Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
The facility failed to complete several MDS assessments within the required 14-day window after the ARD. Record review showed overdue annual and quarterly MDSs for multiple residents, and the MDS Coordinator confirmed the assessments were not completed on time.
A resident with schizophrenia and depression had a BIMS score of 09 on the quarterly MDS, indicating cognitive impairment, but the clinical record contained no evidence of a Level 1 PASARR screen. The NHA confirmed the facility could not provide documentation of the required PASARR pre-screening.
A facility failed to develop and implement comprehensive, resident-centered care plans for two residents. One resident with stroke and aphasia was observed in bed with bilateral 3/4 length rails in use, and although bed rails had been assessed as indicated for positioning and bed mobility, no care plan was in place. Another resident developed a large fluid-filled blister on the right forearm, but the care plan contained no goals or interventions related to the skin alteration.
A resident with stroke, aphasia, and severe cognitive impairment was observed in bed with bilateral 3/4 length rails raised. The record showed inconsistent bed rail assessments, and several entries documented no recommendation and no informed consent, while the DON confirmed the findings.
Medication administration errors exceeded the allowed rate during an observed med pass, with 3 errors in 26 opportunities. An LPN nearly gave a resident the wrong med after selecting Oyster Calcium instead of ordered Cyanocobalamin, administered Nitroglycerin SL orally with water to a resident complaining of chest pain, and gave Metformin without food while the resident was not eating.
A resident with an order for Nitroglycerin 0.4 mg SL PRN for chest pain reported chest pain during the med pass, but an LPN administered the tablet orally with water instead of sublingually. The resident was observed swallowing the medication, and the LPN confirmed the error during interview.
Expired and improperly dated meds were found in 2 medication carts during survey. An LPN could not identify the open date on an insulin vial, another insulin vial had expired more than 2 months earlier, Famotidine tablets were expired, and additional insulin vials had dates written on them that did not clearly match the 28-day discard instructions.
Failure to clean and disinfect a glucometer after use. During a morning med pass, an LPN obtained a resident's blood glucose, discarded the test strip, and returned the monitor to the cart without cleaning or disinfecting it. The LPN stated she believed the monitor did not contact blood and said she would have used small alcohol wipes stored on the cart, but she was not aware of the required EPA-registered healthcare disinfectant or drying time.
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.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure MDS assessments were completed within 14 days after the ARD for four of seven sampled residents. Record review showed that Resident R32’s annual MDS had an ARD of June 21, 2025, and was completed on July 14, 2025; Resident R109’s quarterly MDS had an ARD of October 7, 2025, and was completed on October 23, 2025; Resident R16’s quarterly MDS had an ARD of June 17, 2025, and was completed on July 2, 2025; Resident R16’s next quarterly MDS had an ARD of September 17, 2025, and was completed on October 15, 2025; and Resident R4’s quarterly MDS had an ARD of October 8, 2025, and was completed on October 23, 2025. During an interview on November 20, 2025, the MDS Coordinator confirmed the assessments were not completed timely for Residents R32, R109, R16, and R164.
Missing PASARR Level 1 Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to provide evidence of a Level 1 PASARR pre-screening for a resident with diagnoses of schizophrenia and depression. Review of the resident’s clinical record showed admission to the facility with those diagnoses, and the quarterly MDS dated September 4, 2025, showed a BIMS score of 09, indicating cognitive impairment. Further review of the resident’s MDS also documented schizophrenia and depression. The clinical record contained no documented evidence that the facility completed a Level 1 PASARR screen, and during an interview on November 20, 2025, the Nursing Home Administrator confirmed the facility was unable to provide evidence of the resident’s Level 1 PASARR screen.
Incomplete Care Planning for Bed Rails and Skin Alteration
Penalty
Summary
The facility did not ensure a comprehensive, resident-centered care plan was developed and implemented for Resident R24 related to bed rails. R24 was admitted with diagnoses of intracerebral hemorrhage (stroke) and aphasia. On November 19, 2025, R24 was observed awake in bed with bilateral 3/4 length bed rails in the up position, running from the resident’s shoulder to hip. An LPN confirmed the bed rails were in place. The clinical record showed R24 had been assessed for bed rails on October 25, 2025, and that bed rails were indicated at that time for positioning and bed mobility, but the comprehensive care plan contained no care plan for bed rails. The LPN confirmed there was no care plan in place for bed rails. The facility also did not develop or implement a care plan for Resident R29 related to a right forearm blister. A nursing progress note dated November 15, 2025, documented that a nurse aide noted a skin alteration on the right forearm, and the nurse observed a large fluid-filled blister that appeared to have been partially drained. The area was cleansed, skin prep was applied, and a wound care consult was placed; the RP and MD were notified. During interview, R29 stated she did not know how or why the blister formed. Review of the care plan showed no goals or interventions related to the right forearm blister.
Bed Rail Assessment and Consent Deficiency
Penalty
Summary
Resident R24, who was admitted with diagnoses of intracerebral hemorrhage (stroke) and aphasia, had a quarterly MDS assessment showing a BIMS score of 0, indicating severe cognitive impairment. The resident was observed awake in bed with bilateral 3/4 length bed rails in the up position, running from the resident’s shoulder to hip, and an LPN confirmed the bed rail setup during the observation. The clinical record showed multiple bed rail assessments with inconsistent findings and documentation. One assessment dated October 25, 2025 stated that bedrails were indicated and served as an enabler to promote independence and documented that informed consent had been provided and the resident displayed understanding. Other assessments dated July 25, June 25, June 16, March 25, December 25, and December 21, 2025 contained conflicting conclusions about whether bedrails were indicated, and several of those assessments documented no recommendation and no informed consent. The DON confirmed these findings during interview.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
Medication administration errors exceeded the required rate of less than 5 percent during an observed medication pass, with 3 errors identified out of 26 medication administration opportunities for a medication error rate of 11.54%. During the morning medication pass for one resident, an LPN looked at the order for Cyanocobalamin 1000 mcg daily but picked up Oyster Calcium 500 mg, 2 tablets, and was about to administer the wrong medication before the surveyor intervened and stopped the administration. During the same medication pass for another resident, the resident reported chest pain and the LPN removed Nitroglycerin 0.4 mg SL from the cart but administered it orally with water, and the resident was observed swallowing the medication. The same resident was also given Metformin HCl 500 mg without any food, and it was observed that the resident was not eating any meals or food at the time. The LPN confirmed the findings and stated the resident's breakfast was over around 9:00 a.m.
Significant Medication Error: Nitroglycerin Given by Wrong Route
Penalty
Summary
A significant medication error occurred when Nitroglycerin sublingual tablets were administered by the wrong route to a resident who had an order for Nitroglycerin 0.4 mg sublingually as needed for chest pain. During the morning medication pass, the resident told the LPN that he was having chest pain, and the LPN removed the Nitroglycerin tablet from the cart and gave it orally with water. The resident was observed swallowing the medication. The LPN later confirmed the observation during interview. The report also notes that FDA-approved prescribing information requires Nitroglycerin sublingual tablets to be placed under the tongue or in the buccal pouch and not swallowed, chewed, or crushed.
Expired and improperly dated medications found in medication carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional standards for 2 of 6 medication carts reviewed, including the 400 cart 2 and the 400-unit split cart. During observation of the 400-unit split cart with an LPN, an insulin vial (Degludec) was found with two dates written on the bottle, and the LPN could not identify which date represented when the vial was opened. The same cart also contained a vial of insulin glargine with an opened date written on it that the LPN confirmed had expired more than two months earlier, as well as a bottle of Famotidine 10 mg tablets that had expired in [DATE]. During observation of the 400 cart two with another LPN, an insulin vial (Amelog) was found with a date written on the bottle and instructions to discard the medication 28 days after opening. The cart also contained a vial of insulin lispro with two dates written on the bottle, while the bottle instructions stated the medication should be discarded 28 days after opening.
Failure to Clean and Disinfect Glucometer After Use
Penalty
Summary
The facility failed to ensure proper infection control practices were followed when a blood glucose monitor was not cleaned and disinfected after use for one resident. The facility policy titled "Glucometer Cleaning and Disinfection Policy" dated October 2025 stated that blood glucometers are to be cleaned and disinfected after each use with a wipe pre-saturated with an EPA-registered healthcare disinfectant effective against HIV, Hepatitis C, Hepatitis B virus, and C. diff, and that the glucometers should be cleaned and disinfected before and after each use according to the manufacturer's instructions. During observation of the morning medication pass for a resident on November 17, 2025, an LPN obtained the resident's blood glucose and then returned the glucose monitor to the medication cart. The LPN removed and discarded the test strip and placed the monitor back in the cart without cleaning or disinfecting it. In interview, the LPN stated she did not clean the monitor because she believed it did not come into contact with blood, and said she would use small alcohol wipes stored on the cart for skin preparation prior to needle sticks. She was not aware of the required cleaning process using wipes pre-saturated with an EPA-registered healthcare disinfectant or the required drying time.
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.
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Illustrative
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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Illustrative
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Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakwood Healthcare & Rehabilitation Center | 0.3 mi | ★★★★★ | 6 | 0 |
| Paul's Run | 1 mi | ★★★★★ | 7 | 0 |
| Delaware Valley Veteran's Home | 1.7 mi | ★★★★★ | 3 | 0 |
| Chapel Manor | 1.9 mi | ★★★★★ | 21 | 0 |
| Accela Rehab And Care Center At Somerton | 2.2 mi | ★★★★★ | 9 | 1 |
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