St Francis Center For Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Darby, Pennsylvania.
- Location
- 1412 Lansdowne Avenue, Darby, Pennsylvania 19023
- CMS Provider Number
- 395282
- Inspections on file
- 27
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at St Francis Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
The facility did not provide food that accommodated resident allergies, intolerances, and preferences, nor did it ensure appealing meal options. This resulted in residents not consistently receiving meals tailored to their individual dietary requirements.
A nurse left medications, including inhalers and a bottle of MiraLAX, unattended on top of the medication cart while administering medications to residents in their rooms. The nurse confirmed leaving the medications unattended, which was not in accordance with the facility's medication storage policy.
A resident with hypothyroidism did not receive a physician-ordered TSH lab test within the specified timeframe. Review of clinical records and staff interviews confirmed that the test was not completed as ordered, despite ongoing monitoring noted in the physician's progress notes.
The facility failed to treat residents with dignity and respect by not serving meals simultaneously to all residents at a table in the Fourth Floor Main dining room. Two residents received their lunch trays early, while others at the same table waited an hour longer. Staff interviews confirmed the delay, highlighting a breach in resident rights.
A facility failed to develop a baseline care plan for a resident's oxygen therapy within 48 hours of admission. The resident, with chronic obstructive pulmonary disease and other conditions, had a physician's order for continuous oxygen, but the care plan lacked a focus area for this therapy. An interview with a nurse confirmed the absence of a care plan for the resident's oxygen needs.
The facility failed to update care plans for several residents, leading to deficiencies in addressing bed rail use, bed positioning, oxygen therapy, and dietary needs. A paraplegic resident's request for bed rails was not documented, and another resident's oxygen therapy was not included in their care plan. Additionally, two residents had their beds positioned against the wall without care plan updates, and a resident's diet order was not reflected in their care plan.
A resident with multiple health issues experienced a decline in mobility due to inconsistent restorative therapy. The facility's practice of reassigning restorative aides to other duties during understaffing resulted in the resident receiving only six days of therapy over a month, contrary to the care plan. The DON confirmed this staffing issue, which affected the resident's ability to maintain or improve walking distance.
The facility failed to administer medications timely for two residents, with medications given hours later than prescribed. A resident reported receiving medications late, affecting those needing to be taken with meals. The pharmacist and DON confirmed inappropriate timing, particularly for Apixaban, which requires an 8-hour interval.
A facility failed to follow physician orders for a resident with COPD, administering oxygen at 3L/min instead of the prescribed 2L/min. This discrepancy was confirmed by a nurse, indicating non-compliance with the facility's oxygen administration policy.
A resident with an anxiety disorder did not receive prescribed Ativan gel due to repeated delays in pharmacy delivery. Despite the facility's policy requiring timely medication provision, nursing notes from January to June 2024 documented ongoing unavailability of the medication, highlighting a failure in the facility's pharmacy services.
The facility failed to implement proper infection control during dining services on the Fourth Floor Main unit. Observations showed that five employees served lunch to 14 residents without performing hand hygiene. Despite the presence of hand sanitizer units, staff did not use them, and residents, many with cognitive impairments, were not assisted with hygiene. The Unit Manager confirmed the lack of hand hygiene practices.
The facility failed to maintain an effective antibiotic stewardship program over four months, lacking protocols and a system to monitor antibiotic usage. Documentation revealed multiple infections treated with antibiotics without adequate surveillance tools, missing stop dates, therapy duration, outcomes, and adverse events. The Infection Preventionist confirmed the absence of necessary protocols and monitoring systems.
The facility failed to maintain safe handrails in the corridors on the Fourth Floor Main. Observations showed that several handrails were loose, detached, or missing near resident rooms and other areas. The Maintenance Director confirmed these deficiencies.
An aide mistakenly believed a resident needed her brief changed and removed the covers without asking for permission, leading the resident to feel violated. The resident clarified that the aide did not touch her and should have asked before proceeding.
The facility failed to maintain complete and accurate medical records for eight residents, with multiple instances of unsigned medical orders and treatments. An interview with the Nursing Home Administrator and the Director of Nursing confirmed the expectation that all treatments be signed out at the time they are provided.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not provide appealing options. This deficiency was identified based on observations and findings that the facility did not consistently provide meals tailored to individual dietary needs and preferences, as required.
Medications Left Unattended on Medication Cart During Administration
Penalty
Summary
Facility staff failed to ensure that medications were stored in a safe and secure manner during medication administration. During observation, a zip-lock bag containing Spiriva (oral inhalation spray) and Fluticasone Propionate (nasal spray), both labeled for a specific resident, was found left unattended on top of the medication cart. The licensed nurse responsible for administering medications confirmed that she left these medications unattended while she went into a resident's room to administer other medications. Upon returning, she put the medications away. A further observation revealed that a bottle of MiraLAX was also left unattended on top of the medication cart while the same nurse went to administer medication to another resident. The nurse confirmed during interview that she left the MiraLAX unattended while she was away from the cart. These actions were not in accordance with the facility's medication storage policy, which requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, and that only authorized personnel have access to medications.
Failure to Complete Ordered Laboratory Test for Hypothyroid Resident
Penalty
Summary
The facility failed to obtain laboratory services as ordered for a resident diagnosed with hypothyroidism. Clinical records showed that a physician ordered a thyroid stimulating hormone (TSH) test to be completed in five weeks. However, review of the resident's records and staff interviews revealed that there was no documentation that the TSH test was completed as ordered. The Unit Manager and an LPN confirmed during interviews that the physician's progress notes indicated continued monitoring, but the specific order for the TSH test from May was not carried out.
Failure to Serve Meals Timely in Dining Room
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect in the Fourth Floor Main dining room. On September 25, 2024, observations revealed that 14 residents were present in the dining room during lunchtime. Two residents at a table were served their lunch trays early, around 11:30 a.m., and finished eating by 12:30 p.m., while the remaining five residents at the same table were not served until an hour later. The cart with trays for the other residents arrived at 12:32 p.m., and meals were served by 12:35 p.m., leaving one resident without a tray until 12:40 p.m. Interviews with staff confirmed the delay in serving meals to residents at the same table, with Employee E8, a nurse aide, and Employee E9, the unit manager, acknowledging the discrepancy in meal service times. This inconsistency in meal service timing led to a failure in maintaining the residents' right to a dignified existence and self-determination, as outlined in 28 Pa. Code: 201.29(j) Resident rights.
Failure to Develop Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for Resident R99, specifically regarding oxygen administration. Resident R99 was admitted with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Despite having a physician's order for continuous oxygen therapy at 2 liters via nasal cannula dated August 20, 2024, the baseline care plan did not include a focus area for oxygen therapy. An observation on September 24, 2024, confirmed that Resident R99 was receiving oxygen while resting in bed. However, an interview with a licensed nurse, Employee E3, on September 25, 2024, revealed that there was no current care plan in place for the resident's oxygen therapy, despite the resident having been on oxygen since admission. This oversight was identified as a deficiency in the facility's adherence to its care planning policy.
Care Plan Deficiencies in Resident Safety and Treatment
Penalty
Summary
The facility failed to ensure that care plans were revised for five residents concerning bed rails, bed positioning, oxygen therapy, and diet. Resident R106, who is paraplegic, requested bed side rails for assistance and safety, but her care plan lacked any goals or interventions related to bedrail use despite an evaluation indicating their necessity. Resident R42, who was receiving oxygen therapy, did not have a care plan addressing this treatment, as confirmed by the Director of Nursing. Additionally, Resident R96's care plan was outdated, reflecting a renal diet, while the current physician's order indicated a regular diet. Further deficiencies were noted with Residents R125 and R574, whose beds were positioned against the wall without corresponding care plans. Resident R125, admitted to hospice care, had her bed against the wall, confirmed by a registered nurse, but this was not documented in her care plan. Similarly, Resident R574's bed was moved against the wall after a fall, as per her request, but this change was not reflected in her care plan. The Director of Nursing confirmed these omissions, indicating a failure to update care plans to reflect residents' current needs and preferences.
Inconsistent Restorative Therapy Leads to Decline in Resident Mobility
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's ability to perform activities of daily living was maintained. The resident, identified as R141, was admitted with multiple diagnoses including chronic pain syndrome, muscle wasting and atrophy, muscle weakness, osteoarthritis, and morbid obesity. Despite having a care plan initiated to address impaired walking ability, the resident reported a significant reduction in restorative therapy sessions, which were intended to maintain or improve his walking distance. The resident expressed that when the facility was short-staffed, restorative nurses were reassigned to other duties, resulting in a lack of consistent therapy. The clinical record review revealed that the resident's restorative nursing program was not consistently implemented, with documentation showing only six days of therapy over a 30-day period. The Director of Nursing confirmed that restorative aides were reassigned as nursing aides during understaffing, impacting the delivery of the restorative program. This inconsistency in providing restorative therapy contributed to the resident's diminished ability to walk, as he noted a decline in his mobility since the reduction in therapy sessions.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications in a timely manner as ordered by the physician and according to professional standards of practice for two residents. Resident R147 reported receiving medications late, including those that needed to be taken with or before meals. The review of the physician's orders for Resident R147 showed multiple medications, including Apixaban, Cymbalta, Farxiga, Furosemide, Metoprolol Succinate, Mometasone Furoate Inhalation, and Sacubitril-Valsartan, were not administered at the prescribed times. For instance, Apixaban, which should be taken twice daily, was given only 5.5 hours apart, and morning medications were administered around noon instead of before 9 a.m. Similarly, Resident R179's medication administration was not timely. The resident was prescribed Baclofen and Gabapentin to be taken three times a day, with the morning dose scheduled for 9:00 a.m. However, these medications were administered at 11:27 a.m. and 2:19 p.m., less than three hours apart. Interviews with the pharmacist and the Director of Nursing confirmed that the timing of medication administration was inappropriate, with specific reference to Apixaban needing at least an 8-hour interval between doses.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that physician orders for oxygen administration were followed for a resident diagnosed with chronic obstructive pulmonary disease. The facility's policy on oxygen administration, revised in December 2022, outlines specific steps for safe oxygen delivery, including starting the flow at the rate ordered by the physician. However, during an observation on September 24, 2024, it was noted that the resident was receiving oxygen at a rate of 3 liters per minute, contrary to the physician's order of 2 liters per minute via nasal cannula. Further review on September 25, 2025, confirmed that the oxygen level remained at 3 liters, which was acknowledged as incorrect by a licensed nurse. This discrepancy indicates a failure to adhere to the prescribed oxygen administration guidelines, as outlined in the facility's policy and the physician's orders. The deficiency was identified under the Pennsylvania Code sections related to resident care policies and nursing services.
Failure to Provide Timely Medication Delivery
Penalty
Summary
The facility failed to ensure the timely availability of medication for a resident diagnosed with an anxiety disorder. According to the facility's policy on Pharmacy Services, effective March 2020, the facility is required to provide or obtain pharmacy services, including routine and emergency medication, and employ a licensed pharmacist. However, the facility did not adhere to this policy for one resident, as evidenced by the repeated unavailability of Ativan gel, a medication prescribed to be applied three times daily. The clinical record review revealed multiple instances where the Ativan gel was not administered due to delays in pharmacy delivery. Nursing notes from January to June 2024 consistently documented that the medication was either awaiting delivery or pending from the pharmacy. Despite communication with the pharmacy, the medication remained unavailable, indicating a failure in the facility's pharmacy services to meet the resident's needs as per the physician's orders.
Inadequate Infection Control During Dining Services
Penalty
Summary
The facility failed to implement an effective infection prevention and control program during dining services on the Fourth Floor Main nursing unit. Observations on September 25, 2024, revealed that five employees were serving lunch to 14 residents in the dining room without performing hand hygiene. Employee E8, a Nurse Aide, was seen passing trays, setting up utensils, and assisting residents without washing hands between tasks. Similarly, Employee E12 collected finished trays and delivered new ones without any hand hygiene. None of the five employees assisting with meal trays performed hand hygiene before or during the meal service. The residents in the dining room, many of whom were cognitively impaired or had dementia, were observed touching their clothes, tables, and wheelchairs without any hand hygiene before receiving their meal trays. One resident was seen eating with her hands. Despite the presence of two wall-mounted hand sanitizer units in the dining room, they were not utilized by staff or residents. An interview with Employee E9, the Unit Manager, confirmed the lack of hand hygiene practices during meal services, acknowledging the residents' need for assistance with hygiene.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a four-month period, as evidenced by a lack of antibiotic use protocols and a system to effectively monitor antibiotic usage. The review of facility documentation from May to August 2024 revealed that the facility did not have a comprehensive surveillance tool that included essential elements such as stop dates, total days of therapy, outcomes, and adverse events related to antibiotic use. Additionally, there was no antibiotic review conducted to determine the appropriateness of the antibiotic usage during this period. Throughout the months reviewed, the facility documented multiple cases of urinary tract infections (UTIs) and other infections such as skin, respiratory, intestinal, and wound infections, all treated with antibiotics. However, the facility's surveillance tool was inadequate, lacking critical information necessary for effective monitoring and evaluation of antibiotic use. This deficiency was confirmed through an interview with the Infection Preventionist, who acknowledged the absence of use protocols and a system for reviewing antibiotic orders to ensure their appropriateness. The report highlights that the facility did not integrate dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship. This integration is crucial for ensuring antibiotics are ordered appropriately and for developing antibiotic monitoring and infection management guidance. The lack of adherence to CDC guidelines and the absence of a structured antibiotic stewardship program contributed to the facility's failure to optimize antibiotic use and reduce the threat of antibiotic resistance.
Deficient Corridor Handrails
Penalty
Summary
The facility failed to equip corridors with safe handrails on each side, specifically on the Fourth Floor Main. Observations revealed that several corridor handrails were loose or not secured properly near multiple resident rooms. Additionally, some handrails were found detached from the wall next to the attic access wall towards the nurses' station, next to elevator B, and near another room. There was also a missing handrail next to the attic access wall. During an interview, the Maintenance Director confirmed the issues with the handrails, acknowledging that they were broken, detached, or missing.
Failure to Respect Resident's Dignity During Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during a care interaction. An incident occurred where an aide on the night shift mistakenly believed that a resident needed her brief changed. Without asking for permission, the aide removed the covers from the resident's bed. The resident, identified as R322, expressed feeling violated by this action, as the aide did not ask before pulling the sheets off. The resident clarified that the aide did not touch her and mistakenly thought she wore a brief, emphasizing that the aide should have asked before proceeding.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility did not maintain complete and accurate medical records for eight out of ten residents reviewed. Specifically, the Treatment Administration Records (TAR) for multiple residents showed that various medical orders were not signed off as completed. For instance, Resident R2's order to check the placement of a wearable tracking device was not signed off on multiple shifts in April 2024. Similarly, Resident R3's order for Silvadene External Cream was not signed off on April 8, 2024, and Resident R4's order for suprapubic catheter care was not signed off on the evening shift of April 9, 2024. Other residents, including R5, R6, R7, R8, and R10, also had missing sign-offs for their respective medical treatments and checks on various dates in April 2024 and March 2024. An interview with the Nursing Home Administrator and the Director of Nursing confirmed that it is the facility's expectation that all medications and treatments be signed out at the time they are provided to the resident. The review and interview revealed that these treatments had not been signed as appropriate, indicating a failure to maintain complete and accurate medical records as required by the facility's standards and regulations.
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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