Springfield Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Pennsylvania.
- Location
- 463 West Sproul Road, Springfield, Pennsylvania 19064
- CMS Provider Number
- 395690
- Inspections on file
- 39
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Springfield Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe protein-calorie malnutrition, low BMI, impaired skin integrity, and an altered texture diet experienced significant weight loss over a short period while having variable and often minimal oral intake, including multiple days with zero meal consumption. Facility policy required prompt reweighing, dietitian notification, and interdisciplinary evaluation for significant weight changes, as well as ongoing monitoring of intake and weekly weights. Although a dietitian initially assessed the resident, documented a >10% weight loss, and recommended increased supplements, fortified foods, and weekly weights, there was no documented evidence of weekly weights, further dietitian evaluation, or additional monitoring of caloric intake after the initial assessment, despite continued poor and refused intake. Interviews with the administrator and dietitian confirmed that no further weights were obtained and no additional documented interventions were made to address the resident’s poor appetite.
A resident with dementia, documented forgetfulness, and a moderate elopement risk was able to access an elevator that had been left unlocked during dialysis suite construction, despite policies requiring identification and control of environmental hazards and elopement risks. The resident traveled via the elevator to an unoccupied hallway, forced open an emergency exit door, left the building wearing a jacket, and walked toward a nearby bus stop, where staff observed the resident boarding a public bus and then returned the resident to the facility.
A resident recovering from a left foot amputation and Achilles tendon lengthening did not receive a custom-fitted diabetic shoe with filler as recommended by a consulting podiatrist. Despite repeated recommendations and documented need, the facility did not arrange for the fitting or acquisition of the adaptive equipment, resulting in the resident lacking necessary support for ambulation and experiencing discomfort during therapy.
A resident's discharge papers included the personal and medical records of two other residents, resulting in unauthorized disclosure of sensitive information such as names, contact details, and medical diagnoses. Staff confirmed that these records should not have been included, and the facility's policy requires safeguarding resident confidentiality.
The facility failed to provide necessary personal hygiene services to several residents, as they did not receive scheduled showers due to short staffing. Interviews and documentation confirmed that multiple residents missed their scheduled showers, and one resident was left in bed without assistance. This deficiency highlights a failure to adhere to the facility's ADL policy.
A long-term care facility failed to provide appropriate pain management for four residents, as their pain medications were either unavailable or administered without clear parameters. This resulted in inadequate pain relief, with one resident leaving for a hospital due to unrelieved pain. The facility's pain management policy was not followed, leading to deficiencies in addressing residents' pain effectively.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call bells and unmet care needs for residents. Grievances and interviews revealed issues such as missed showers, delayed assistance, and low weekend staffing. A resident experienced an unwitnessed fall due to waiting for help, and another was left soiled for extended periods. The facility's documentation confirmed low staffing levels, corroborated by the Administrator and DON.
The facility failed to implement enhanced barrier precautions for several residents, as required by physician orders, and did not maintain infection control standards during wound care for a resident. Additionally, tuberculosis testing was not administered upon entry for a resident, as required. These deficiencies were confirmed through observations and staff interviews.
The facility failed to create comprehensive care plans for two residents, one requiring management of long-term antibiotic use for a chronic joint infection and another needing assistance with oral hygiene due to dependency. The absence of these care plans was confirmed by the DON.
A facility failed to update a resident's care plan to reflect their end-of-life wishes. The resident, diagnosed with prostate cancer, had a POLST and physician orders indicating DNR and DNH status, but the care plan incorrectly listed them as FULL CODE. This error was confirmed by the DON, who acknowledged the care plan should have been revised to align with the resident's preferences for comfort measures only.
A resident's pressure ulcer treatment was missed due to unavailable supplies, and the physician was not informed. The resident reported the issue, and the TAR confirmed the missed treatment. The DON acknowledged that staff should notify the physician when treatments are not completed.
The facility did not complete an annual performance evaluation for a nurse aide, Employee E7, as required by their policy. Employee E7, hired in May 2023, had her last evaluation in November 2023, which was not in compliance with the policy mandating evaluations at the end of a 90-day probation and annually thereafter. This was confirmed by the DON.
The facility failed to administer a scheduled antibiotic to a resident due to a clogged port, resulting in missed doses. The resident was supposed to receive Daptomycin intravenously for a bacterial skin infection, but the medication was not given on two occasions. The Assistant Director of Nursing confirmed that the treatment should have been extended to account for the missed doses. The Nurse Practitioner was informed, and the resident's labs were within normal limits.
A resident with multiple diagnoses, including altered mental status and chronic pain, experienced a delay in communication of lab results to the physician. A urine sample collected for urinalysis showed possible contamination, but there was no documentation of the results being communicated or further testing conducted. The DON confirmed the facility's expectation for timely communication was not met.
A facility failed to provide necessary dental services for a resident who was completely dependent on assistance for oral hygiene. The resident, with diagnoses including Anoxic Brain Damage and Tracheostomy Status, had no dental care plan and had not been seen by a dentist. An observation noted a yellowish, greenish substance on the resident's teeth, and the DON confirmed the lack of dental care.
The facility did not complete at least one required Performance Improvement Project (PIP) as mandated by regulations. The QAPI committee's process involves reviewing data from risk meetings to prioritize improvement opportunities, but no evidence of a completed PIP was found in the meeting minutes. An interview with the administrator and DON confirmed this deficiency.
A resident with hypotension and dehydration was ordered a repeat BMP blood test, but the facility failed to place the order in the electronic system, resulting in no lab work being obtained. The resident later exhibited severe symptoms and was transferred to the hospital. The DON confirmed the oversight.
A resident with cognitive deficits frequently refused showers or baths, but the facility failed to update the care plan to address these refusals. Despite staff noting that the resident complied when approached in a specific manner, this was not communicated or reflected in the care plan, resulting in a deficiency.
A resident with dementia and a history of wandering eloped from the facility due to inadequate supervision and failure to ensure the placement of a Wander Guard Bracelet. The resident was able to leave the unit through unsecured doors and exit the building undetected, crossing a high-traffic street before being found by a community member. The incident highlighted lapses in the facility's adherence to its policies for managing residents at risk of elopement.
The facility did not notify the State LTC Ombudsman in writing about residents' transfers or discharges for two months. This was found through staff interviews and documentation review, revealing that the Ombudsman did not receive required notices before these events, violating regulatory requirements.
A resident with a fractured pelvis and toe touch weight-bearing status was given a small bell instead of a functioning call bell due to the roommate's equipment needs. The resident's room was far from the nursing station, causing concern about the resident's ability to alert staff. The DON confirmed the lack of a call bell.
A resident experienced a significant medication error when the facility failed to verify the correct medication list received from the hospital. The resident, with a history of neurological and psychiatric conditions, was given an incorrect medication list belonging to another patient, leading to the discontinuation of their prescribed medications. The error was confirmed by the DON, highlighting a failure to adhere to the facility's medication administration policy.
The facility failed to provide scheduled bathing assistance to three residents, as evidenced by missed showers and inadequate documentation. One resident did not receive a shower for a week after admission, while another missed scheduled showers on two occasions. A third resident, requiring assistance due to chronic back pain, was not provided showers on multiple scheduled dates. This indicates a failure to adhere to care plans and provide necessary nursing services.
The facility failed to maintain safe water temperatures in resident bathroom hand sinks, with temperatures exceeding the policy limit of 110°F, leading to an Immediate Jeopardy situation. Observations revealed that maintenance staff did not consistently monitor water temperatures, and staff were unaware of the safe temperature range. Additionally, infrastructure issues, such as the absence of a thermometer near the East side boiler, contributed to the deficiency.
The Nursing Home Administrator failed to manage hot water temperatures effectively, leading to an immediate jeopardy situation in the North Side Nursing Unit. Observations showed water temperatures in resident rooms exceeded safe limits, and there was a lack of thermometers near the boiler and mixing valve. Interviews revealed that most nursing staff were unaware of safe water temperatures, placing residents at risk for burns.
The facility failed to manage medications properly, with three residents having unauthorized medications at their bedside. A resident had lactase enzyme capsules and Artificial Tears, another had two inhalers, and a third had a probiotic pill pack, all without proper orders or staff awareness, violating safety and supervision policies.
The facility failed to adhere to professional standards for food service safety, with observations revealing dirty conditions in the kitchen and improper food storage in resident areas. Expired, unlabeled, and undated food items were found in refrigerators and freezers, along with human hair and spills. These deficiencies were confirmed by the FSD and DON.
The facility failed to ensure that three residents with severe cognitive impairment, as indicated by low BIMS scores, had the capacity to understand the terms of binding arbitration agreements they signed upon admission. The Nursing Home Administrator confirmed that these residents should not have been signing such documents due to their cognitive impairments.
The facility failed to maintain effective infection control practices. A Nurse Aide improperly transported clean linen by allowing it to touch her uniform, risking contamination. Additionally, an LPN discarded a used gown on the floor after tracheostomy care for a resident on Enhanced Barrier Precautions, due to the absence of a designated PPE disposal container in the room.
The facility failed to treat two residents with dignity and respect. One resident was not weighed as ordered, and a nurse discussed care difficulties in front of the resident and their sister. Another resident, who was alert and oriented, was denied additional breakfast food by the Food Service Director after not receiving the initial delivery, leading to a confrontation in the kitchen.
The facility failed to provide a safe, clean, and homelike environment for several residents. Observations revealed issues such as liquid spills on air conditioning units, call bells out of reach, trash on floors, dirty linens, and non-functional facility phones. Residents reported non-working phones for weeks, and staff confirmed these deficiencies. The Nursing Home Administrator acknowledged the phone issues on the East Wing.
The facility failed to create comprehensive care plans for three residents, neglecting to address chronic constipation, suicide ideations, and dementia care. This lack of person-centered planning was confirmed by the DON, highlighting deficiencies in meeting residents' specific medical and psychosocial needs.
The facility did not follow physician orders for medication administration and Pleurx catheter care for two residents. One resident did not receive a replacement pill after dropping it, and another resident's catheter was drained by his girlfriend instead of nursing staff, with no documentation of the discussion prohibiting this action.
A resident with multiple medical conditions experienced significant weight loss due to the facility's failure to monitor and address their nutritional needs. Despite requiring 1:1 feeding assistance and having specific food preferences, the resident did not consistently receive the necessary support or preferred meals. Observations showed lapses in feeding assistance and documentation, contributing to the deficiency.
The facility failed to provide nourishing snacks between meals for several residents, as revealed through resident council interviews and record reviews. Multiple residents reported not receiving evening snacks, and specific records confirmed the absence of snacks on various dates. One resident, who experienced significant weight loss, also did not receive snacks on several occasions.
The facility did not ensure proper disposal of garbage and refuse, as one dumpster was found open with visible contents, including cardboard boxes. Additionally, the employee smoking area near the loading dock was littered with cigarette butts. These findings were confirmed by the Food Service Director.
The facility's loading dock was found to be unsafe, with an open door leading to a five-foot-high wooden structure lacking safety railings. This posed a risk to staff, delivery drivers, and potentially wandering residents. The Food Service Director and Administrator confirmed the absence of safety measures.
A Nurse Aide was observed improperly transporting clean linens by allowing them to touch their uniform, violating infection control protocols. The aide confirmed the linens should not have contacted their clothing, as per facility policy.
A facility failed to develop a baseline care plan for a resident admitted with clostridium difficile. The resident, who was on an antibiotic therapy regimen with oral Vancomycin, did not have a care plan created for the infection until three days after admission.
A resident admitted with a c-diff infection did not have appropriate infection control measures documented at the time of admission, and a care plan for the infection was delayed until three days after admission.
Failure to Monitor and Intervene for Significant Weight Loss in a Malnourished Resident
Penalty
Summary
The deficiency involves the facility’s failure to monitor and intervene appropriately for significant weight loss in a resident with severe protein-calorie malnutrition. Facility policy required residents to be weighed on admission and at intervals set by the interdisciplinary team, with any weight change of 5% or more to be rechecked the next day and, if confirmed, immediately reported to the dietitian. The policy also required evaluation of undesirable weight changes by the treatment team, including review of target weight range, nutrient needs versus intake, and medical conditions or medications contributing to weight loss. Despite these requirements, the facility did not consistently follow its own policy for one resident. The resident was admitted with a diagnosis of unspecified severe protein-calorie malnutrition and an initial malnutrition risk assessment documented severe fat and muscle loss and risk for malnutrition related to acute and chronic medical conditions. A subsequent nutritional risk assessment showed a recent weight of 126.6 lbs and identified moderate decreased food intake over the prior three months, low BMI for age, impaired skin integrity with stage 2 and 3 pressure injuries, and an altered texture diet. The care plan documented a nutritional problem related to multiple chronic conditions, severe PCM, and significant recent weight loss, with goals to maintain weight within 5% of current body weight and consume at least 75% of three meals daily. Interventions included monitoring and recording intake, obtaining weights at ordered intervals, and reporting significant weight loss and signs of malnutrition to the practitioner. Weight records showed the resident’s weight decreased from 127 lbs to 110 lbs within a short period, with reweighs on the same and following day showing 113.8 lbs and 107 lbs, respectively, resulting in a documented unintentional and unfavorable 13.4% weight loss in less than one month. A dietitian’s progress note on that date attributed the weight loss to variable oral intake with refusal of some meals and increased nutrient demands, and recommended increased supplements, fortified foods, additional protein, vitamins, and weekly weight monitoring. However, there was no documented evidence that weekly weights were obtained after that date until discharge, nor that the dietitian conducted further evaluation or monitoring of the resident’s weight, food, or caloric intake. Food intake records for multiple days in the same month showed repeated zero or low intake at meals, with frequent refusals, and interviews with the administrator and the full-time dietitian confirmed the absence of further weights and documented interventions to address the resident’s poor appetite.
Resident Elopement Through Unsecured Elevator and Exit Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident environment was free of accident hazards when an unlocked elevator allowed access to an exit door through which a resident left the building. Facility policy on Safety and Supervision of Residents required ongoing identification of safety risks and environmental hazards, and the Wandering and Elopements policy required identification of residents at risk of unsafe wandering. Despite these policies, the elevator associated with a newly constructed dialysis suite remained accessible to residents, creating an unmonitored route from a locked unit to an unsecured emergency exit door. The resident involved, identified as R1, was admitted with diagnoses including dementia and difficulty walking. The clinical record showed a BIMS score of 15, indicating cognitive intactness, but progress notes documented the resident as awake, alert, and oriented x1–2 with forgetfulness, able to recall long-term events but unable to remember what was said 30 minutes to one hour earlier. An Elopement/Wandering Risk Evaluation completed on admission identified the resident as being at moderate risk for elopement. According to the facility’s investigation and staff interviews, R1 resided on a locked unit but was able to access the elevator due to its availability during the dialysis suite construction. The resident entered the elevator, traveled to the unoccupied dialysis suite hallway, and then pushed on an emergency exit door until it opened, allowing the resident to exit the building while wearing a jacket. The resident proceeded toward a nearby bus station and was observed by staff boarding a public bus, at which point staff approached and assisted the resident back to the facility.
Failure to Provide Prescribed Foot Care and Adaptive Equipment
Penalty
Summary
The facility failed to provide necessary foot care and treatment for a resident who was admitted for rehabilitation and nursing care following a traumatic amputation of the left foot and Achilles tendon lengthening. The consulting podiatrist evaluated the resident and recommended a custom-fitted diabetic shoe with filler to support ambulation and meet the resident's foot care needs. Despite these recommendations, there was no documented evidence that the facility arranged for the resident to be fitted for the adaptive equipment or provided transportation for this purpose. Subsequent evaluations by the podiatrist reiterated the need for the diabetic shoe, but the resident continued to lack the prescribed adaptive equipment. Observations showed the resident was not wearing any adaptive equipment and was using a wheelchair for mobility. Physical and occupational therapy notes indicated the resident experienced pain and discomfort when trialed with a boot, and interviews with the resident and staff confirmed that the recommended custom-fitted diabetic shoe was never obtained. The lack of appropriate foot care and adaptive equipment impeded the resident's ability to safely ambulate and prepare for discharge to a community setting that required stair navigation, as documented in interviews and clinical records.
Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records during the discharge process. When a resident was discharged home, the discharge papers provided to the family included medical records belonging to two other residents. These records contained sensitive information such as full names, addresses, telephone numbers, sex, dates of birth, citizenship, contact persons with their information, and medical diagnoses. The documents were confirmed to be the face sheets of the two other residents, and their inclusion in the discharge packet was verified by both the Director of Nursing and another staff member. The facility's policy on confidentiality, last revised in October 2017, states that personal privacy and confidentiality of all residents and medical records must be safeguarded, with access limited to authorized staff and business associates. Despite this policy, the incident resulted in the unauthorized disclosure of protected health information for two residents, as confirmed by review of the documents and staff interviews. The affected residents had significant medical conditions, including non-traumatic intracerebral hemorrhage, essential hypertension, anoxic brain damage, tracheostomy status, and chronic respiratory failure.
Failure to Provide Scheduled Showers Due to Short Staffing
Penalty
Summary
The facility failed to ensure that residents received necessary services to maintain personal hygiene and mobility, as evidenced by the lack of scheduled showers for five residents. The facility's policy on Activities of Daily Living (ADL) requires appropriate care and services for residents unable to perform ADLs independently. However, observations and interviews revealed that several residents did not receive their scheduled showers. Resident R35 did not receive showers on two scheduled dates, and Resident R40 missed a scheduled shower due to short staffing. Resident R65 expressed concern about not receiving a shower since admission, and documentation confirmed missed showers on scheduled days. Additionally, Resident R233 did not receive a scheduled shower, and Resident R13 was observed in bed, complaining about the lack of staff to assist her out of bed. The facility's failure to provide these essential services was attributed to short staffing, as confirmed by interviews with staff members. The deficiency was identified under the Pennsylvania Code 28 Pa Code 211.10(d) and 28 Pa Code 211.12 (d)(1)(5), which pertain to resident care policies and nursing services.
Inadequate Pain Management in LTC Facility
Penalty
Summary
The facility failed to provide appropriate pain management for four residents, as evidenced by a review of clinical records, facility policy, and staff interviews. The facility's pain management policy outlines a comprehensive approach to pain assessment and treatment, including recognizing pain, identifying its characteristics, addressing underlying causes, and monitoring the effectiveness of interventions. However, the facility did not adhere to these guidelines, resulting in inadequate pain relief for the residents involved. Resident R79 was admitted with shortness of breath and leg pain, and although prescribed Tramadol for pain, it was unavailable, leading to inadequate pain relief. The resident was given acetaminophen for moderate pain, but due to the lack of Tramadol, the resident left the facility for a hospital. Similarly, Resident R290 experienced delays in receiving pain medication due to procedural issues with accessing controlled substances, resulting in untreated pain despite having a high pain scale. Residents R292 and R293 also experienced deficiencies in pain management. Both residents had physician orders for pain medications that lacked specific parameters for administration based on pain intensity. This led to inappropriate administration of medications, such as giving acetaminophen for mild pain when stronger medication was warranted. The facility's failure to establish clear guidelines and ensure timely access to pain medications contributed to the inadequate management of these residents' pain.
Insufficient Nursing Staff Leads to Delayed Care and Resident Grievances
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available at all times to meet the needs of residents, as evidenced by 43 out of 50 grievances reviewed over several months. The grievances highlighted issues such as delayed responses to call bells, missed scheduled showers, and insufficient assistance for residents. Interviews with staff and residents revealed that the facility was short-staffed, leading to unmet care needs. A nurse aide reported that residents did not receive scheduled showers due to staffing shortages, and multiple residents expressed concerns about delayed assistance and inadequate staffing, particularly on weekends. Specific incidents included a resident experiencing an unwitnessed fall while attempting to transfer from bed to chair after waiting a long time for assistance. Another resident reported being left in bed soiled for extended periods due to delayed responses from nursing staff. The facility's documentation confirmed excessively low weekend staffing, and the findings were corroborated with the facility's Administrator and Director of Nursing. The report cites violations of Pennsylvania Code related to nursing services and management responsibilities.
Infection Control and Barrier Precaution Deficiencies
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for four residents, as evidenced by the absence of EBP signage and personal protective equipment (PPE) outside their rooms, despite active physician orders for such precautions. This deficiency was observed for residents with various medical needs, including wounds, PEG tubes, Foley catheters, and central lines. The lack of compliance with the facility's policy on EBPs was confirmed through observations and interviews with staff, highlighting a failure to adhere to infection prevention protocols. Additionally, the facility did not maintain infection control standards during wound care for one resident. A licensed nurse was observed failing to perform hand hygiene and change gloves appropriately while handling sterile wound care supplies. This lapse in protocol was confirmed by the nurse involved and the Director of Nursing. Furthermore, the facility did not administer tuberculosis testing upon entry for one resident, as required, with no documentation to indicate the test was performed. This was confirmed through interviews and a review of the resident's medical records.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their specific medical needs. Resident R2, who was admitted with a diagnosis of infection and inflammatory reaction due to an unspecified internal joint prosthesis, was prescribed a long-term antibiotic, Bactrim DS, for a chronic joint infection. Despite this, there was no care plan developed to manage the long-term antibiotic use, as confirmed by the Director of Nursing. Additionally, Resident R43, who was admitted with conditions including Anoxic Brain Damage and Tracheostomy Status, was observed to have poor oral hygiene, with yellowish, greenish substance on their teeth. The resident's clinical record indicated dependency on others for oral hygiene, yet there was no care plan addressing these deficits. The Director of Nursing confirmed the absence of an oral/dental care plan for this resident, acknowledging the oversight.
Failure to Update Care Plan for Resident's End-of-Life Wishes
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely manner for a resident, identified as R81, who was admitted with a diagnosis of malignant neoplasm of the prostate. The resident's Minimum Data Set (MDS) indicated that he passed away on February 27, 2025. Despite having physician orders and a POLST indicating a Do Not Resuscitate (DNR) and Do Not Hospitalize (DNH) status, the care plan incorrectly documented the resident as FULL CODE, suggesting that life-saving measures should be initiated in an emergency. This discrepancy was confirmed by the Director of Nursing, who acknowledged that the care plan should have been updated to reflect the resident's wishes for comfort measures only and withholding of life-saving treatments.
Failure to Notify Physician of Missed Wound Care
Penalty
Summary
The facility failed to ensure proper pressure ulcer treatment for a resident, as evidenced by a missed wound care treatment that was not communicated to the physician. Resident R59 reported to the County Ombudsman Program representative that his wound care was not performed on March 25, 2025, due to a lack of access to necessary supplies. The Treatment Administration Record (TAR) for March 2025 confirmed that the evening shift treatment for the resident's sacrum was not given, marked as code 22, indicating treatment not administered. There was no documentation explaining the unavailability of the treatment or any notification to the physician about the missed care. The Director of Nursing acknowledged the lapse and confirmed that staff are expected to inform the physician if a treatment cannot be completed.
Failure to Conduct Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to ensure that an annual performance evaluation was completed for one nurse aide, Employee E7, out of five nurse aides whose training records were reviewed. According to the facility's policy on 'Performance Evaluations,' revised in September 2020, each employee is required to have a performance evaluation at the end of their 90-day probation period and at least annually thereafter. Employee E7 was hired on May 10, 2023, and her last performance evaluation was conducted on November 7, 2023. This deficiency was confirmed through a review of facility-provided performance evaluations and an interview with the facility's Director of Nursing.
Failure to Administer Scheduled Antibiotic Due to Clogged Port
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two out of 18 residents reviewed. Resident R235 did not receive her scheduled antibiotic, Daptomycin, on March 7 and March 8, 2025, due to a clogged port. The physician had ordered the antibiotic to be administered intravenously for 26 days to treat a bacterial skin infection. Progress notes confirmed that the medication was not administered on March 6 and March 7, 2025. The Assistant Director of Nursing acknowledged that the treatment should have been extended by two days to compensate for the missed doses. An incident report indicated that the resident's PICC line was clogged, and once unclogged, the staff failed to add the missing two days of treatment. The Nurse Practitioner was aware, and the resident's labs were within normal limits at the time.
Failure to Communicate Lab Results Timely
Penalty
Summary
The facility failed to ensure timely communication of laboratory results to the physician for a resident, identified as Resident R2. Resident R2 was admitted with multiple diagnoses, including altered mental status, chronic pain, cognitive communication deficit, and morbid obesity. On March 11, 2025, a physician noted that the resident reported symptoms of dysuria, pressure, and incomplete bladder emptying. A urine sample was collected for urinalysis with culture and sensitivity on the same day, and the results, indicating a possible contaminated specimen, were sent to the facility on a later date. However, there was no documentation in the progress notes that these results were communicated to the physician, nor was there any indication of further testing being performed. An interview with the Director of Nursing confirmed that the facility's expectation is for laboratory results to be communicated to the physician upon receipt, which did not occur in this instance. This oversight was identified during a review of clinical records and staff interviews, highlighting a deficiency in the facility's communication process regarding laboratory results.
Failure to Provide Dental Care for a Dependent Resident
Penalty
Summary
The facility failed to provide necessary dental services for Resident R43, who was admitted with diagnoses including Anoxic Brain Damage and Tracheostomy Status. The resident's annual Minimum Data Set (MDS) indicated a complete dependency on assistance for oral hygiene, yet there was no dental or oral hygiene care plan in place. Additionally, there was no documented evidence of the resident being seen by a dentist. An observation revealed a yellowish, greenish substance on the resident's upper and lower incisors. The Director of Nursing confirmed that the resident had not been seen by a dentist and that an appointment was being scheduled.
Failure to Complete Required Performance Improvement Project
Penalty
Summary
The facility failed to ensure the completion of at least one Performance Improvement Project (PIP) as required by regulatory standards. According to the regulation S483.75(e)(3), facilities must conduct distinct performance improvement projects annually, focusing on high-risk or problem-prone areas identified through data collection and analysis. The facility's documentation, 'Risk Identification and Quality Assurance Performance Improvement,' outlines a process where the Quality Assurance Performance Improvement (QAPI) committee reviews data from risk meetings and prioritizes opportunities for improvement. However, upon review of the QAPI meeting minutes, there was no evidence of a completed performance improvement project. An interview with the facility's administrator and director of nursing confirmed that the facility did not complete at least one performance improvement project. This deficiency was identified during a survey conducted on March 27, 2025. The lack of a completed PIP indicates a failure to adhere to the regulatory requirement of conducting at least one improvement project annually, which is essential for addressing high-risk or problem-prone areas within the facility.
Failure to Obtain Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for a resident. The physician's progress note indicated that the resident was experiencing hypotension and dehydration, and intravenous fluids were administered. A repeat basic metabolic panel (BMP) blood test was ordered for the following day. However, the clinical records revealed that the staff did not place an order in the electronic system to draw the lab, and there was no evidence that the lab was obtained or that results were available on the specified date. Subsequently, the resident was observed with weakness, in and out of consciousness, and using abdominal muscles to breathe, leading to a transfer to the hospital at the family's request. The Director of Nursing confirmed that the lab work was not obtained as ordered.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. 1. Resident R1 has been discharged from the center. 2. The DON/Designee conducted a 7-day lookback of physician progress notes on all current residents to ensure that any ordered labs were placed in the electronic system to draw the lab. Any variances were noted on the facility audit tool. 3. Nursing staff were educated by the Director of Nursing/Designee on ensuring that labs get entered into the electronic system to draw the lab. 4. The Director of Nursing/Designee will conduct an audit of 10 physician progress notes for 4 weeks and 10 physician progress notes monthly for 2 months to ensure that ordered labs were entered into the electronic system to draw the lab. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.
Failure to Update Care Plan for Resident's Bathing Refusals
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect specific care needs, particularly regarding the resident's refusal of showers or baths. The resident, who was admitted with diagnoses including muscle wasting, cognitive communication deficit, and bed confinement status, had a BIMS score of 0, indicating a lack of cognitive intactness. Despite the resident's frequent refusals of showers or baths, as documented in the clinical records, there was no follow-up documentation or reasoning provided for these refusals. Additionally, the care plan did not include interventions for the resident's refusals. Interviews with facility staff revealed that the resident did not refuse showers or baths when approached by certain staff members, suggesting a need for specific approaches to encourage compliance. However, this information was not communicated effectively among the staff, and the care plan remained unchanged. The facility's administration confirmed that no care plan or interventions were developed or implemented to address the resident's refusals, leading to a deficiency in meeting the resident's care needs.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. F0657-CARE PLAN TIMING AND REVISION 1. Resident R1's plan of care was updated on 12/11/2024. 2. An audit was conducted of all current residents care plans as it relates to refusals of care. Any variances were addressed and noted on the facility audit tool. 3. Nursing staff were educated by the Director of Nursing/Designee on communication regarding resident refusals of showers/bathing and ensuring the residents plan of care is up to date. 4. The Director of Nursing/Designee will conduct an audit of the care plans of 10 residents weekly for 4 weeks, and 10 residents monthly for 2 months to ensure refusals of care for showers/bathing are appropriately care planned. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.
Resident Elopement Due to Inadequate Supervision and Device Failure
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a history of wandering and at risk for elopement, resulting in an Immediate Jeopardy situation. The resident, diagnosed with unspecified dementia and other cognitive impairments, was assessed as an elopement risk upon admission. Despite being identified as at risk, the resident was able to elope from the facility, cross a high-traffic street, and was found by a community member in a lot across from the facility entrance. The facility's policy on Wander Management and Elopement Prevention required the use of a wander management system device, such as a Wander Guard Bracelet, to prevent elopement. However, on the night of the incident, a Licensed Practical Nurse (LPN) failed to verify the placement of the resident's Wander Guard Bracelet, documenting an inability to verify its placement without notifying a supervisor. This oversight allowed the resident to leave the facility undetected, as the armature of the door was loosened, and the resident was able to pass through unsupervised areas. The facility's investigation revealed that the resident left the unit through closed double doors, which were not adequately secured, and exited the building without being noticed. The lack of supervision at the reception area and the failure to ensure the functionality and placement of the wander management device contributed to the resident's elopement, highlighting significant lapses in the facility's adherence to its own policies and procedures for managing residents at risk of elopement.
Removal Plan
- The resident returned to the Center from the hospital with an abrasion to right knee. All other studies were within normal limits.
- RN Supervisor completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably, Variances identified included discharged residents.
- The Nursing Administrator reviewed all resident EHR for accurate elopement/wandering evaluations, orders for every shift placement checks, daily function tests and care plans. Elopement books found at reception desk and on every unit were reviewed to ensure that all residents identified as elopement risks were current and resident identifiers were available.
- Nursing Staff were educated on if they find an identified resident without an elopement device, supervision is established for the resident, another device is located and applied. If the device cannot be reapplied, 1:1 supervision is maintained. The DON/designee will be notified immediately.
- Review of Center elopement drills for completeness and staff participation. Plant Operations provided elopement drills held monthly for the last quarter.
- RN supervisors were educated on completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Reception/off shift staff were educated on the process of each visitor receiving a badge that must be returned prior to door being open and visitor leaving the premises.
- Staff educated on elopement/missing person policy and procedures including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas notification process including local police department.
- Staff educated on elopement drills including how often and expected response.
- Reception staff were educated on the need for constant supervision of the front reception area. The RN supervisor/designee is to be notified of relief prior to leaving area.
- The double door leading out of unit will be modified to include a mag lock on both doors. Parts have been ordered and will be added/installed upon receipt. Double doors were monitored via 1:1 until mag locks were installed.
- All the training above will be added to our general orientation schedule for all future new employees.
- Auditing census compared to headcount every 4 hours for 3 days then every 8 hours for 3 days then every shift for 14 days then daily.
- Random audit of five visitors to ensure compliance to pass system two times daily for 14 days then daily.
Failure to Notify Ombudsman of Transfers/Discharges
Penalty
Summary
The facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman in writing about residents' transfers and/or discharges for two consecutive months, July and August 2024. This deficiency was identified through staff interviews and a review of facility documentation. Specifically, the facility's records for July 2024 showed that the Ombudsman did not receive a copy of the notice sent to the residents and/or their representatives prior to the transfers or discharges. This oversight is a violation of the regulatory requirements outlined in 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(2), which mandate the responsibility of the licensee and management to ensure proper notification procedures are followed.
Failure to Provide Call Bell Accommodation
Penalty
Summary
The facility failed to provide a reasonable accommodation of needs for a resident diagnosed with a fractured pelvis, who was toe touch weight-bearing. Upon admission, the resident was given a small bell instead of a functioning call bell due to the roommate's special equipment using the call bell outlet. The resident's room was located far from the nursing station, raising concerns about the resident's ability to alert staff in case of need, especially given the resident's non-weight-bearing status. This deficiency was confirmed by the Director of Nursing, who acknowledged that the resident did not have a call bell and was provided with a small bell instead.
Significant Medication Error Due to Incorrect Hospital Discharge Paperwork
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of one resident, identified as Resident R9. The facility's policy on administering medications requires the individual administering the medication to check the label three times to verify the right resident, medication, dosage, time, and method of administration. However, this protocol was not followed, leading to a significant medication error. Resident R9 was admitted with a history of left-sided weakness, balance issues, progressive lower extremity weakness, intermittent slurred speech, and trouble swallowing. The resident's treatment plan included medications such as Propranolol, Keppra, Gabapentin, Zofran, Trazadone, and Sertraline. An incident report revealed that on a specific date, Resident R9 exhibited increased lethargy due to an incorrect medication list received from the hospital. The list belonged to another patient, resulting in the discontinuation or tapering down of all of Resident R9's medications. The Director of Nursing confirmed the error, acknowledging that the facility did not notice the different name on the medication list provided by the hospital. This oversight led to a significant medication error, violating the facility's policy and state nursing service regulations.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that residents received assistance with bathing, as evidenced by the experiences of three residents. Resident R1 did not receive a shower for a week after admission, despite her preference for showers over bed baths. Her care plan, initiated on August 5, 2024, did not specify the level of assistance needed or her bathing preferences. The nurse aide documentation indicated that Resident R1 was scheduled for showers on Mondays and Thursdays, but she did not receive them on August 5 and 8, 2024, with no explanation provided. Similarly, Resident R2, who required assistance from one staff member for bathing, did not receive scheduled showers on July 26 and August 16, 2024, without any documented reason. Resident R4, who also required assistance for bathing due to chronic back pain, was not provided showers on multiple scheduled dates, including July 25, July 29, August 1, August 8, August 15, and August 19, 2024. The lack of proper documentation and adherence to scheduled bathing routines for these residents highlights the facility's failure to provide necessary nursing services as required by 28 Pa Code 211.12(d)(5).
Unsafe Water Temperatures in Resident Sinks
Penalty
Summary
The facility failed to maintain safe water temperatures in resident bathroom hand sinks on the North Side nursing unit, exposing residents to the risk of serious injury from burns. Observations and water temperature checks revealed that the hot water temperatures in several resident rooms exceeded the facility's policy limit of 110 degrees Fahrenheit, with some readings as high as 131 degrees Fahrenheit. This situation resulted in an Immediate Jeopardy designation due to the potential harm to residents. The facility's policy on Safety of Water Temperatures mandates that water heaters servicing resident areas should not exceed 110 degrees Fahrenheit. However, the maintenance staff did not consistently monitor and record water temperatures, as evidenced by the random checks conducted only on weekdays. Interviews with staff revealed a lack of awareness regarding the safe water temperature range, further contributing to the deficiency. The investigation also uncovered issues with the facility's infrastructure, such as the absence of a thermometer near the East side boiler and the improper setting of the mixing valve thermometer. These deficiencies in monitoring and equipment contributed to the unsafe water temperatures experienced by residents, highlighting a failure in the facility's management and maintenance practices.
Removal Plan
- Plant operations worked to regulate the temperature at the mixing valve for the north side of the center. The east side of the center was noted to not have a temperature gauge. The plumber responded. The temperatures will be monitored in all the shower rooms and care areas. If the temperature is found to be greater than 110 F, the ship supervisor will be notified, and staff will cease to use the water until the temperature returns to 110 F or lower.
- Planned operations completed a full house audit of hot water temperatures at the hand sinks in all resident rooms to ensure safe water temperatures.
- Nursing administration rounded on each resident to ensure that all are comfortable and were not affected by elevated water temperatures. All shower rooms were inspected to ensure a thermometer was present for staff testing prior to showers, and in resident care areas. Care staff have been educated on the process for taking a water temperature prior to showering. All others will be educated prior to next shift.
- Center staff shall have been educated on the process for monitoring for temperatures that are excessive to the touch in residence sinks and non-resident areas. Remaining staff will be educated on their next scheduled shift.
- Plant operations staff will be educated on the process for daily water temperatures, including recording and notification of administration if outside the acceptable range.
- A temperature gauge will be installed on the mixing valve of the East Unit hot water heater to allow for accurate temperature monitoring of water prior to leaving the boiler room.
- Ongoing compliance will be monitored by: monitoring of the water temperatures completed by the Maintenance Department will be completed on a random sampling of eight resident rooms, three times a day on all units for two weeks, then two times a day for two weeks, then daily ongoing. Any variances will be addressed and reported to the Monthly QA Committee.
- A random questionnaire will be completed with three staff members daily on the process for taking a water temperature, as well as the acceptable temperature range. The questionnaire will be completed daily for two weeks, then three times a week for two weeks. Then weekly for two weeks. All variances will be immediately addressed and reported to the monthly QA Committee.
Immediate Jeopardy Due to Unsafe Water Temperatures
Penalty
Summary
The Nursing Home Administrator failed to effectively manage the facility concerning hot water temperatures in the North Side Nursing Unit, leading to an immediate jeopardy situation. Observations and water temperature checks revealed that the hot water temperatures in several resident rooms ranged from 113 to 129 degrees Fahrenheit, exceeding safe limits. The President for Plant Operations, Employee E3, confirmed that the mixing valve thermometer on the North side was reading 130 degrees Fahrenheit, which was then adjusted to 118 degrees Fahrenheit. However, the boiler's knob was set at 130 degrees Fahrenheit, and there was no thermometer near the boiler or on the ceiling where the mixing valve was located. Interviews with the President for Plant Operations, Employee E3, and the Director of Plant Operations, Employee E4, confirmed the absence of a thermometer for the east side boiler mixing valve. Employee E3 revealed that mixing valve temperatures were checked once a day, and random water temperature checks were conducted from Monday to Friday. Additionally, interviews with nursing staff indicated that 11 out of 12 staff members were unaware of the safe water temperature for resident use. This lack of knowledge and oversight placed residents at risk for serious injury from burns, resulting in an Immediate Jeopardy situation.
Medication Management Deficiency
Penalty
Summary
The facility failed to ensure an environment free from potential hazards related to medications left at the bedside for three residents. In the case of one resident, lactase enzyme capsules and a bottle of Artificial Tears were found on the nightstand, with the resident stating they were used as needed before meals. However, there was no order for these medications, and the nurse was unaware of their presence. Another resident had two inhalers, Dulera and Spiriva, at the bedside, which were brought from the hospital upon discharge. The resident had been using these inhalers regularly, yet there was no order for them, and the nurse was unaware of their presence. Additionally, a probiotic pill pack was found on the nightstand of a third resident, with a care aide indicating that the resident's girlfriend administered the pill daily. Again, there was no order for this medication, and the nurse was unaware of its presence. These findings indicate a lack of adequate supervision and management of medications, as the facility's policy emphasizes resident safety and supervision to prevent accidents. The absence of proper medication orders and the lack of staff awareness contributed to the deficiency.
Deficiencies in Food Storage and Safety Standards
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, several deficiencies were observed, including a dirty mop room with a heavily soiled mop sink and debris on the floor. The kitchen area near the pot sink had walls spattered with food particles and a sanitizer mount covered in dirt and dust. In the walk-in freezer, a box of breaded veal patties was found open to the air, and the oven under the flat-top griddle had a heavy buildup of burned-on food spatters. Further observations revealed issues with food storage in resident areas. In the north wing unit, expired, unlabeled, and undated food items were found in the resident refrigerator, along with human hair and spills. Similar conditions were noted in the east wing refrigerator, with expired and unlabeled items and food spills. The resident freezer also contained unlabeled and undated items, with liquid spills present. These findings were confirmed through interviews with the Food Service Director and the Director of Nursing, highlighting a lack of adherence to the facility's policies on food storage and labeling.
Failure to Ensure Residents' Capacity for Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three residents. Resident R226, who was admitted with diagnoses of fracture and orthopedic aftercare, had a BIMS score of 3, indicating severe cognitive impairment. Despite this, she signed a binding arbitration agreement upon admission. Similarly, Resident R227, diagnosed with aphagia and also having a BIMS score of 3, signed the agreement on admission. Resident R228, with a diagnosis of cerebral infarction and a BIMS score of 6, indicating severe cognitive impairment, also signed the agreement upon admission. The Nursing Home Administrator confirmed that these residents had low BIMS scores, indicating severe cognitive impairment, and should not have been signing admissions documents, including the binding arbitration agreement, as they did not have the capacity to understand the terms. This failure to ensure residents' capacity to understand the agreements they were signing constitutes a deficiency in the facility's responsibility to its residents.
Infection Control Deficiencies in Linen Handling and PPE Disposal
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper handling of clean linen and inappropriate disposal of personal protective equipment (PPE). During an observation, a Nurse Aide was seen transporting clean linen from the Linen Storeroom while allowing it to come into contact with her uniform, which could lead to contamination. The Nurse Aide confirmed that the linen should have been transported without touching her clothing to maintain infection control standards. Additionally, a Licensed Practical Nurse (LPN) improperly disposed of a used gown on the floor after providing tracheostomy care to a resident on Enhanced Barrier Precautions. The LPN admitted to discarding the gown on the floor due to the absence of a trash bin for PPE disposal in the resident's room. This action was contrary to infection control protocols, which require used PPE to be disposed of in a designated container to prevent contamination.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by two separate incidents involving Residents R13 and R47. For Resident R13, there was a failure to follow a new order to weigh the resident weekly due to significant weight loss. On the scheduled day for weighing, May 15, 2024, the resident was not weighed, and there was no documentation of refusal. Furthermore, a licensed nurse, Employee E5, discussed the resident's care difficulties in front of the resident and their sister, which compromised the resident's dignity. In the case of Resident R47, the resident, who was alert and oriented with hemiplegia following a stroke, requested extra breakfast food. The Social Worker, Employee E14, delivered the food to the resident's room, but the resident was not present at the time. When the resident later went to the kitchen to request the food again, the Food Service Director, Employee E3, refused to provide additional food, stating that a lot had already been sent. The Director instructed the resident to leave the kitchen, asserting authority over the food, and did not provide the requested meal, despite the resident's insistence that he had not received it.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for 16 out of 21 residents reviewed. Observations during an initial tour revealed multiple deficiencies, including air conditioning units with liquid spills, call bells out of reach, trash on floors, dirty linens, and non-functional facility phones. Specific instances included a resident's room with an air conditioning unit covered in liquid, another resident's call bell hanging on the wall, and several rooms with overflowing trash cans and no liners. Additionally, some residents reported that their facility phones had not been working for weeks. Further observations highlighted issues such as wet soiled linens on the floor, bent air conditioning unit grates, and a baseboard heater coming off the wall. Interviews with residents and staff confirmed these deficiencies, with several residents expressing concerns about non-functional phones and inaccessible call bells. The Nursing Home Administrator confirmed that the phones on the East Wing had been non-functional since the end of April, corroborating the residents' reports.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific medical and psychosocial needs. Resident R32, who was admitted with Type Two Diabetes Mellitus, experienced hypoglycemia and fecal impaction but did not have a care plan addressing chronic constipation. This oversight in care planning potentially contributed to the resident's hospitalization. Resident R46, admitted after a fall and diagnosed with lymphoma, had a history of suicide ideations noted in a physician's progress note. However, the facility did not create a care plan to address these mental health concerns. Similarly, Resident R48, diagnosed with Non-Alzheimer's Dementia and receiving antipsychotic and antidepressant medications, lacked a care plan with measurable goals and interventions for dementia care. The Director of Nursing confirmed these findings, acknowledging the facility's attempt to make care plans specific, yet failing to meet the required standards.
Failure to Follow Physician Orders and Proper Care Protocols
Penalty
Summary
The facility failed to ensure that physician orders were followed for medication administration and care of a Pleurx catheter for two residents. One resident reported during a Resident Council meeting that she dropped a pill during medication administration and informed the nurse, but the nurse did not return with a replacement pill. Upon investigation, it was confirmed that the pill was Acebutolol HCI, which was prescribed to be taken every 12 hours for hypertension. The pill was found on the resident's bedside tray table, indicating a lapse in medication administration. Another resident had a Pleurx catheter in place, and it was noted that the resident's girlfriend was performing the catheter drainage, which is a nursing responsibility. The Director of Nursing confirmed that the girlfriend had drained the catheter once and was subsequently informed that she could not perform this task while the resident was in the facility. However, there was no documentation of this discussion, highlighting a lack of proper communication and adherence to care policies.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of a resident, identified as R13, who experienced significant weight loss over a month. Despite having a care plan that required 1:1 feeding assistance at all meals, the resident's preferences for finger foods and sandwiches were not consistently met. Observations revealed that the resident was not receiving the preferred finger foods during meals, and there was no documentation of these preferences in the clinical record. Additionally, the resident's meal intake percentages were not recorded on several occasions, and weekly weights were not consistently taken as ordered. The resident's clinical record indicated a series of medical conditions, including muscle wasting, dysphagia, and cognitive communication deficit, which necessitated careful monitoring of nutritional intake. Despite these needs, there were lapses in providing the required feeding assistance, as evidenced by the absence of staff during meal times and discrepancies in staff reports about feeding the resident. The facility's failure to adhere to its own policies and the resident's care plan contributed to the deficiency in maintaining the resident's nutritional status.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to provide nourishing snacks between meals for five out of 21 residents reviewed, as determined through resident council interviews, meal time schedule reviews, and clinical record reviews. During a resident council meeting, four out of five residents reported not receiving evening snacks. Specific records showed that Resident R275 did not receive a snack on May 14, 2024. Resident R22 missed snacks on multiple dates in April and May 2024. Resident R326 did not receive snacks on May 11, 14, and 16, 2024. Resident R14 missed snacks on May 6, 9, and 14, 2024. Resident R13, who experienced significant weight loss over a month, did not receive snacks on several dates in April and May 2024.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during an initial tour of the Food Service Department. During the inspection, one of the three dumpsters in the receiving area was found with its lid open, exposing its contents, including cardboard boxes. Additionally, the employee smoking area, located adjacent to the loading dock, was observed to be littered with hundreds of cigarette butts scattered on the ground. These observations were confirmed in an interview with the Food Service Director, who acknowledged the findings. The deficiency was noted under the regulations 28 Pa. Code 201.18(b)(3) Management and 28 Pa. Code 201.14(a) Responsibility of Licensee.
Unsafe Loading Dock Conditions
Penalty
Summary
The facility failed to ensure the safety of the loading dock area, which was observed to be in unsafe conditions. During a tour of the kitchen, it was noted that the loading dock door was open, leading to a receiving area with a wooden structure five feet off the ground. This structure lacked any railing or chain to restrict access, posing a safety risk to staff, delivery drivers, and potentially wandering residents. The Food Service Director confirmed that the door was open due to a delivery and acknowledged the absence of safety railings. It was also noted that residents have previously entered the hallway leading to the receiving area, indicating a risk of them wandering out to the loading dock. The Administrator confirmed the lack of safety railing around the loading dock.
Infection Control Breach in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices in the handling and transportation of linens on the East Wing. During an observation, a Nurse Aide, identified as Employee E6, was seen transporting clean linens in a manner that allowed them to come into contact with the aide's uniform. This practice is contrary to the facility's infection control policies, which require that linens be transported without touching the employee's clothing to prevent contamination. The deficiency was confirmed through an interview with Employee E6, who acknowledged that the linens should not have been allowed to touch their clothing.
Failure to Develop Baseline Care Plan for Infectious Disease
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was admitted with a community-acquired infectious disease, specifically clostridium difficile. The resident was admitted for skilled nursing care post-discharge from an acute care hospital and was on an antibiotic therapy regimen with oral Vancomycin. Despite the hospital documentation noting the infection and treatment, the facility did not create a care plan for the c-difficile infection until three days after the resident's admission.
Failure to Implement Infection Control Measures for Admitted Resident
Penalty
Summary
The facility failed to follow acceptable infection control practices for a resident admitted with a community-acquired infectious disease. Resident R1 was admitted for skilled nursing care post-discharge from an acute care hospital with a diagnosis of clostridium difficile (c-diff) and was on an antibiotic therapy regimen. Although the resident was transferred to a private room and transmission-based precautions were implemented on September 18, 2023, there was no documentation in the clinical record to verify that appropriate infection control measures were implemented at the time of admission. Additionally, the review of Resident R1's care plan revealed that a care plan for the c-diff infection was not developed until September 18, 2024, despite hospital documentation noting the infection and treatment plan at the time of discharge on September 15, 2024. This delay in developing a care plan and lack of documentation of infection control measures at the time of admission led to the deficiency identified by the surveyors.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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