Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Francis Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
A resident with anxiety disorder and unspecified dementia was observed wearing an ankle monitoring device ordered to prevent elopement. The clinical record contained no documentation that the resident's family or representative was notified of the wander guard use, and the DON confirmed the unit manager did not call the family to inform them of the device.
Failure to provide written notice before a room change. A cognitively intact resident was moved to another room and reported being unhappy with the move and not being told why it was needed. The chart had no documentation that the resident or representative received notice or responded to the change, and the DON and SW confirmed no written notice was documented.
Delayed Physician Notification After Resident Head Injury: A resident with severe cognitive impairment, anemia, osteoarthritis, malnutrition, and anticoagulant therapy sustained a head injury during repositioning when staff unintentionally hit the resident’s head on a headboard. The resident later complained of head pain and was found to have a quarter-size hematoma, but the nurse aide and RN did not promptly notify the physician or document the incident until after the hematoma was discovered the next morning.
Incomplete Investigation of Alleged Abuse and Neglect: The facility did not complete a thorough investigation of alleged abuse/neglect involving two residents. One resident with severe cognitive impairment and a history of falls was found on the floor with a head laceration, but the bed position and key details of the event were not documented. Another resident with severe cognitive impairment, anemia, malnutrition, and anticoagulant use developed a head hematoma during repositioning, but the investigation relied on unsigned staff statements, included one staff member who did not work that day, and did not obtain statements from the resident or other witnesses.
A resident with tongue cancer and malnutrition had IV fluids running with a bright yellow solution in the NS bag, and an LPN confirmed the bag was improperly labeled and mixed with Infuvite even though the MD order did not direct that mix. Another resident with prurigo nodularis and a diaper-area rash reported weeks of worsening itching and burning, but the facility did not document ongoing assessment of the rash response, the ordered clotrimazole was entered for fewer days than prescribed, and the resident was not promptly assessed when symptoms worsened.
A resident with severe cognitive impairment, respiratory failure, and tracheostomy care needs had no physician order in the chart for the trach size to be used. An LPN could not locate the order or identify the required size, and the unit manager confirmed the order was absent.
Improperly Labeled IV Solution: A resident with tongue cancer and protein-calorie malnutrition had an IV NS bag running that was discolored bright yellow. Surveyors observed a label for IV additives on the bag, but it did not identify the additive. An LPN confirmed the bag was not properly labeled and stated the NS had been mixed with Infuvite Adult IV Solution for administration.
Improper Handling of Reusable Gowns in Resident Room: The facility failed to follow its infection control PPE process when yellow reusable cloth gowns and a bag of gowns were found inside a resident’s room despite enhanced barrier precautions being posted. The resident had anoxic brain damage, chronic respiratory failure with hypoxia, and a tracheostomy. An LPN confirmed the gowns were in the room and stated they should be used once and then disposed of for laundering.
Facility assessment documentation showed that only the Administrator, DON, Governing Body rep, and Medical Director were involved in the annual review, with no documented input from residents, resident representatives, family members, or direct care staff such as RNs, LPNs, or NAs. The NHA confirmed that no documentation was available to support active involvement from direct care staff or residents.
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 Notify Family of Ankle Monitoring Device
Penalty
Summary
The facility failed to ensure that the resident's next of kin, legal guardian, or power of attorney was notified of a change in care related to the use of an ankle monitoring bracelet for Resident R175. Resident R175 had diagnoses of anxiety disorder and unspecified dementia. On observation, the resident was wearing a monitoring device on the ankle, and physician orders dated April 3, 2026 directed staff to check the function and placement of the [NAME] Chip Function monitoring device on the right ankle daily to prevent elopement. Review of the clinical record found no documented evidence that the family was notified of the wander guard use. The DON confirmed in interview that the unit manager did not call the family to inform them that the wander guard had been applied to Resident R175's ankle.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide written notice before changing the room of one cognitively intact resident, Resident R105, who was admitted to the facility on [DATE]. The resident reported that on May 28, 2026, his/her room was moved from one room to another and stated being unhappy with the move and not being informed why the change was needed. Review of the resident’s clinical record found no documented evidence that the resident or the resident representative were notified of the room change or of any response from them. The DON confirmed there was no documented evidence of the room move process or notification to the resident/representative and stated Social Services would be responsible for such documentation. The Social Worker also confirmed there was no documented evidence that Resident R105 received written notice, including the reason for the room change, before the move.
Delayed Physician Notification After Resident Head Injury
Penalty
Summary
The facility failed to promptly notify the physician after Resident R26 sustained a head injury during repositioning in bed. Resident R26 had a BIMS score of 7, indicating severe cognitive impairment, and diagnoses that included anemia, osteoarthritis, and malnutrition. The resident’s care plan noted anticoagulant therapy and risk for bleeding and bruising. During an interview, Resident R26 reported a bump to the top of the head because nurses were careless during care. Clinical documentation showed that Resident R26 complained of head pain and was assessed with a quarter-size hematoma on the top of the head. The resident also alleged being dropped at home while being carried up steps by family. A nursing note later documented that the resident’s representative was seeking information about the hematoma and alleged the resident was manhandled. The facility incident report stated that while Resident R26 was being repositioned in bed, staff unintentionally hit the resident’s head on the headboard. Staff statements indicated the same event, but the statements were not signed, and the facility later confirmed that Nurse Aide E11 and RN E12 did not promptly notify the physician or document the accidental head strike until after the hematoma was found the next morning.
Incomplete Investigation of Alleged Abuse and Neglect
Penalty
Summary
The facility failed to conduct a complete, accurate, and thorough investigation of alleged abuse and neglect for two residents. Facility policy required investigation of all suspected abuse and collection of written documentation such as signed witness statements, statements of accused personnel, medical records, incident reports, and other pertinent information, but the documentation reviewed did not show that all relevant facts were gathered for either event. For one resident, who was severely cognitively impaired, had obstructive uropathy, used a suprapubic catheter, was incontinent of bowel, and had a history of falls with a care plan intervention to keep the bed in the lowest position, staff found the resident on the floor next to the bed bleeding from the head. The resident was transferred to the hospital for further evaluation. The only witness statement obtained was from a nurse aide, who stated the resident was last cared for at 2:30 a.m. and last seen at 3:00 a.m., but the facility did not document what care was provided or determine the position of the bed when the resident was found on the floor about an hour later. The DON confirmed the facility failed to determine the bed position after the fall. For the second resident, who had severe cognitive impairment, anemia, osteoarthritis, malnutrition, and was on anticoagulant therapy with a care plan noting risk for bleeding and bruising, the resident complained of head pain and was found to have a quarter-size hematoma on the top of the head. The resident alleged being dropped at home and later alleged staff were careless or manhandled the resident. The facility incident report stated the resident was injured while being repositioned in bed when staff unintentionally hit the headboard, but the employee statements were unsigned, one named employee did not work that day, and no witness statements were obtained from the resident or other staff or residents. The DON confirmed the timeline of the alleged incident was unclear and that no statement from the resident or other witnesses was obtained.
Failure to Follow IV Orders and Monitor Worsening Skin Rash
Penalty
Summary
The facility failed to provide care in accordance with physician orders for a resident with malignant neoplasm of the tongue and protein-calorie malnutrition. The resident had an order for Infuvite Adult IV solution at 80 ml/hr once daily and a separate order for 0.9% Sodium Chloride IV solution at 75 ml/hr every shift for four days. During observation, the resident was in bed with the sodium chloride solution running at 75 ml/hr, and the contents of the bag were discolored bright yellow. An LPN confirmed the sodium chloride bag was not properly labeled and had been mixed with the Infuvite Adult IV solution, and also confirmed the physician order for infuvite did not direct that it be mixed with the sodium chloride solution, although pharmacy instructions recommended adding infuvite to sodium chloride. The facility also failed to adequately monitor and follow the treatment course for a resident with prurigo nodularis and a diaper-area rash. The resident reported ongoing itching for weeks, worsening discomfort, and burning when urine contacted the rash, and scratching marks were observed on the torso. A physician ordered zinc oxide ointment twice daily for the rash, but during the period it was used there was no documented ongoing assessment of the resident's response to treatment, and weekly skin checks did not note any new or current skin changes. After the zinc order ended, there was a delay before the resident was seen again, and when the physician later documented worsening symptoms, clotrimazole was ordered; the medication administration record reflected it for seven days instead of the ordered 14 days. The resident was later seen again for worsening pain and irritation, and wound notes showed the resident was not assessed for the skin rash until several days later.
Missing Physician Order for Tracheostomy Size
Penalty
Summary
The facility failed to obtain a physician order for the size of a resident’s tracheostomy tube. Resident R2 was severely cognitively impaired, had a diagnosis of respiratory failure, and received tracheostomy care. The resident’s care plan identified altered respiratory status related to tracheostomy and pulmonary edema. Observation showed the resident had a tracheostomy, and the clinical record contained a physician order to change the disposable inner cannula every day shift, but there was no physician order specifying the tracheostomy size to be used. An assigned LPN stated she could not find an order for the tracheostomy size and did not know what size the resident required, and the unit manager confirmed that no such order was present.
Improperly Labeled IV Solution
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with professional standards for one resident, R287. The resident was admitted with diagnoses of malignant neoplasm of the tongue and protein-calorie malnutrition. The clinical record showed a physician order dated May 24, 2026, for Infuvite Adult IV Solution at 80 ml/hr intravenously once daily, and a physician order dated June 2, 2026, for Sodium Chloride 0.9% IV Solution at 75 ml/hr intravenously every shift for four days. On June 2, 2026, at 11:45 a.m., observations showed R287 in bed with the Sodium Chloride IV Solution running at 75 ml/hr, and the solution was discolored bright yellow. Further observation showed a label reading "Intravenous Solution Additives" affixed to the Sodium Chloride IV bag, but the label did not identify the additive. During an interview at approximately 12:00 p.m., an LPN confirmed the Sodium Chloride Solution bag was not properly labeled with the additive and stated that the Sodium Chloride Solution had been mixed together with the Infuvite Adult IV Solution for administration.
Improper Handling of Reusable Gowns in Resident Room
Penalty
Summary
The facility failed to implement an effective infection control program related to personal protective equipment for one resident. Facility policy stated that appropriate PPE must be available at all times and that employees performing tasks involving exposure to blood or body fluids must be provided appropriate protective clothing and equipment. Resident R2 was admitted with diagnoses including anoxic brain damage and chronic respiratory failure with hypoxia and had a tracheostomy at the time of the observation. During observation, an enhanced barrier precaution sign was posted outside R2’s bedroom door with PPE available, including re-washable cloth gowns. However, yellow re-washable cloth gowns and a plastic bag containing yellow cloth gowns were observed on top of a chair inside R2’s room. The licensed nurse confirmed that the yellow reusable cloth gowns and the bag of gowns were inside the room and stated that the gowns should be used only once and then properly disposed of for laundering. The nurse then placed the gowns in the plastic bag and removed them from the room for disposal.
Facility Assessment Lacked Required Input
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment with active input from residents, resident representatives, family members, and representatives of direct care staff. Review of the facility assessment dated April 22, 2026 showed that the people involved in the process were the Administrator, DON, Governing Body representative, and the Medical Director. Review of the assessment and the sign-in sheet for the annual review on April 22, 2026 found no documented evidence that residents or resident representatives were included, and no documented evidence of active involvement from direct care staff such as RNs, LPNs, or NAs. During an interview on June 5, 2026 at 1:00 p.m., the Nursing Home Administrator confirmed that no documentation was available to support active involvement from direct care staff or input from residents.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Darby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Rehab And Hlthcare Ctratmercyfitzgerald | 0.4 mi | ★★★★★ | 8 | 0 |
| Little Flower Manor | 0.4 mi | ★★★★★ | 1 | 0 |
| Edenbrook Of Yeadon | 0.8 mi | ★★★★★ | 21 | 0 |
| Holy Family Home | 2.6 mi | ★★★★★ | 8 | 0 |
| Care Pavilion Nursing And Rehabilitation Center | 2.7 mi | ★★★★★ | 56 | 0 |
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