St John Neumann Ctr For Rehab & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 10400 Roosevelt Avenue, Philadelphia, Pennsylvania 19116
- CMS Provider Number
- 395182
- Inspections on file
- 38
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at St John Neumann Ctr For Rehab & Healthcare during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including dementia, CKD, DM2, HTN, anemia, and a history of falls, was documented as being incontinent of bowel and bladder and had an approved bedside rail evaluation to promote independence. However, the resident’s care plan did not include any goals or interventions addressing incontinence care or the use of bedside rails, despite facility policy requiring person-centered care plans with measurable objectives and timetables based on comprehensive assessments.
Surveyors identified that the facility did not maintain clean and sanitary shower and bathroom areas on two nursing units. On one unit, shower floors were visibly soiled with dirt and muddy footprints, and a bathroom trashcan was overflowing with no hand cloths or paper towels available for hand hygiene. On another unit, shower rooms contained dirty linen carts overflowing with soiled linens so that the lids could not fully close, accompanied by a strong, unpleasant odor. A unit manager confirmed that soiled linen carts are stored in shower rooms until the end of each shift, despite facility policy requiring soiled linen to be covered. Multiple residents reported that shower room floors are consistently dirty, trash is frequently overflowing, and that housekeeping does not clean resident bathrooms even when requested, which was corroborated by observation of a resident bathroom with visible grime and poor sanitation.
A dementia unit failed to maintain a clean and homelike environment when a shared bathroom was found dirty with feces, urine odor, and flies, and was not cleaned due to housekeeping shortages. Staff did not promptly address or report the issue, and a resident who used the bathroom was later hospitalized with a UTI and ESBL infection. Infection control confirmed that exposure to a dirty bathroom could lead to such infections.
The facility failed to maintain safe and comfortable air temperatures on the 300 nursing unit, with heating systems in several rooms not functioning properly. This resulted in temperatures as low as 56 degrees Fahrenheit, placing residents, particularly those with cognitive impairments, at risk for hypothermia. Issues with the heating units had been reported since November, but no corrective actions were documented, leading to an Immediate Jeopardy situation.
The facility failed to maintain safe, operating conditions for resident care equipment, with multiple reports of clogged sinks across three nursing units. Residents expressed dissatisfaction, and observations confirmed defective sinks and other maintenance issues. The deficiency was noted under 28 Pa. Code 201.14 (a).
A resident with multiple diagnoses, including mood disorder and dementia, was transferred to the hospital due to refusal of care and aggressive behavior. The facility failed to document the necessity of the transfer or provide evidence that it could not meet the resident's needs, resulting in a deficiency.
A facility failed to create a baseline care plan for a resident admitted with multiple diagnoses, including mood disorder and dementia. The resident exhibited refusal of care and medications, and aggressive behavior, leading to a hospital transfer. Despite these issues, no baseline care plan was developed to address the resident's needs.
A resident with severe cognitive impairment and dementia did not receive a requested consultation with an optometrist or ophthalmologist, despite repeated requests from the family over several months. The resident was observed to have impaired vision and no corrective eyewear, and there was no documentation of any consultation being arranged.
A facility failed to provide trauma-informed care for a resident with PTSD. The care plan did not address the resident's actual diagnosis or identify past experiences and triggers for re-traumatization. The facility was unaware of the resident's PTSD diagnosis, and the social worker confirmed the care plan's deficiencies.
A facility failed to create an individualized care plan for a resident with non-Alzheimer's dementia. Despite the resident receiving antipsychotic and antidepressant medications, there was no care plan with measurable goals and interventions to address their dementia care needs. This was confirmed by the DON during an interview.
The facility failed to provide timely lab services for three residents, leading to significant care deficiencies. A resident with hyperkalemia had critical potassium levels reported but the physician was informed days later, resulting in hospital transfer. Another resident experienced a delay in a recommended urine pH test, and a third resident did not have necessary valproic acid blood level studies completed. These issues highlight a lack of adherence to medical protocols.
The Nursing Home Administrator failed to manage the facility's heating system, resulting in unsafe temperatures for 19 residents. Rooms 310 to 317 had temperatures below the required range, posing an Immediate Jeopardy. Despite staff reports since November, no repairs were documented, leaving residents in cold conditions.
A resident with cognitive impairments and multiple mental health diagnoses repeatedly refused medications and initiated physical altercations, yet the facility failed to update the care plan to address these behaviors. Despite documented incidents of agitation and non-compliance, the care plan remained unchanged, resulting in a deficiency in care planning.
A resident with a complex medical history, including dementia, sustained multiple injuries, including bruises and a cut above the eye, which were not thoroughly investigated by the facility. Despite the resident's known inability to get up unassisted, the facility's follow-up report suggested the injuries might have been caused by hitting the edge of a TV, without any incident noted on prior shifts. This failure to conduct a comprehensive investigation violated several Pennsylvania Code regulations.
The facility failed to provide written notice, including the reason for the change, before a resident's room change. The resident and their family were only verbally informed about the move to a semiprivate room due to a change in the level of care, which was confirmed by the Administrator and the DON.
Failure to Develop Care Plan for Incontinence and Bedside Rail Use
Penalty
Summary
Facility policy on comprehensive person-centered care plans requires that each resident have a care plan with measurable objectives and timetables based on a thorough analysis of the comprehensive assessment to meet physical, psychosocial, and functional needs. For one resident (R2), who had a medical history including anemia, history of falling, chronic kidney disease, type 2 diabetes mellitus, hypertension, and dementia, the clinical record showed documentation of bowel and bladder incontinence in a nursing note dated April 4, 2026, at 9:10 p.m. The record also contained a bed rail evaluation completed on September 10, 2025, approving bedside rails to promote independence. Despite these documented needs and assessments, review of the resident’s care plan revealed no goals or interventions related to incontinence care or the use of bedside rails. This lack of corresponding care plan goals and interventions for incontinence care and bedside rail use for Resident R2 constituted a failure by the facility to develop and implement a complete, measurable care plan that addressed all identified needs, as required by facility policy and 28 Pa Code 211.12(d)(1)(5) regarding nursing services.
Failure to Maintain Clean, Sanitary Shower and Bathroom Areas
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment on the 600 and 700 nursing units, contrary to its own soiled linen policy requiring that potentially contaminated linen be kept covered with a lid at all times. On the 600 unit, both shower room floors were visibly soiled with dirt and muddy footprints smeared across the surfaces, and the shower room bathroom trashcan was overflowing with no hand cloths or paper towels available for hand hygiene. On the 700 unit, both shower rooms contained a dirty linen cart overflowing with soiled linens so that the lid could not be fully closed, and a strong, unpleasant odor was present throughout the shower rooms. The Unit Manager confirmed these conditions and stated that the soiled linen cart is stored in the shower room and removed at the end of each shift. Two residents reported that the shower room floors are consistently dirty and that the bathroom trash is frequently overflowing, and another resident reported that housekeeping does not clean the resident bathroom even when requested; observation of that resident’s bathroom showed visible grime and poor sanitation. These findings were cited under 28 Pa. Code 207.2(a) regarding the administrator’s responsibility.
Failure to Maintain Clean and Homelike Environment in Dementia Unit
Penalty
Summary
The facility failed to maintain a clean and homelike environment in a dementia care unit, as evidenced by observations and staff interviews. During an inspection, the bathroom shared by three residents was found to be dirty, with feces present in the toilet bowl, a strong urine odor, and flies in the bathroom. The facility's policy requires daily cleaning of resident rooms and bathrooms by housekeeping staff, but the Housekeeping Director confirmed that the bathroom had not been cleaned due to a shortage of housekeeping staff. Additionally, a nurse aide reported cleaning a resident after an episode of diarrhea but did not inform housekeeping that the bathroom required cleaning. Staff interviews revealed that when families raised concerns about the cleanliness of resident rooms or environmental issues, nursing staff attributed the problems to resident behaviors and indicated they would address them when time permitted. One resident who used the affected bathroom was hospitalized with a urinary tract infection (UTI) and ESBL (extended-spectrum beta-lactamase producing bacteria) and was receiving antibiotics. The infection control staff confirmed that using a dirty bathroom could result in exposure to such bacteria.
Failure to Maintain Safe Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable air temperature levels on the 300 nursing unit, placing residents at risk for developing hypothermia. The facility's policy required room and lounge temperatures to be maintained between 71 to 81 degrees Fahrenheit, with any variance to be reported to the administrator and maintenance director. However, observations and interviews revealed that the heating systems in several rooms were not functioning properly, resulting in temperatures as low as 56 degrees Fahrenheit in some areas. Residents, particularly those with cognitive impairments, were exposed to these cold temperatures. For instance, a resident in room 313 reported that the heating system was not working, and observations confirmed that the heating unit was not operational. Another resident was found in a thin hospital gown in a hallway with a temperature of 56 degrees Fahrenheit. Many residents required assistance with dressing and were unable to adequately protect themselves from the cold. The maintenance communication logs indicated that issues with the heating units had been reported as early as November 2024, but there was no documentation of any response or repair actions taken. Interviews with staff confirmed that the heating units had not been fully functioning since November, affecting multiple rooms and leaving residents in an unsafe environment. The facility's failure to address these issues in a timely manner resulted in an Immediate Jeopardy situation for the affected residents.
Removal Plan
- All affected residents were moved to other areas of the facility where the temperature was maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit. All residents were assessed for signs and symptoms of hypothermia. Vital signs were taken on all affected residents. All responsible parties and all residents' physicians were made aware.
- Room temperatures of other units were audited after the affected rooms were identified and all rooms were found to have temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit. Vital signs were taken on all unaffected residents.
- Education was provided to the facility staff that were working when the areas were found to be affected and education will continue for staff who will work until temperatures are maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit in the affected rooms. The education includes reporting any residents with concerns of being cold, offering blankets, acceptable temperature ranges, or have signs and symptoms of hypothermia. The facility is taking hourly temperatures of resident rooms to assure that the temperature is maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit. Staff has been added to the schedule for the immediate nursing shifts to assure resident safety. Staff will continue to be added to the schedule to assure resident safety until the temperature is maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit in the affected area and residents are returned to their original rooms.
- Industrial heating units have been procured and will be placed in the affected area.
- Vital signs will be taken for all residents at the facility to assure that no resident will have any negative effects as related to the signs and symptoms of hypothermia and vital signs will continue until heat is restored to the affected area.
- Repairs of heating units will continue until heat is restored to the affected area and the temperature is maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit.
- The Maintenance Director or designee will audit room temperatures to ensure that the room temperature is between 71 and 81 degrees Fahrenheit. Corrective action will be taken as necessary. The results of the audits will be reported at monthly QAPI meeting until substantial compliance is reached.
Facility Fails to Maintain Safe Resident Care Equipment
Penalty
Summary
The facility failed to maintain resident care equipment in safe, operating conditions across three of the seven nursing units toured. Observations and interviews with residents and staff revealed that multiple bathroom sinks were malfunctioning, specifically being clogged and not draining properly. Maintenance work orders from September 9, 2024, through January 22, 2024, showed numerous ongoing and recurring requests for repairs of clogged sinks in various rooms. Residents expressed dissatisfaction with the non-functioning sinks, and one resident reported that her sink had been leaking since her arrival, despite multiple complaints to the facility staff. Further observations during the survey confirmed the presence of defective, clogged sinks filled with water. Additionally, a rusted seat riser was observed in one of the bathrooms, and a loose faucet was noted in another. These issues were confirmed during a tour with the Regional Administrator and a housekeeping employee. The facility's failure to address these maintenance issues resulted in a deficiency under 28 Pa. Code 201.14 (a), which outlines the responsibility of the licensee to maintain equipment in safe, operating conditions.
Inadequate Documentation and Justification for Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident's transfer to the hospital was necessary and did not document the basis for the transfer in the resident's medical record. Resident R 212, who was admitted with multiple diagnoses including mood disorder, dementia, and bipolar disorder, was transferred to the hospital after exhibiting behaviors such as refusing care, medications, and meals, and displaying verbal aggression. Despite these behaviors, the facility's documentation did not provide sufficient evidence that the transfer was necessary for the resident's welfare or that the facility could not meet the resident's needs. Interviews with staff revealed that the decision to transfer the resident was influenced by the resident's refusal of care and aggressive behavior. However, the Director of Nursing was unable to provide evidence that the transfer was necessary for the health and safety of the resident or others at the facility. The facility documentation lacked detailed justification for the transfer, and the resident was sent to the hospital with all personal belongings, indicating a discharge rather than a temporary transfer.
Failure to Develop Baseline Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required. The resident, who was admitted with multiple diagnoses including unspecified mood disorder, dementia, kidney failure, and a history of falling, exhibited significant behavioral issues such as refusal of care, medications, and verbal aggression. Despite these challenges, there was no evidence of a baseline care plan addressing these behaviors and refusals. The resident's clinical records indicated a pattern of refusal to take medications, undergo lab tests, and accept care, which escalated to aggressive behavior. Nursing notes documented the resident's refusal of care and medications over several days, leading to a psychological consultation and a new medication order. However, the resident continued to refuse care, resulting in a transfer to a hospital due to safety concerns. The lack of a baseline care plan contributed to the inability to effectively manage the resident's needs and behaviors during their stay at the facility.
Failure to Obtain Vision Services for Resident
Penalty
Summary
The facility failed to ensure that a consultation with an optometrist or ophthalmologist was obtained for a resident, identified as Resident R201. The resident's responsible family member, who visits daily, reported having requested an eye examination for the resident multiple times over several months. Despite these requests, there was no documentation indicating that the consultation had been discussed with the physician, nor were there any vision consults available for review. Observations revealed that the resident, who was sitting in a well-illuminated dining area, could not follow objects with her eyes and had no corrective eyewear, suggesting a need for corrective lenses. Resident R201 was admitted to the facility with a comprehensive assessment indicating severe cognitive impairment and a diagnosis of dementia. Interviews with the nursing staff confirmed that the family member had requested an evaluation by an eye specialist in November and December 2024, and January 2025, but no action was taken. This lack of action constitutes a deficiency in the facility's responsibility to provide necessary vision services, as required by the relevant Pennsylvania codes.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for a resident diagnosed with anxiety disorder and post-traumatic stress disorder (PTSD). The clinical record review revealed that the facility was unaware of the resident's PTSD diagnosis. The resident's care plan, dated December 19, 2024, included a plan for PTSD but did not address the resident's actual diagnosis or condition, nor did it identify the resident's past experiences and possible triggers that could lead to re-traumatization. An interview with the social worker confirmed that the care plan lacked these critical elements.
Failure to Develop Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. The resident, identified as R88, was admitted to the facility and diagnosed with non-Alzheimer's dementia. Despite the diagnosis and the administration of antipsychotic and antidepressant medications, the facility did not create a care plan with measurable goals and interventions to address the resident's dementia care needs. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a specific care plan for the resident.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely and appropriate laboratory services for three residents, leading to significant deficiencies in care. Resident R72, diagnosed with hyperkalemia, had critical potassium levels reported on November 29, 2024, but the physician was not informed until December 1, 2024, resulting in the resident being transferred to the hospital for further evaluation and management. This delay in communication of critical lab results highlights a breakdown in the facility's process for handling urgent medical information. Resident R204 experienced a delay in the ordering and completion of a recommended lab test for urine pH with Methenamine, which was suggested by a pharmacist on September 20, 2024, but not ordered by the physician until January 8, 2025. Additionally, Resident R169, who was on valproic acid for bipolar disorder, did not have the necessary blood level studies completed as ordered by the physician on December 16, 2024. These failures to conduct timely lab tests as recommended or ordered by healthcare professionals indicate a lack of adherence to proper medical protocols and oversight within the facility.
Failure to Maintain Safe Air Temperatures in Resident Rooms
Penalty
Summary
The Nursing Home Administrator failed to effectively manage the facility's heating system, resulting in unsafe and uncomfortable air temperatures for 19 cognitively impaired residents. The deficiency was identified in rooms 310 to 317, where temperatures ranged from 56 to 71 degrees Fahrenheit, well below the required range of 71 to 81 degrees Fahrenheit. This situation was reported as an Immediate Jeopardy due to the risk posed to residents' safety and comfort. Interviews and observations revealed that the heating units in these rooms were not functioning properly since November 2024. Residents and staff reported the cold conditions, with some residents wearing multiple layers of clothing and blankets to stay warm. Specific residents, such as one who was severely cognitively impaired and another who was independent in dressing, were directly affected by the cold temperatures, highlighting the facility's failure to maintain a safe environment. The maintenance communication logs showed that staff had reported the heating issues multiple times, but there was no documentation of any response or repair actions taken by the maintenance or administrative staff. The Nursing Home Administrator confirmed the cold temperatures and acknowledged the ongoing issue, which had not been addressed, leading to the Immediate Jeopardy situation.
Failure to Update Behavioral Health Care Plan for Resident
Penalty
Summary
The facility failed to review and revise the behavioral health care plan for a resident who was cognitively impaired and diagnosed with dementia, anxiety disorder, depression, and manic depression. The resident, who primarily spoke Spanish, had a history of refusing medications and initiating physical altercations with a roommate. Despite these ongoing issues, the comprehensive care plan was not updated to address the resident's behavior of refusing care and medications. The resident's clinical records indicated multiple instances of agitation, confusion, and refusal to take medications, including a specific incident where the resident expressed a desire to die and refused to eat. The resident's behavior was noted by nursing staff and a nurse practitioner, who documented the resident's dissatisfaction with the facility and non-compliance with medication. Despite these documented concerns, there was no evidence that the care plan was reviewed or revised to address these behaviors, leading to a deficiency in the facility's care planning process.
Inadequate Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury sustained by a resident, identified as Resident R1, who has a complex medical history including dementia, major depressive disorder, and other conditions. On October 2, 2024, Resident R1 was noted to be physically aggressive during morning care and was initially assessed to be without injury. However, later that day, bruises were observed on the resident's right hand, wrist, and arm. By the early hours of October 3, 2024, a cut above the right eye was noted, which was bleeding. Further discoloration was observed on both eyes by October 5, 2024. The facility's investigation into the incident was inadequate, as it failed to determine the cause of the injuries. Statements from nurse aides indicated that the resident was combative, but no skin tears were initially noticed. The follow-up investigation report suggested the injury might have been caused by hitting the edge of a TV, yet no incident was noted on prior shifts. An interview with a licensed nurse revealed that Resident R1 had not been getting up from bed unassisted for about a year, which raises questions about the plausibility of the suggested cause of injury. The facility's failure to conduct a comprehensive investigation into the injuries violated several Pennsylvania Code regulations related to the responsibility of the licensee, management, and resident care policies.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for the change, before a resident's room change. The facility's policy, revised November 27, 2023, allows for room changes when medically necessary or if the resident requires a different level of care. However, for Resident R2, the clinical records revealed that only verbal notification was given to the resident and their family member about the move to a semiprivate room due to a change in the level of care. An interview with the Administrator and the Director of Nursing confirmed that no written notice was provided to Resident R2 or their representative before the room change was initiated.
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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