resident experiencing increased anxiety and depression due to repeated abuse by another. Facility records and interviews confirmed that the abuse had been ongoing and intensified over time, and the facility failed to prevent both physical and mental abuse.
A resident with significant medical conditions reported to staff and a psychologist that another resident had been sexually harassing, threatening, and physically hitting him. Despite facility policy requiring prompt reporting, the incident was not reported to the State Survey Agency.
The facility failed to assess and monitor wounds and implement preventive interventions for two residents. A resident with diabetes and peripheral vascular disease had a new wound that was not assessed or monitored for several days. Another resident, at risk for skin breakdown, had boggy heels documented multiple times without timely preventive interventions. The DON confirmed these deficiencies.
A facility failed to develop a comprehensive care plan for a resident with anxiety and psychotic disorder, as required by the MDS CAA summary. Despite the resident receiving antipsychotic and antidepressant medications, there was no documented evidence of interventions to address psychotropic drug use in the care plan. The Administrator confirmed this deficiency during an interview.
Two residents with muscle disorders and mobility issues did not receive consistent assistance with walking as recommended by therapists. Despite care plans indicating the need for daily ambulation support, there was no documented evidence of such assistance being provided over the last 30 days. Both residents reported not receiving consistent help, and the facility's administration acknowledged the lack of documentation.
The facility failed to properly store food and maintain sanitary conditions in two unit pantries, Station 2 and Arcadia. Observations revealed unlabeled and outdated food items in the refrigerators and freezers, contrary to the facility's policy requiring labeling and discarding after three days. Additionally, unsanitary conditions were noted, such as dried liquid debris and hair inside the refrigerators. This deficiency was cited under CFR 483.60(i) Food Safety Requirement.
The facility failed to maintain dignity during dining assistance for a resident with Alzheimer's and dysphagia, as a nurse aide was observed standing while feeding the resident, contrary to the care plan. Additionally, another resident with physical limitations did not receive timely assistance despite activating the call bell, which was not answered by available staff, violating the facility's policy for prompt response.
The facility failed to maintain a safe, clean, and comfortable environment in three nursing units. Observations included stained sinks, cluttered areas with trash, marred walls, odors, insects, and structural damage such as holes and peeling paint.
The facility failed to serve food at an appetizing temperature, as identified through resident interviews and a test tray audit. Residents reported that their food was often served cold, and a test tray audit confirmed that a smothered pork chop and roast potatoes were served at temperatures below the facility's standard. The Director of Dining Services confirmed the food was cool to taste.
The facility failed to serve two residents their preferred and selected food items, impacting their nutritional care. One resident, with a history of weight loss, did not receive his chosen iced tea and garlic bread, while another resident, with folate deficiency anemia, was served an alternate meal instead of her selected main meal. Both residents expressed that this issue occurred frequently.
The facility did not post current nurse staffing information, as observed during tours when the lobby displayed outdated staffing data. The Nursing Home Administrator confirmed the inaccuracy.
The facility was found to have improperly disposed of trash and refuse. Observations revealed garbage and debris, such as used gloves and plastic items, scattered around the trash compactor. A full garbage bag was stuck between the compactor and the ground, and the dumpster lid was open with trash bags overflowing. A walker was also found next to the dumpster.
The facility did not ensure a safe, clean, and comfortable environment on four nursing units. Issues included a broken toilet seat, dirt and debris under air conditioning units, a non-functioning bathroom light, a dirty wheelchair, and lifting linoleum flooring. These deficiencies compromised the residents' right to a homelike environment.
Two residents, one with hemiplegia and diabetes and another with osteoporosis and depression, were not offered showers as scheduled in an LTC facility. Both residents, who required staff assistance for bathing, reported not being offered showers multiple times over the past month, despite their preference to shower twice a week.
Failure to Follow Physician Orders for Lorazepam and Oxycodone Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for a resident with Hodgkin’s lymphoma and anxiety, contrary to its own medication administration policy. The facility policy dated February 12, 2026, required medications to be administered in accordance with prescriber orders and specified that bedtime medications be given up to one hour prior to the resident’s scheduled bedtime. Clinical record review showed that a physician’s order dated October 27, 2025, directed staff to administer lorazepam 0.5 mg, three tablets at bedtime. However, nursing progress notes and the Individual Patient Narcotic Dispensing Record documented that on December 11, 2025, an LPN administered only one lorazepam tablet at 5:30 p.m., rather than three tablets at the scheduled 8:00 p.m. bedtime. An additional physician’s order dated January 19, 2026, again directed staff to administer lorazepam 0.5 mg, three tablets at bedtime, but the narcotic dispensing record showed that on February 4, 2026, at 8:00 p.m., another LPN administered only one tablet instead of three. A separate order dated January 19, 2026, required oxycodone HCL (IR) 10 mg every four hours for pain. Review of the January 2026 Medication Administration Record revealed that the 8:00 p.m. oxycodone dose on January 29, 2026, was missed because no medication was available, as confirmed by a nursing progress note and the narcotic dispensing record, which showed the last dose on hand was given at 4:00 p.m. and the next dose not administered until midnight on January 30, 2026. In an interview, the Administrator stated there was no documented evidence that staff followed the physician orders as described.
Resident’s Hair Cut and Shaved Against Expressed Refusal, Constituting Abuse
Penalty
Summary
The facility failed to protect a resident from physical and mental abuse when staff cut and shaved the resident’s hair against her expressed wishes. Facility policies on Abuse Prohibition and Treatment: Considerate and Respectful required that residents be free from abuse, mistreatment, and neglect, and that grooming respect resident preferences for hairstyle and length. The resident had chronic pain syndrome, major depressive disorder, and anxiety, and her MDS showed she was alert, oriented, reported feeling down or hopeless several days per week, and was dependent on staff for personal hygiene. Her care plan documented that she often refused care due to personal preference and that staff were to postpone activities if she refused. On the date of the incident, the resident reported that staff told her not to talk to anyone about certain things and that staff shaved her head using an electric razor after she said no. She stated she previously had a ponytail and that staff shaved her hair like she was a prisoner, without trying any other options. She reported that after staff shaved her head, they took her to the shower. Observation showed her hair was visibly short and uneven, with varying lengths from close to the scalp to about a half inch, and she was seen rubbing her hand over her hair and moving her head during the interview. Staff interviews confirmed that the DON instructed staff to cut the resident’s hair and that scissors and an electric razor were used. The DON acknowledged that the resident “freaked out,” said she did not want her ponytail cut, and objected to the hair being cut, and that no other options were discussed or attempted. A nurse aide stated that the resident screamed no until after her hair was cut, then became silent. The resident’s roommate reported that after staff cut the resident’s hair, the resident was in the room crying. There was no documentation that the resident had tangled hair, a medical need, or any other condition requiring her hair to be cut, no evidence that alternatives such as consultation with a hairdresser or a scheduled haircut were offered, and no documentation that staff acknowledged or honored the resident’s refusal.
Removal Plan
- Resident 1 was seen by social services, psychiatry, and the physician.
- The facility will conduct a full abuse investigation.
- The facility will report the allegation to the Department of Health, Pennsylvania Department of Aging, the local Police Department, and the Area Agency on Aging.
- Psychiatry/psychology services will continue to follow Resident 1 routinely.
- All residents will be assessed for injuries or trauma, with follow-up if needed. If any allegations are brought forward, they will be reported to the abuse coordinator, the resident will be removed from the situation, and staff will be placed on leave if identified as the perpetrator.
- The Administrator will re-review the abuse policy.
- The facility will educate all staff on abuse protocols, resident rights, and refusal of care. Staff members will be given a quiz with the education.
- The facility suspended all involved staff members.
- Weekly audits and then monthly audits will be conducted of any potential abuse allegations and the results discussed at the QAPI committee.
Failure to Honor Resident Refusals and Grooming Preferences
Penalty
Summary
The facility failed to honor a resident’s rights to dignity, self-determination, and personal preferences regarding hygiene and grooming. Facility policy required that residents be groomed as they wished, including maintaining preferred hair style and length. The resident involved had chronic pain syndrome, major depressive disorder, and anxiety, and her MDS showed she was alert, oriented, reported feeling down or hopeless several days per week, and was dependent on staff for personal hygiene. Her care plan indicated she often refused care due to personal preference, that staff were to postpone activities if refused, and that it was important for her to choose between a shower or bed bath. Despite this, the nurse aide Kardex directed staff to provide bed baths twice weekly, and documentation showed that staff provided a shower instead of a bed bath on a specific date. During interviews, the resident stated she did not want to go for a shower but staff took her anyway, and that staff cut her hair with an electric razor despite her repeated refusals. She was observed in bed with visibly short, uneven hair, rubbing her hand over her head and moving her head from side to side, and reported that staff had shaved her head, removed her ponytail, and made her feel like a prisoner. A nurse aide reported that the DON instructed her to cut the resident’s hair and that the resident screamed “no” until after the hair was cut, then became silent. Two other nurse aides confirmed the resident had refused a shower but was given one regardless. The DON confirmed she told staff to cut the resident’s hair, acknowledged that the resident objected and “freaked out,” and confirmed that scissors and an electric razor were used and no other options were discussed or attempted. The resident’s roommate reported that after staff cut the resident’s hair, the resident was in the room crying.
Failure to Follow Care Plan for Resident’s Refusal of Personal Care
Penalty
Summary
The facility failed to implement a comprehensive care plan that addressed an individual resident’s assessed needs and documented preferences. Clinical record review showed that the resident had chronic pain syndrome, major depressive disorder, and anxiety, and the Minimum Data Set dated November 6, 2025 indicated the resident was alert and oriented, reported feeling down, depressed, or hopeless several days per week, and was dependent on staff for personal hygiene. The resident’s care plan documented that she often refused care due to personal preference and directed staff to postpone the activity if she refused. However, the resident reported that staff cut her hair and took her for a shower even though she refused, and the Director of Nursing confirmed that staff provided the hair cutting and shower on January 6, 2026 despite the resident’s refusal. There was no documented evidence that staff postponed these activities in accordance with the resident’s care plan.
Failure to Meet Minimum Nurse Aide Staffing Ratio on Night Shift
Penalty
Summary
A review of nursing time schedules for a 21-day period revealed that the facility did not meet the required minimum nurse aide (NA) to resident ratio on one occasion. Specifically, on the night shift from 11:00 p.m. to 7:00 a.m. on December 9, 2025, the facility failed to provide at least one NA for every 15 residents, as mandated by regulation. This deficiency was identified through direct examination of staffing records for the specified period. No additional details regarding the residents' medical history or condition at the time of the deficiency were provided in the report.
Plan Of Correction
1, 2) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios are met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements. 4) Weekly audit of nurse aide ratios will be conducted for 60 days by NHA/designee to ensure nurse aide ratios are met. Tracking and trends to be submitted to the QAPI committee.
Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum LPN-to-resident ratios on five out of twenty-one days reviewed, as evidenced by nursing time schedules. Specifically, on two days, the day shift did not have at least one LPN per 25 residents, and on three separate days, the evening shift did not have at least one LPN per 30 residents. These deficiencies were identified through a review of staffing schedules covering the period from late November to mid-December 2025. No information about specific residents, their medical histories, or their conditions at the time of the deficiency is provided in the report.
Plan Of Correction
1,2) LPN staffing ratios will be reviewed for the last 7 days to evaluate if LPN ratios are met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements. 4) Weekly audit of LPN ratios will be conducted for 60 days by NHA/designee to ensure LPN ratios are met. Tracking and trends to be submitted to the QAPI committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules over a 21-day period revealed that on three specific days, the total nursing care hours fell below the mandated minimum. Specifically, on November 30, 2025, only 3.11 care hours per resident were provided; on December 6, 2025, 3.12 care hours per resident were provided; and on December 13, 2025, 3.09 care hours per resident were provided. This deficiency was identified through a review of the facility's nursing time schedules and affected the overall care provided to residents during those days.
Plan Of Correction
1,2) HPPD will be reviewed for the last 7 days to evaluate if the state minimum PPD of 3.2 is met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements. 4) Weekly audit of HPPD will be conducted for 60 days by NHA/designee to ensure minimal HPPD is met. Tracking and trends to be submitted to the QAPI committee.
Unsanitary Kitchen Conditions Observed
Penalty
Summary
During an environmental tour of the kitchen, surveyors observed unsanitary conditions, including a black substance present on ceiling tiles around the exhaust vents. Additionally, several ceiling tiles were missing, and a central air vent was noted to be dripping water onto the floor. These findings indicate that the facility failed to maintain sanitary conditions in the kitchen as required by professional standards and regulatory requirements. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Required Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for three residents who required staff assistance with activities of daily living, specifically nail care. Clinical record reviews and resident interviews revealed that each resident had care plans directing staff to assist with hygiene and nail care on bath days and as needed. Despite these documented needs, observations on multiple occasions showed that the residents' nails were long and dirty, and the residents reported that staff had not offered to provide nail care during recent showers or at other times. The affected residents had significant medical conditions, including cerebral palsy, seizure disorder, congestive heart failure, kidney failure, and Parkinson's disease, and required varying levels of assistance with self-care. All three residents expressed a preference for short nails and indicated that staff had not fulfilled their care plan requirements regarding nail care. These findings were corroborated by both direct observation and resident statements, demonstrating a pattern of staff inaction in providing necessary hygiene services as outlined in the residents' care plans.
Environmental Maintenance Deficiency Noted on Nursing Unit
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents and staff on one of four nursing units, specifically Station 2. During observations conducted over two days, surveyors noted peeling wallpaper on all four walls in the Chapel, damage to the wall to the left of the door in one resident room, and damage to the wall behind the bathroom sink and toilet, as well as damaged linoleum below the sink in another resident room. The Administrator confirmed in an interview that these environmental issues should have been addressed. These findings indicate that the facility did not uphold required standards for environmental maintenance as outlined in state regulations, resulting in a deficiency related to the physical condition of the environment.
Failure to Convey Resident Funds to Estate After Death
Penalty
Summary
The facility failed to convey a deceased resident's personal funds and provide a final accounting of those funds to the appropriate individual or probate jurisdiction within 30 days of the resident's death. Review of the clinical record and resident fund account showed that the resident was admitted and later expired at the facility, with a remaining account balance of $2,961.70. The account was closed, but there was no documented evidence that a final accounting was provided to the estate as required. Instead, a check was issued to the Social Security Administration rather than to the resident's estate. The Administrator confirmed in an interview that the required final accounting and transfer of funds to the estate did not occur within the specified timeframe.
Failure to Protect Residents from Abuse Resulting in Psychosocial Harm
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in psychosocial harm to one of them. One resident, with a history of hemiplegia, anxiety, and depression, was subjected to ongoing harassment and sexual threats by another resident, who had diagnoses including borderline personality disorder and schizoaffective disorder. Documentation showed that the harassing resident repeatedly demanded food and money, entered the victim's room without permission, took food, made threatening phone calls, and made explicit sexual threats and requests. The victim reported these incidents to staff and a psychologist, describing increased anxiety and depression as a result of the ongoing abuse. The situation escalated when the victim, after enduring repeated harassment and threats, struck the perpetrator with a walker following an argument. Facility records and interviews confirmed that the abuse had been ongoing for several months and had intensified in the weeks leading up to the incident. The facility's failure to intervene and protect both residents from physical and mental abuse constituted a violation of resident rights and resulted in documented psychosocial harm.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by its own policy. According to the policy, the Administrator or designee is responsible for reporting allegations of abuse to the appropriate state and local authority within two hours. Clinical record review showed that a resident with diagnoses including hemiplegia, hemiparesis, anxiety, depression, and heart disease reported to staff and a psychologist that another resident had been sexually harassing him, making threats for food and money, and physically hitting his arm. Despite these reports, the Administrator confirmed that the incident was not reported to the State Survey Agency.
Failure to Assess and Monitor Wounds and Implement Preventive Interventions
Penalty
Summary
The facility failed to adhere to its policy on skin integrity and wound management, resulting in inadequate assessment and monitoring of wounds for two residents. Resident 1, who had multiple diagnoses including diabetes and peripheral vascular disease, developed a new wound on the right third toe. Despite a treatment order, there was no documented evidence of assessment or monitoring of this wound for several days. Additionally, a calloused area on Resident 1's left foot was not assessed or monitored for an extended period, despite being noted to have an odor that resolved after cleansing. Resident 3, who was at risk for skin breakdown due to fragile skin, advanced age, and urinary incontinence, was documented to have boggy heels on multiple occasions. However, interventions to prevent pressure ulcers were not implemented until a physician's order was given much later. The Director of Nursing confirmed the lack of documented evidence for weekly assessments and daily monitoring for Resident 1, as well as the delayed implementation of preventive interventions for Resident 3.
Failure to Develop Comprehensive Care Plan for Psychotropic Drug Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 189, who was admitted with diagnoses including anxiety and psychotic disorder with delusions. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated May 9, 2024, indicated that the resident's use of psychotropic drugs should be addressed in the care plan. However, a review of the medication administration records showed that the resident was receiving both an antipsychotic and an antidepressant at the time of the MDS CAA summary, yet there was no documented evidence of interventions to address the psychotropic drug use in the current care plan. An interview with the Administrator on August 27, 2024, confirmed the absence of documented interventions in the care plan to address the resident's psychotropic drug use, which is a requirement under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Provide Consistent Ambulation Assistance
Penalty
Summary
The facility failed to provide necessary services to improve the activities of daily living, specifically walking, for two residents who required assistance. Resident 128, diagnosed with a disorder of the muscle and a history of repeated falls, was recommended a restorative ambulation program by a therapist. The program aimed for the resident to safely ambulate up to 30 feet using a walker with supervision or stand-by assistance. However, there was no documented evidence that the facility consistently offered assistance with walking on a daily basis for the last 30 days. The resident reported feeling unsteady when walking alone and not receiving consistent assistance from the staff. Similarly, Resident 157, who had a diagnosis of muscle disorder and lumbago with sciatica, was also recommended a restorative ambulation program. The program intended for the resident to ambulate 10-50 feet using a walker with minimal assistance. Again, there was no documented evidence of consistent daily assistance with walking for the last 30 days. The resident confirmed the lack of consistent assistance from the staff. The facility's Administrator and Director of Nursing acknowledged the absence of documented evidence that staff consistently assisted the residents with walking as per their care plans and therapist recommendations.
Improper Food Storage and Sanitation in Unit Pantries
Penalty
Summary
The facility failed to properly store food and maintain sanitary conditions in two of its unit pantries, specifically on Station 2 and Arcadia. The facility's policy, last reviewed on April 3, 2024, requires staff to label food items requiring refrigeration with the resident's name and the date the food was brought in, and to discard the food after three days. However, observations revealed that this policy was not followed. In the Arcadia unit pantry, the refrigerator had a sign indicating it was for resident food only and that foods must be discarded after three days. Despite this, the freezer contained unlabeled raspberry orange sherbet and frozen grape concentrate, and the refrigerator had items such as dished applesauce, milk, and juice that were either past their use-by dates or not labeled with a resident's name or date. Additionally, there was dried liquid debris and hair inside the refrigerator. Similarly, the Station 2 unit pantry had a sign with the same instructions, but the freezer contained a half-eaten whoopie pie without a name or date. The refrigerator held a sandwich dated August 16, 2024, and other items like a bun, juice, string cheese, and various opened bottles and containers that were not labeled with a resident's name or date. These observations indicate a failure to adhere to the facility's food storage policy, resulting in unsanitary conditions and potential food safety issues. The deficiency was cited under CFR 483.60(i) Food Safety Requirement and had been previously cited on September 29, 2023.
Failure to Maintain Dignity in Dining Assistance and Timely Response to Call Bell
Penalty
Summary
The facility failed to provide assistance with dining in a manner that promoted and maintained dignity for a resident diagnosed with Alzheimer's disease, dysphagia, and protein-calorie malnutrition. The resident required total assistance with feeding, as indicated in their care plan, which included feeding slowly and providing verbal cueing. However, observations on two separate occasions revealed that a nurse aide assisted the resident with lunch while standing, which did not align with the care plan's directives for promoting dignity during meals. Additionally, the facility did not ensure timely response to a call bell for another resident with peripheral vascular disease, a muscle disorder, and a history of falling. This resident required staff assistance for repositioning due to physical limitations. Despite the resident activating the call bell and staff being present in the vicinity, the call bell was not answered, and no assistance was provided. The facility's policy required prompt response to call lights, which was not adhered to in this instance.
Environmental Deficiencies in Multiple Nursing Units
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment across three of its five nursing units: Medbridge, Station 2, and Arcadia. On the Medbridge unit, a large brown stain was observed in the bathroom sink of one room, along with a black substance around and inside the drain plug. Additionally, clutter was noted outside another room, including a box containing a new toilet and two large, uncovered garbage cans, one of which was overflowing with trash. On Station 2, several rooms had marred walls and chipped paint, with specific issues such as a pervasive odor of urine and small black crawling insects on a nightstand in one room. Other rooms had gouged walls, bowing ceilings with peeling tape, and unpainted spackle. In one room, tube feed was splattered on the base of the pump, floor, and wall, with black streaks under the sink and used gloves on the floor. The Arcadia unit also had marred walls and chipped paint, with additional damage such as holes in the walls and bathroom doors.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature on one of its nursing units. This deficiency was identified through a review of Dining Council Minutes, resident interviews, and a test tray audit. Residents reported that their food was frequently served cold, which was confirmed during a group interview with three residents. The facility's documentation specified that hot main entrees, starches, and vegetables should be served at temperatures greater than 140 degrees Fahrenheit. However, during a test tray audit, a smothered pork chop was served at 112.6 degrees Fahrenheit and roast potatoes at 108 degrees Fahrenheit, both of which were cool to taste. The Director of Dining Services confirmed the food items were cool to taste.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that residents were served their preferred and selected food items on their meal trays, affecting two residents. Resident 199, who had a diagnosis of adjustment disorder with mixed anxiety and depressed mood, was at nutritional risk due to a history of weight loss. Despite being alert and oriented, the resident frequently did not receive the food and drink items he selected, such as iced tea and garlic bread, as observed on August 26, 2024. The resident expressed that this issue occurred regularly, impacting his enjoyment of meals. Similarly, Resident 202, diagnosed with folate deficiency anemia and also at nutritional risk, did not receive the meal she selected. On August 25, 2024, she was served an alternate meal instead of her chosen main meal, which included country fried steak, green beans, and mashed potatoes. The resident, who was alert and oriented, stated that she often did not receive the meals she preferred or selected. These incidents highlight the facility's failure to honor food preferences as outlined in the residents' care plans.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information as required. During tours of the facility on August 25 and 26, 2024, it was observed that the staffing information displayed in the lobby was outdated, showing the date of August 23, 2024. This discrepancy was confirmed in an interview with the Nursing Home Administrator on August 27, 2024, who acknowledged that the posted staffing information was incorrect.
Improper Disposal of Trash and Refuse
Penalty
Summary
The facility failed to properly dispose of trash and refuse, as observed on August 25, 2024. During the inspection, garbage and debris, including used gloves, plastic food bags, plastic straws, and a gauze roll, were found scattered on the ground around the trash compactor. Additionally, a full garbage bag was stuck between the compactor and the ground. The garbage dumpster was observed with its top lid wide open and filled with trash bags. A walker was also found next to the dumpster.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment across four of its five nursing units, as observed during a survey. On the Medbridge unit, a broken and rusted toilet seat was found in one room, along with dirt and debris under the air conditioning unit in another room, and a non-functioning bathroom light in a third room. The Arcadia unit also had an accumulation of dirt and debris under the air conditioning unit in one room. On Station 2, a resident's wheelchair was observed to have dirt and debris on its bars. Additionally, on Station 3, the linoleum on the bathroom floor was lifting in one room. These observations indicate a failure to uphold the residents' right to a safe, clean, and homelike environment as required by regulations.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide services to enhance the quality of life for two residents by not offering showers as scheduled. Resident 1, diagnosed with hemiplegia and diabetes mellitus, was oriented and required staff assistance for bathing. The resident was supposed to receive a shower twice a week but reported not being offered the opportunity to do so four out of nine scheduled times in the past 30 days. Similarly, Resident 10, who had osteoporosis and depression, was also oriented and required staff assistance for bathing. This resident preferred to take a shower twice a week but was not offered the opportunity six out of nine scheduled times in the past 30 days. Both residents stated they would not refuse the opportunity to shower.
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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