St Monica Center For Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 2509 South Fourth Street, Philadelphia, Pennsylvania 19148
- CMS Provider Number
- 395558
- Inspections on file
- 29
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at St Monica Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility did not create individualized care plans for several residents with COPD, oxygen therapy needs, depression, anxiety, and dementia. Despite physician orders and ongoing treatments, required care plans and interventions were missing, as confirmed by record reviews, staff interviews, and direct observation.
Surveyors identified multiple food service safety and sanitation deficiencies, including lack of a designated area for dented cans, improperly stored food items with open packaging in the freezer, and unsafe kitchen conditions such as water overflow from the dish machine, worn floor grout, a missing grease trap plug, and leaking milk containers that created slipping hazards. These issues were confirmed by the Food Service Director.
The facility did not provide dignified meal service by serving all residents on one unit with disposable paperware and plasticware, and failed to assist a resident with cognitive deficits who was observed eating with her hands. Additionally, a resident was inappropriately denied ice by an LPN despite no clinical restrictions, and the unit manager confirmed no such restrictions existed. These actions failed to respect residents' rights and dignity.
A resident with multiple diagnoses, including TIA, seizures, kidney failure, diabetes, and xerosis cutis, was found with a prescribed medicated lotion stored in her room and accessible for self-use. The facility did not complete an assessment or obtain physician orders to determine if self-administration was clinically appropriate, as confirmed by the ADON.
A resident with end stage renal disease and dependent on dialysis was not accurately identified as receiving dialysis services on the admission MDS, despite physician orders indicating regular dialysis treatments. The DON confirmed that the appropriate section of the MDS should have been completed to reflect this service.
A resident with CHF, diabetes, and kidney failure experienced a rapid and significant weight gain, but staff did not notify the physician as required by facility policy. Additionally, the PRN Furosemide order lacked clear instructions on when to administer the medication, and staff did not clarify the order, resulting in unclear care protocols.
A resident with dementia and chronic kidney disease, fully dependent on staff for mobility, did not receive consistent turning, repositioning, or heel offloading as required for pressure ulcer prevention. Despite care plan risk identification and physician orders, staff failed to implement or document these interventions, leading to the development and worsening of a pressure ulcer.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A resident with asthma was observed receiving oxygen at a higher flow rate (3L/min) than ordered by the physician (2L/min via nasal cannula PRN for SOB). The discrepancy was confirmed by the unit manager, who then adjusted the oxygen to the correct rate, indicating a failure to follow the physician's order for respiratory care.
Surveyors found that medications and biologicals were not properly labeled or stored on two units. Two opened vials of PPD were found in a medication refrigerator, with one lacking a date and the other missing a label. An unopened bottle of Pedialyte was also found to be expired. Additionally, a resident with multiple medical conditions had a prescribed medicated lotion stored in an unlocked drawer in their room, without proper labeling. Staff confirmed these deficiencies during the survey.
The facility employed a Food Service Director who lacked the required certifications and did not receive regular consultations from a qualified dietitian, resulting in noncompliance with regulatory standards for food and nutrition services.
Several residents reported that meals were frequently served cold or at improper temperatures, with complaints about cold hot foods and inadequately chilled beverages. Direct observation confirmed that both hot and cold food items were served outside the facility's acceptable temperature ranges, and the Food Service Director acknowledged these deficiencies.
A review of facility documents and staff interviews revealed that the binding arbitration agreement did not include language ensuring residents or their representatives could communicate with federal, state, or local officials, as required. This omission was confirmed by the facility's administrator and regional operations director.
A resident with multiple chronic conditions and on hospice care did not have a hospice nurse's recommendation for Ativan to manage breakthrough agitation addressed or implemented by the facility, as confirmed by review of clinical records and staff interview.
The facility failed to maintain safe and comfortable air temperatures on the 300 nursing unit, with temperatures dropping as low as 56°F, affecting 19 residents, many of whom were cognitively impaired. Despite multiple reports to the maintenance department, the heating issues were not addressed, leading to an Immediate Jeopardy situation.
The facility failed to maintain safe operating conditions for resident care equipment, with multiple clogged sinks reported across three nursing units. Despite numerous work orders and resident complaints, issues such as clogged sinks, a rusted seat riser, and a loose faucet persisted, leading to unsafe conditions.
A resident with multiple diagnoses, including mood disorder and dementia, was transferred to a hospital without sufficient documentation of necessity. The resident exhibited refusal of care and aggression, but the facility failed to provide evidence that the transfer was necessary for the resident's welfare or that the facility could not meet the resident's needs. Staff interviews confirmed the lack of documentation and the facility's unwillingness to continue care.
A facility failed to develop a baseline care plan for a resident with multiple diagnoses, including mood disorder and dementia, who exhibited refusal of care and aggressive behavior. Despite documented behaviors and a psychological consultation, no baseline care plan was created to address these issues, leading to the resident's discharge due to safety concerns.
A resident with severe cognitive impairment and dementia did not receive a necessary consultation with an eye specialist, despite repeated requests from the family over several months. The resident was observed to have impaired vision and lacked corrective eyewear, yet the facility failed to document or act on the requests for an optometrist or ophthalmologist evaluation.
A facility failed to provide trauma-informed care for a resident with PTSD. The resident's care plan did not address their PTSD diagnosis or identify past experiences and triggers for re-traumatization. The facility was unaware of the PTSD diagnosis, and the social worker confirmed the care plan's deficiencies.
A resident diagnosed with non-Alzheimer's dementia did not have an individualized care plan to address their dementia care needs. Despite being on antipsychotic and antidepressant medications, the facility failed to implement measurable goals and interventions, as confirmed by the DON.
The facility failed to timely report critical lab results and conduct necessary tests for three residents. A resident with hyperkalemia had critical potassium levels reported late, leading to a hospital transfer. Another resident's lab test was delayed despite a pharmacist's recommendation, and a third resident did not have ordered valproic acid level tests completed.
The Nursing Home Administrator failed to manage the facility's heating system, leading to unsafe temperatures for 19 residents. Heating units in several rooms were not functioning, with temperatures as low as 56°F. Despite reports through the maintenance system, the issue persisted since November, causing discomfort and potential health risks. This led to an Immediate Jeopardy situation due to the failure to maintain safe and comfortable conditions.
The facility failed to maintain its fire alarm system, as evidenced by four failed batteries noted in a previous inspection report without documentation of replacement, and a blocked fire alarm strobe in the Chapel Lobby. These issues were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain and inspect portable fire extinguishers, lacking technician certification and monthly inspections. Fire extinguishers were blocked by storage, indicator lights were out, and one extinguisher was not mounted. These issues were confirmed during an exit interview.
The facility failed to maintain documentation of weekly battery voltage testing for the emergency generator, as discovered during a document review. This deficiency was confirmed in an interview with the Administrator and Maintenance Director, affecting the entire facility's emergency power system.
The facility failed to maintain clear egress paths, with blocked exits from the Multi-purpose Room and unshoveled paths in several locations. Additionally, an exit door required excessive force to open. These issues were confirmed by the Administrator and Maintenance Director.
The facility failed to maintain delayed egress doors on the first floor. One door by the Laundry did not alarm and open, and another near a resident room lacked required signage. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain and inspect exit signage as required, lacking documentation of monthly inspections before April 2024. This affected nine of twelve inspections, confirmed by the Administrator and Maintenance Director during an exit interview.
The facility did not conduct the required monthly inspections of the kitchen hood suppression system on the first floor, as observed during a survey. This deficiency was confirmed in an interview with the Administrator and Maintenance Director.
The facility did not properly install fire alarm initiating devices, affecting one level of the building. The manual pull station for the double exit doors in the Kitchen on the first floor was not mounted within 5 feet of the exit doors, as observed and confirmed during an interview with the Administrator and Maintenance Director.
The facility did not maintain the fire resistance of smoke barriers, as observed on the first floor where smoke barrier doors failed to close properly in multiple locations. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the fire resistance of its gas cylinder storage, as the door to the Oxygen Storage Room on the first floor did not close and positively latch. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to provide accurate, portable floor plans as required by the Life Safety Code, affecting the entire facility. During a document review, it was found that the necessary floor plans, which should include smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls, were not available. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility was found to have three smoke compartments exceeding the maximum allowable size of 22,500 square feet. Smoke compartments one, two, and five were identified as non-compliant during a document review and interview. This issue was confirmed in an exit interview with the Administrator and Maintenance Director.
The facility's Emergency Preparedness Plan was found lacking in essential components, such as addressing the resident population, particularly persons at-risk, and detailing the types of services available during emergencies. This deficiency was confirmed during a document review and an exit interview with the Administrator and Maintenance Director, highlighting a significant gap in the facility's emergency management strategy.
The facility's emergency preparedness communication plan was found lacking as it did not include a method for providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction or the Incident Command Center. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
A resident with cognitive impairments and multiple mental health diagnoses at St. John Neumann Center for Rehab & Healthcare was involved in several incidents of medication refusal and aggressive behavior. Despite these events, the facility failed to update the resident's care plan to address these issues, leading to a deficiency in compliance with care plan requirements.
The facility did not properly dispose of garbage and refuse in the area where food and laundry are received. A dumpster was leaking a foul-smelling liquid, which spread over the floor, covered with dark, greasy substances. This was confirmed by the Director of Environmental Services.
Two residents in the facility experienced significant medication errors. A resident with a seizure disorder missed three doses of Vimpat due to a lack of a new prescription, while another resident with atrial fibrillation did not receive a nitroglycerine patch because it was unavailable. The Director of Nursing confirmed the unavailability of these medications.
A resident at risk for pressure ulcers, with diagnoses of muscle weakness and malnutrition, did not have a comprehensive care plan developed or implemented by the facility. Despite assessments indicating risk and the development of a Stage 2 pressure ulcer, the facility failed to address the resident's needs, as confirmed by the DON.
A resident with severe cognitive impairment was found with a medication cup containing pills on their bedside table, contrary to facility policy. The resident was not authorized to self-administer medication, and the Assistant DON confirmed the error, unable to identify the pills or responsible staff.
A facility failed to provide necessary emergency supplies for a resident receiving hemodialysis. The resident, dependent on renal dialysis, had a physician order to ensure an emergency clamp was at the bedside. However, an observation revealed the absence of this equipment, confirmed by the Unit Manager.
A resident with anxiety did not receive prescribed diazepam doses due to the facility's failure to implement procedures for medication availability. The medication was marked as unavailable, and there was no documentation of notifying the physician or seeking alternative treatments. An interview revealed the absence of a written procedure for such situations.
The facility failed to ensure timely physician review and documentation of drug regimen irregularities for two residents. A consultant pharmacist's recommendations regarding inappropriate antipsychotic use and gradual dose reductions were not promptly acknowledged or acted upon by the physician, with no clinical rationale provided for disagreements. A licensed nurse indicated a backlog of unaddressed pharmacy reviews.
A facility failed to document a specific diagnosed condition for a resident receiving olanzapine, an antipsychotic medication. Despite recommendations from a consultant pharmacist to review the diagnosis, the physician delayed acknowledgment and disagreed, ordering a psychiatric consultation instead. The clinical record lacked necessary documentation, indicating non-compliance with medication management standards.
The facility experienced a medication error rate of 7.41% due to incorrect administration of Vitamin D3 to a resident and an attempt to crush an extended-release Metoprolol tablet for another resident. These errors were confirmed by the respective LPNs involved.
A facility failed to obtain necessary lab services for a resident with schizophrenia, who was prescribed Divalproex for schizoaffective disorder. Despite a psychiatrist's recommendation to check valproic acid levels, there was no evidence that these levels were drawn. This was confirmed by the Unit Manager.
A resident experiencing dental pain did not receive timely dental services as per the facility's policy. Despite requests from the resident's family and documentation in the resident's care plan, the resident was not seen by a dentist until several months later. The facility also failed to provide the resident's dental history upon request.
The facility failed to maintain effective infection control during medication administration. An LPN used medical equipment on multiple residents without disinfecting it, and another LPN did not perform hand hygiene before handling medications. These actions violated the facility's infection control policies.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents with specific medical needs, as required by facility policy and regulatory standards. For residents with COPD and physician orders for continuous oxygen therapy, there was no individualized respiratory care plan or documentation addressing their oxygen use, despite clinical records and direct observations confirming their ongoing oxygen therapy. Interviews with nursing staff confirmed the absence of these required care plans. Additionally, residents with mental health diagnoses such as depression, anxiety, and dementia did not have care plans or interventions documented to address these conditions. Clinical records and care plan reviews showed that residents with new or existing diagnoses of depression, anxiety, and dementia were not provided with individualized care plans or interventions tailored to their needs, as required by the facility's interdisciplinary care planning protocol. The deficiency was identified through a combination of clinical record reviews, staff and resident interviews, and direct observation of residents receiving care. The findings demonstrated that the facility did not follow its own policies for timely and specific care planning, resulting in the lack of comprehensive care plans for residents with COPD, oxygen therapy needs, depression, anxiety, and dementia.
Food Service Safety and Sanitation Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations. In the dry storage area, there was no designated area for dented cans. In the walk-in freezer, several food items, including chocolate chip cookie dough, pizza shells, and bacon, were found with their inner plastic bags open and exposed to circulating air. The Food Service Director (FSD) confirmed these findings and reported slipping and falling in the dish room, where bleach got on his clothing. During a follow-up visit, the dish machine was seen draining between cycles, causing water to overflow the open floor drain trough and splash onto the floor, resulting in a soapy, slippery surface up to an inch deep. The grout around the floor tiles in this area was worn away, and water was leaking into a grease trap that was missing a plug. Additionally, during tray-line operation, the FSD slipped on the wet floor, and milk stored in an ice bath was leaking and dripping onto the floor, further contributing to the slipping hazard. All findings were confirmed through interviews with the FSD.
Failure to Uphold Resident Dignity and Rights During Meal Service and Beverage Requests
Penalty
Summary
The facility failed to uphold residents' rights to dignity and self-determination by serving meals on disposable paperware and plasticware to all residents on one unit, and by not providing appropriate assistance to a resident with cognitive and communicative deficits during mealtime. Observations revealed that all desserts were served in disposable plastic cups with lids, and some residents received plastic utensils. One resident with Alzheimer's, dementia, and a cognitive communicative deficit was observed eating with her fingers despite having plastic utensils, and staff did not intervene to assist or redirect her. The resident's clinical record did not document any recent behaviors necessitating the use of disposable utensils, and the facility could not provide evidence of such behaviors. Additionally, another resident with a history of falls, macular degeneration, diabetes, and depression was denied a request for ice by a licensed nurse, who stated that the resident was not allowed to have ice, despite there being no clinical restrictions documented in the resident's record. The unit manager confirmed that there were no restrictions on ice or beverages for this resident. These actions and inactions demonstrate a failure to provide care and services that enhance residents' dignity and respect their rights.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including transient ischemic attack, seizures, kidney failure, diabetes, and xerosis cutis, was found to have a prescribed medicated lotion (Ammonium Lactate 12%) stored in her room. The lotion was observed on the resident's dresser and later in an unlocked drawer, accessible to the resident. The resident acknowledged that the lotion was hers and that it was used for application to her legs as ordered by her physician. Despite the medication being kept in the resident's room and accessible to her, there was no documentation in the clinical record indicating that the facility had assessed the resident's ability to self-administer medication. Additionally, there were no physician orders or completed assessments authorizing self-administration. This lack of assessment and documentation was confirmed by the Assistant Director of Nursing during an interview.
Failure to Accurately Document Dialysis on MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the clinical status of a resident who was admitted with end stage renal disease and was dependent on dialysis. Review of the resident's clinical record showed that the resident was receiving dialysis three times a week at a local dialysis center, as indicated by physician orders. However, the admission MDS did not identify the resident as receiving dialysis services. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that Section O of the MDS should have been triggered for dialysis.
Failure to Notify Physician and Clarify PRN Diuretic Order After Significant Weight Gain
Penalty
Summary
The facility failed to ensure that a physician was notified of a rapid and significant weight gain for a resident with multiple complex medical conditions, including congestive heart failure, diabetes, kidney failure, and a history of TIA and seizures. The resident experienced an 11.6-pound (9.2%) weight gain over a six-day period, as documented in the clinical record. Facility policy required nursing staff to confirm significant weight changes and notify the dietitian, with further interdisciplinary analysis of the resident's status. However, there was no evidence in the clinical record that the physician was notified of this significant weight gain, as confirmed by staff interviews and record review. Additionally, the facility failed to clarify a physician's order for Furosemide, which was prescribed as needed for shortness of breath or weight gain related to heart failure. The order did not specify how often the resident should be weighed or the exact criteria for administering the medication (such as the timeframe or amount of weight gain that would trigger administration). Staff confirmed that the order was not clarified, leaving ambiguity in care instructions for the resident.
Failure to Implement and Document Pressure Ulcer Prevention for Dependent Resident
Penalty
Summary
A resident with diagnoses including dementia and chronic kidney disease, who was totally dependent on staff for bed mobility, was identified as being at high risk for pressure ulcers. The resident's care plan noted risk factors such as impaired mobility and incontinence, but there was no documented evidence that staff implemented or documented regular turning and repositioning interventions. Nursing notes indicated the development of redness on the sacrum, which progressed to an open area with slough and mild erythema, later assessed as end-stage skin failure with a full-thickness wound. Despite physician orders for offloading the heels every shift, observations and staff interviews confirmed that the resident's heels were not consistently offloaded, and there was no evidence of a turning and repositioning schedule or documentation of these interventions. Staff interviews revealed that there was no set schedule or documentation process for turning and repositioning the resident, and the facility lacked a policy for residents requiring total assistance. The DON confirmed that all residents were expected to be turned every two hours, but there was no documentation to support this for the resident in question. Observations further confirmed that the resident's heels were not offloaded as ordered, and the care plan did not include this intervention. These failures resulted in the development and progression of a pressure ulcer for a resident at high risk.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Oxygen Therapy Not Administered Per Physician Order
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of asthma was not administered oxygen therapy according to the physician's order. The facility's policy requires that oxygen be administered by licensed staff and at the flow rate specified by the physician. The resident had a physician's order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. However, during an observation in the dining area, the resident was found receiving oxygen at 3 liters per minute. The unit manager confirmed that the oxygen was set at 3 liters per minute and subsequently adjusted it to the ordered 2 liters per minute. The clinical record, facility policy, and staff interviews all indicated that the oxygen should have been administered at the prescribed rate, but this was not followed at the time of observation.
Improper Medication Labeling and Storage Identified
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of medications and biologicals on two of three units reviewed. On the second-floor medication room, two opened vials of Tuberculin Purified Protein Derivative (PPD) were found in the medication refrigerator; one vial was labeled with a date (4/2), while the other was not labeled or dated. The unit manager confirmed that multidose vials are to be discarded 30 days after opening, and acknowledged the improper labeling. Additionally, in the St. [NAME] medication room, an unopened bottle of Pedialyte was found with an expiration date of October 1, 2021, which was confirmed by the unit manager. For one resident, who had diagnoses including transient ischemic attack, seizures, kidney failure, diabetes, and xerosis cutis, a medicated lotion (Ammonium Lactate External Lotion 12%) ordered for topical application was found stored in an unlocked drawer in the resident's room, mixed with personal belongings. The bottle was not properly labeled with the resident's name, only marked with the room number. The unit manager observed and removed the medication from the resident's room after this was brought to their attention.
Unqualified Food Service Director Employed
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as required by regulation. An interview with the Food Service Director (FSD) revealed that he was responsible for oversight of ordering, receiving, storing, preparation, and service of food, but he was not a Certified Dietary Manager (CDM), Certified Food Manager (CFM), nor did he hold a national certification for food service management and safety. Additionally, the FSD had not received regularly scheduled consultations from a qualified dietitian. Review of the FSD's personnel file confirmed that he had been working at the facility for several years without meeting the statutory qualifications for the position. The Nursing Home Administrator was unable to provide evidence of the FSD's required certification, confirming the deficiency.
Failure to Serve Palatable Food and Drink at Safe Temperatures
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at appropriate temperatures for five of 35 residents reviewed. Multiple residents reported that hot foods were often served cold and that cold items, such as milk, were not sufficiently chilled. Specific complaints included consistently cold food, uncooked French fries, and unappetizing eggs. During a resident council meeting, several residents voiced dissatisfaction with the temperature and quality of the meals provided. A test tray observation revealed that food items were served outside the acceptable temperature ranges established by the facility's standards. The tray cart left the kitchen at 12:20 p.m., but the last tray was not served until 12:45 p.m., resulting in hot foods such as chicken, rice, and vegetables being below the required temperature, and cold items like fruit cups, apple juice, and milk being above the acceptable range. The Food Service Director confirmed that these temperatures were not within the palatable range, corroborating the residents' complaints.
Arbitration Agreement Lacked Required Resident Rights Language
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement, included as part of the admission agreement, contained the required language to protect the rights of residents or their representatives. Specifically, the agreement did not state that residents or their representatives retained the right to communicate with federal, state, or local officials, including surveyors, health department employees, or representatives of the Office of the State Long Term Care Ombudsman. This omission was confirmed during interviews with the Nursing Home Administrator and the Regional Operations Director, who acknowledged that the required language was not present in the arbitration agreement. The deficiency was identified through a review of facility documents and staff interviews, with no mention of specific residents or their medical conditions in the report.
Failure to Implement Hospice Medication Recommendation for Symptom Management
Penalty
Summary
The facility failed to address and implement a medication management recommendation made by the contracted hospice agency for a resident receiving hospice care. Specifically, the hospice nurse recommended Ativan 1mg to be administered orally or sublingually every two hours as needed for breakthrough agitation. Review of the resident's physician orders did not show that this medication was ordered or addressed by the facility. The resident involved had multiple complex diagnoses, including multiple sclerosis, COPD, dementia, and anxiety, and was admitted to hospice care for senile degeneration of the brain. Despite the hospice agency's documented recommendation for symptom management, there was no evidence in the clinical record that the facility acted on or implemented the suggested medication. This was confirmed by the Assistant Director of Nursing during staff interview.
Failure to Maintain Safe Temperature Levels in Resident Rooms
Penalty
Summary
The facility failed to maintain comfortable air temperature levels on the 300 nursing unit, placing residents at risk for developing hypothermia. Observations and temperature readings revealed that the air temperatures in several rooms and the hallway were significantly below the required range of 71 to 81 degrees Fahrenheit. Specifically, temperatures as low as 56 degrees Fahrenheit were recorded, affecting 19 residents, many of whom were cognitively impaired and required assistance with daily living activities. Interviews with residents and staff highlighted the ongoing issue with the heating system, which had been reported as non-functional since November 2024. Despite multiple reports and work orders submitted by nursing staff to the maintenance department, there was no documentation indicating that the issues were addressed. Residents expressed discomfort due to the cold temperatures, and staff had to resort to using multiple blankets to keep residents warm. The affected residents had various diagnoses, including dementia, Alzheimer's disease, schizophrenia, and cerebral vascular accident, which made them particularly vulnerable to the cold conditions. The facility's failure to provide necessary maintenance services to ensure safe and comfortable temperatures in resident rooms and common areas posed a significant safety risk, leading to the identification of an Immediate Jeopardy situation.
Plan Of Correction
1. HVAC system repaired 1/23/25 to assure a temperature range of 71-81 degrees Fahrenheit was maintained for resident room 310, 311, 312, 313, 314, 315, 316, and 317. 2. Audit was conducted on resident room temperatures to assure room temperatures were maintained between 71 degrees Fahrenheit - 81 degrees Fahrenheit. No other rooms were noted to be outside of the desired range. 3. Education was completed for the Maintenance Director on the requirements for maintaining resident room temperatures to range between 71 degrees Fahrenheit - 81 degrees Fahrenheit. Preventive maintenance has been scheduled to ensure all heating units function within the required temperature ranges on an ongoing basis. 4. The Administrator/designee is auditing temperatures of resident rooms 310, 311, 312, 313, 314, 315, 316, and 317 every shift, weekly x4, monthly x2; to assure the temperatures are maintained between 71-81 degrees Fahrenheit. Results of the audit to be discussed at monthly QA x3.
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 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 having signs and symptoms of hypothermia.
- Hourly temperatures of resident rooms are being taken 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 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 Operating Conditions for 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 multiple instances of malfunctioning bathroom sinks that were clogged and filled with water. The maintenance work orders from September 9, 2024, through January 22, 2024, showed numerous ongoing and reoccurring requests for repairs of clogged sinks in various rooms, including rooms 701, 734, 506, 509, 732, 733, 601, 308, 300, and several others. Residents expressed dissatisfaction with the persistent issues, noting that complaints had been made without resolution. Observations confirmed the presence of clogged sinks during interviews and tours with staff members. Additional observations revealed other maintenance issues, such as a rusted seat riser in the bathroom of room 412 and a loose faucet in room 306. These deficiencies were confirmed during a tour with the Regional Administrator. The report highlights the facility's failure to address these maintenance issues despite repeated work orders and resident complaints, leading to unsafe and unsanitary conditions in the affected rooms.
Plan Of Correction
1. Bathroom sinks in resident rooms 732, 506, 509, 700, 702, 734, 308, 700, 702, 734, 300, 706, 709, 711, 722, 705, 706, 724, the med room and bathroom were inspected and repaired, as needed, on 1/23/25. 2. Maintenance director/ Designee completed audits of sinks in resident rooms, commons areas, and in med rooms to assure sinks are proper functioning. 3. Re-education was provided to maintenance staff on the requirements for maintaining resident care equipment in a safe, operating condition. 4. The Director of maintenance will conduct a random audit (10 sinks) of resident rooms and common areas to ensure the sinks are properly draining, weekly x4 then monthly x2. Results of the audits to be reported to monthly QA x3.
Failure to Document Necessary Transfer for Resident
Penalty
Summary
The facility failed to ensure that a resident's transfer to the hospital was necessary and properly documented. Resident R 212 was admitted with multiple diagnoses, including mood disorder, dementia, and bipolar disorder. During the resident's five-day stay, there were instances of refusal of care, medication, and food, as well as episodes of agitation and 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. The nursing notes indicated that the resident refused medications and care, and a psychological consultation resulted in a new medication order. However, the documentation lacked details on specific safety concerns or attempts by the facility to address the resident's needs. The decision to transfer the resident to the hospital was made without clear evidence of endangerment to the resident or others, and the transfer form was incomplete, stating only 'reason for transfer' without further explanation. Interviews with staff, including a licensed nurse and the Director of Nursing, revealed that the resident was discharged due to aggressive behavior and refusal of care. However, the facility was unable to provide evidence that the transfer was necessary for the resident's welfare or that the health and safety of individuals at the facility were endangered. The Director of Nursing admitted that the facility was unwilling to continue providing care to the resident, highlighting a failure to comply with regulatory requirements for transfer and discharge documentation.
Plan Of Correction
1. R212 is no longer a resident at the facility. 2. An audit was completed for residents that transferred to the hospital from 12/1/24 to 2/6/2025 to ensure that the transfer to the hospital was necessary, and the basis for the transfer was documented. 3. Education was completed with the licensed nurses on the requirements for ensuring a facility-initiated, resident transfer to the hospital is necessary, and the basis for the transfer is documented. 4. The DON/Designee will audit resident transfers to the hospital weekly x 4 weeks then monthly x 2 months to assure that a facility-initiated transfer to the hospital was necessary and the basis for the transfer is documented. Findings of the audits will be reported to monthly QA x3.
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, identified as R212, within 48 hours of admission, as required by regulations. Resident R212 was admitted with multiple diagnoses, including unspecified mood disorder, dementia, kidney failure, and a history of transient ischemic attack, among others. The resident exhibited behaviors such as refusal of care, medications, and verbal aggression, which were documented in nursing notes over several days. Despite these documented behaviors, there was no evidence of a baseline care plan addressing these issues. The resident was admitted to the facility on November 22, 2024, and discharged on November 27, 2024, due to behaviors and safety concerns. During the resident's stay, they consistently refused medications, care, and meals, and exhibited aggressive behavior. A psychological consultation was conducted, and a new medication order was obtained, but the resident continued to refuse care. The lack of a baseline care plan was confirmed during an interview with a licensed nurse, who acknowledged the resident's behavior concerns and the absence of a care plan addressing these issues.
Plan Of Correction
1. R212 is no longer a resident at the facility. 2. An audit was completed for new admissions and readmissions from 12/24/24 to 1/24/25 to assure that the residents had a baseline care plan developed. 3. Education was completed with licensed nurses on the requirements for ensuring a baseline care plan is developed. 4. The DON/Designee will audit new admissions and readmissions weekly x 4 weeks then monthly x 2 months to assure that baseline care plans are developed in a timely manner. Findings of the audits will be reported to monthly QA x3.
Failure to Obtain Vision Consultation 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, who was part of a group of 35 residents reviewed. The deficiency was identified through observations, clinical record reviews, and interviews with the resident's family and staff. The resident's family member, who visits daily, reported having requested an eye examination for the resident multiple times over several months, specifically in November and December 2024, and January 2025. Despite these requests, there was no documentation indicating that the consultation had been discussed with the physician or that any action had been taken to arrange for the resident to be evaluated by an eye specialist. Resident R201 was admitted to the facility in September 2024 and was noted to be severely cognitively impaired with a diagnosis of dementia. Observations revealed that the resident was unable to follow objects with her eyes and did not have corrective eyewear, suggesting a need for corrective lenses. Interviews with the nursing staff confirmed the family's repeated requests for an eye specialist consultation, yet no vision consults were available for review. This lack of action and documentation led to the determination that the facility did not meet the requirement to assist the resident in maintaining vision abilities.
Plan Of Correction
1. R201 has an appointment scheduled with the optometrist on 2/19/25. 2. An audit was completed for residents to determine if they have had any vision concerns and/or wish to be seen by the optometrist. 3. Education was completed with licensed nurses regarding communicating with the optometrist for residents who report vision concerns. 4. The DON/Designee will audit the nursing 24-hour report, weekly x 4 weeks then monthly x 2 months to assure that any resident noted with vision concerns are communicated to the optometrist. Findings of the audits will be reported to monthly QA x3.
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 resident was admitted to the facility with these diagnoses, but the facility was unaware of the PTSD diagnosis. The resident's care plan, reviewed on December 19, 2024, included a plan for PTSD but did not address the 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.
Plan Of Correction
1. R191's care plan has been updated to ensure that culturally competent, trauma informed care is in place to eliminate and/or mitigate triggers that may cause re-traumatization. Staff that care for R191 were educated about changes to the care plan including triggers and interventions. 2. An audit was completed for residents to assure that care plans were developed related to culturally competent trauma informed care to assure elimination/mitigation of triggers for any resident with the diagnosis of PTSD. 3. Education was completed with licensed nurses and social workers on the requirements for developing care plans related to culturally competent trauma informed care to ensure elimination/mitigation of triggers for residents with a diagnosis of PTSD. 4. The Director of Social Services/Designee will conduct random audits of residents (10 residents) weekly x 4 weeks then monthly x 2 months to assure that care plans were developed related to culturally competent trauma informed care to assure elimination/mitigation of triggers for those having a diagnosis of PTSD. Findings of the audits will be reported to monthly QA x3.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. Resident R88, who was admitted to the facility in March 2021, was diagnosed with non-Alzheimer's dementia in January 2023. Despite this diagnosis, a review of the resident's care plan on January 25, 2025, revealed that there were no measurable goals or interventions in place to address the resident's dementia care needs. This lack of a specific care plan was confirmed by the Director of Nursing during an interview. The resident's Minimum Data Set (MDS) assessment, dated December 16, 2024, indicated active diagnoses of non-Alzheimer's dementia and the use of antipsychotic and antidepressant medications. However, the facility did not have a care plan tailored to the resident's dementia care requirements, which is a violation of the requirement to provide appropriate treatment and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Plan Of Correction
1. R88's care plan has been updated to include a personalized care plan to address the residents' dementia care needs. Staff that care for R88 were educated about the changes to the care plan. 2. An audit was completed for residents with a diagnosis of dementia to ensure that a personalized care plan was developed to address their dementia care needs. 3. Education was completed with licensed nurses on the requirements for developing a personalized care plan to address each resident's dementia care needs. 4. The DON/Designee will audit new residents with a diagnosis of dementia weekly x 4 then monthly x 2 months to ensure there is a personalized care plan in place to address the resident's dementia care needs. Findings of the audits will be reported to monthly QA x3.
Failure to Timely Report and Conduct Laboratory Tests
Penalty
Summary
The facility failed to obtain and report laboratory results in a timely manner for three residents, leading to deficiencies in meeting their medical needs. Resident R72, diagnosed with hyperkalemia, had critical lab values indicating elevated potassium levels on November 29, 2024. However, the physician was not informed of these critical results until December 1, 2024, resulting in the resident being transferred to the hospital for further evaluation and management. Interviews with staff confirmed the delay in notifying the physician about the critical lab values. Resident R204 was admitted with multiple diagnoses, including a urinary tract infection and sepsis. A pharmacist recommended a lab test for urine pH with Methenamine on September 20, 2024, but the physician did not order it until January 8, 2025, and there was no evidence that the test was completed in a timely manner. Additionally, Resident R169, who was prescribed valproic acid for bipolar disorder, had a physician's order for laboratory studies to measure valproic acid levels on December 16, 2024. However, there was no documentation indicating that these studies were completed as ordered, which was confirmed by a registered nurse.
Plan Of Correction
1. R72, R204, and R169 lab reports have been obtained and reported to their individual physician. Notification of the physician was documented in the medical record of each resident. 2. An audit was completed for residents who had labs ordered from 12/1/2024 to 2-6-2025 to assure lab reports have been obtained and reported to the physician. 3. Education was completed with licensed nurses on the procedure for obtaining and reporting residents laboratory results to the resident's physician and documenting as such. 4. The DON/Designee will audit laboratory orders weekly x 4 weeks then monthly x 2 months to assure that resident's laboratory results are obtained and reported to their individual physician. Findings of the audits will be reported to monthly QA x3.
Failure to Maintain Safe Air Temperatures
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 heating units in rooms 310, 311, 312, 313, 314, 315, 316, and 317 were not functioning properly, with temperatures recorded as low as 56 degrees Fahrenheit in some areas. This issue persisted despite being reported through the facility's maintenance communication system, indicating a lack of timely response and resolution. Interviews with residents and staff revealed that the heating problems had been ongoing since November 2024. Residents expressed discomfort and concern for their well-being, with some residents requiring multiple layers of clothing and blankets to stay warm. Observations confirmed that the heating units were either not operational or not providing adequate warmth, contributing to the residents' discomfort and potential health risks. The facility's failure to maintain appropriate temperature levels in resident rooms and common areas led to an Immediate Jeopardy situation. The Nursing Home Administrator did not fulfill their responsibilities to ensure the facility was maintained in a safe and comfortable manner, as evidenced by the lack of action taken to address the heating issues reported by staff.
Plan Of Correction
1. The heating units in rooms 310, 311, 312, 313, 314, 315, 316, and 317 were repaired and residents were returned to their original rooms on 1/23/25. No adverse effect to any resident was noted. Reported event to DOH on 1/22/25. 2. An audit was completed on all units, in all residents' rooms to assure room temps were maintained within desired temperature range. 3. The Nursing Home Administrator was re-educated about maintaining air temperatures ranging from 71 degrees Fahrenheit and 81 degrees Fahrenheit in all resident areas and overseeing preventive maintenance of HVAC units to assure temperatures are sustained in the required range. Weekly walking rounds are conducted with the Administrator and Maintenance director to ensure the facility is maintained in good condition to assure the comfort of the residents. 4. The Administrator/designee will audit resident room temperatures of rooms 310, 311, 312, 313, 314, 315, 316, and 317 QSHIFT, weekly x4, monthly x2; to assure the temperatures are maintained between 71-81 degrees Fahrenheit. Results of the audit to reported at monthly QA x3 months. 5. The Regional Administrator will conduct monthly audit x3 to assure effectiveness of QA program.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system, which affected the entire facility. During a document review on January 23, 2025, it was discovered that the fire alarm inspection report from July 29, 2024, indicated the system had four failed batteries. The facility was unable to provide documentation that these batteries had been replaced. Additionally, an observation on the same day revealed that a fire alarm strobe on the first floor in the Chapel Lobby was obstructed by a grandfather clock. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
1. Failed batteries from the report dated 7-29-2024 have been ordered and replaced. The clock in the chapel lobby is moved so the fire alarm strobe is not blocked. 2. NHA/Designee will educate the maintenance director in follow up regarding the requirement for failed reports and to assure furniture does not block the fire alarm strobe. 3. NHA/Designee will audit the fire alarm reports monthly x 3 to ensure all components are functioning. 4. NHA/Designee will audit fire alarm strobes weekly x 4, monthly x 2 to ensure they are not blocked. 5. Results of audits to be reported at monthly QA.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers as required by NFPA 101 and NFPA 10 standards. During a document review, it was found that the facility could not provide certification for the technician responsible for the annual maintenance and inspection of the fire extinguishers. Additionally, observations revealed that several fire extinguishers were obstructed by storage items in various locations, including the first floor dining room, across from the 500 wing Nurses' Station, and in the basement housekeeping storage area. Furthermore, the indicator lights for recessed mounted fire extinguishers were not functioning in multiple areas throughout the facility. The facility also neglected to conduct monthly inspections of portable fire extinguishers in several locations, with some not inspected since October or November 2024, and one in the Elevator Machine Room not inspected since July 2024. Additionally, a fire extinguisher in the Basement Elevator Machine Room was found not mounted to the wall. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
1. The certificate of the technician conducting the annual inspection has been obtained from the vendor. Blocked fire extinguisher in the main dining room, across from the 500-unit nurses' station and housekeeping storage in the basement has been exposed and the area cleared. Indicator lights for recessed portable fire extinguishers are maintained lit. Fire extinguisher monthly checks have been scheduled for maintenance. The basement elevator machine room fire extinguisher is mounted on the wall. 2. NHA/Designee to in-service maintenance staff on the requirement of maintenance and inspection of fire extinguishers monthly, ensuring they remain free from obstruction, and the indicator display is properly functioning. 3. The Maintenance director/Designee has completed an inspection of fire extinguishers in the building to ensure they are stored, functioning, and the display indicator is properly visible. 4. The maintenance director/designee will conduct a random audit (10 total) of the fire extinguishers monthly x 3 to ensure they are properly maintained, inspected, and the indicator display is properly functioning. 5. Results of audits will be reported to QA.
Failure to Document Weekly Generator Battery Testing
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which is crucial for the safety and operation of the entire facility. During a document review on January 23, 2025, it was discovered that the facility could not provide documentation of weekly battery voltage testing for the emergency generator. This lack of documentation indicates a failure to adhere to the required maintenance and testing protocols as outlined by NFPA standards. An interview with the Administrator and Maintenance Director on the same day confirmed the absence of the necessary documentation. This deficiency affects the entire facility, as the emergency generator is a critical component of the essential electrical system, designed to provide power in the event of an outage. The failure to maintain proper records of testing and maintenance could compromise the facility's ability to ensure a reliable power supply during emergencies.
Plan Of Correction
1. The voltage battery of the generator was inspected and noted to be in proper function. The weekly inspection report has been revised to include the voltage battery check of the generator. 2. Education was completed for the maintenance director to ensure they inspect generator battery voltage weekly. 3. NHA/designee will audit the weekly check report weekly x 4 and then monthly x 3 to ensure compliance with the generator battery check. Report on Audit will be reported in QA.
Obstructed Egress Paths and Blocked Exits
Penalty
Summary
The facility failed to maintain egress paths free of obstructions, affecting two of three levels. On January 23, 2025, observations revealed that both exits from the Multi-purpose Room on the first floor were blocked by furniture. Additionally, egress paths were not shoveled in several locations, including the Adult Daycare and the exit door inside the entrance to the 400 wing. Furthermore, the exit door next to resident room 701 on the first floor required excessive force to open. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
1. The multi-purpose room furniture was immediately removed from area. The egress paths from the adult day care center and exit door, inside the entrance to the 400 wing were immediately shoveled. The exit door next to resident room 701 was repaired to ensure proper function. 2. NHA/Designee will complete a house-wide education on keeping egress doors free of obstruction. NHA/Designee will educate maintenance staff on keeping egress paths clear of snow. 3. NHA/Designee will audit exit doors and egress paths throughout the facility to ensure they are free of obstruction. 4. NHA/Designee will conduct a random audit of egress paths and exit doors weekly x4, monthly x2 to ensure they remain free of obstruction. Results of the audit will be reported at monthly QA.
Failure to Maintain Delayed Egress Doors
Penalty
Summary
The facility failed to maintain the delayed egress doors on one of its three levels, specifically on the first floor. During an observation on January 23, 2025, at 10:52 a.m., it was noted that the delayed egress door by the Laundry did not alarm and open as required. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director later that morning. Additionally, another observation on the same day at 11:29 a.m. revealed that the delayed egress door near resident room 701 lacked the necessary signage. The sign should have instructed individuals to 'PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.' This absence of signage was also confirmed during the exit interview with the facility's administration and maintenance staff.
Plan Of Correction
1. The delayed egress door by laundry has been repaired to alarm and properly function. The proper signage was placed on the delayed egress door next to resident room 701. 2. NHA/Designee will educate the Maintenance Director on the requirements for maintaining delayed egress doors and ensuring they have the proper signage that reads "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." 3. NHA/ Designee will audit the delayed egress doors in the facility to ensure proper function and signage. 4. NHA/Designee will conduct a random audit of delayed egress doors to ensure they are properly functioning and have the proper signage posted, weekly x4 monthly x3. 5. Results of the audit to be reported to monthly QA.
Failure to Maintain and Inspect Exit Signage
Penalty
Summary
The facility failed to maintain and inspect exit signage as required by NFPA 101 standards. During a document review on January 23, 2025, it was discovered that the facility lacked documentation of monthly exit sign inspections prior to April 2024. This deficiency affected nine out of twelve inspections. An exit interview with the Administrator and Maintenance Director confirmed the absence of the necessary documentation, indicating a failure to comply with the continuous illumination and emergency lighting system requirements for exit and directional signs.
Plan Of Correction
1. An inspection of all exit signage was completed on 1/27/2025 to ensure proper functioning. 2. NHA/Designee will in-service maintenance department on requirements for completing monthly exit sign inspection. 3. The Director of maintenance/designee will continue to complete monthly inspections of the exit signage to ensure proper functioning. 4. NHA or designee will do audits of the monthly inspection x 3 months. 5. Results of the inspection to be reported at QA.
Failure to Inspect Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system, which is a requirement under NFPA 101 for cooking facilities. During an observation on January 23, 2025, at 10:47 a.m., it was noted that the hood suppression system on the first floor of the kitchen lacked the necessary monthly inspections. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 11:45 a.m.
Plan Of Correction
1. Kitchen hood suppression inspection was completed on 1/29/2025. Monthly inspections have been scheduled for Maintenance. 2. NHA/Designee will in-service maintenance department on requirements for completing monthly Inspection of kitchen Hood suppression system. 3. Maintenance Director/designee will continue to complete monthly inspections of the kitchen hood suppression system to ensure proper functioning. 4. NHA/Designee will audit the monthly reports x 3. 5. Audit reports will be reported at QA.
Improper Installation of Fire Alarm Initiating Devices
Penalty
Summary
The facility failed to properly install fire alarm initiating devices, specifically affecting one of the three levels in the building. During an observation on January 23, 2025, at 10:45 a.m., it was noted that the manual pull station for the double exit doors in the Kitchen on the first floor was not mounted within 5 feet of the exit doors as required. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 11:45 a.m. on the same day.
Plan Of Correction
1. The manual pull station in the kitchen is scheduled to be moved to be within 5 ft of exit door. 2. NHA/Designee will educate the maintenance director on the requirements of having pull stations within 5 feet of exit doors. 3. NHA/Designee will conduct an audit of exit doors to ensure there is a pull station within 5 feet. 4. Audit report will be submitted to QA.
Failure to Maintain Smoke Barrier Integrity
Penalty
Summary
The facility failed to maintain the fire resistance of smoke barriers, which is a requirement for ensuring safety in the event of a fire. During observations conducted on January 23, 2025, it was noted that the smoke barrier doors on the first floor did not close properly in several locations. Specifically, the doors failed to close together next to the 400 wing at 10:59 a.m., by the entrance to the 500 & 600 wing at 11:12 a.m., and by resident room 605 at 11:21 a.m. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 11:45 a.m. on the same day.
Plan Of Correction
1. The smoke barriers doors have been adjusted to ensure they positively latch in the following areas: next to 400 wing, entrance of 500 & 600, and by resident room 605. 2. The Director of maintenance was educated on the requirement for smoke barrier doors to positively latch. 3. Maintenance Director/Designee completed an audit of smoke barrier doors in the facility to ensure they positively latch. 4. Maintenance Director/Designee will conduct a random audit of smoke barrier doors to ensure they positively latch. The audit will be completed weekly x4, then monthly x2. Report of audit will be reported at monthly QA.
Failure to Maintain Fire Resistance in Gas Cylinder Storage
Penalty
Summary
The facility failed to maintain the fire resistance of its gas cylinder storage, specifically affecting one of the three levels in the facility. During an observation on January 23, 2025, it was noted that the door to the Oxygen Storage Room, located on the first floor next to resident room 729, did not close and positively latch as required. This deficiency was identified based on both observation and interview. The issue was confirmed during an exit interview with the Administrator and Maintenance Director on the same day. The failure of the door to close and latch properly compromises the safety standards set for gas cylinder storage, which are crucial for preventing potential hazards associated with oxidizing gases.
Plan Of Correction
1. The door to the oxygen storage room next to resident room 729 has been repaired to ensure it positively latches. 2. NHA/Designee will educate the maintenance director on the requirement for the oxygen storage room to positively latch and close. 3. The maintenance director/designee will audit the doors to the oxygen storage rooms in the facility to ensure they close. 4. The NHA/Designee will audit oxygen storage rooms weekly x4, then monthly x2 to ensure they positively latch and close. Report of audit will be reported in monthly QA meeting.
Deficiency in Providing Accurate Floor Plans
Penalty
Summary
The facility was found deficient in providing accurate, portable floor plans as required by the Life Safety Code. During a document review on January 23, 2025, it was discovered that the facility did not have a set of accurate, portable floor plans available on site. This deficiency affects the entire facility and is a requirement by the Division of Safety Inspection for use during the Life Safety Code Survey. The necessary floor plans should include details such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. An exit interview with the Administrator and Maintenance Director confirmed the absence of these accurate floor plans.
Plan Of Correction
1. The floor plans were accurately revised to include the following, but not limited to smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. 2. NHA/designee will educate maintenance on the requirements for having portable, accurate floor plans on site. NHA/designee will also conduct a house-wide education to ensure staff is aware of up-to-date floor plans. 3. NHA/designee will audit accuracy of floor plans monthly x3. Results of the audit to be reported monthly QA.
Facility Exceeds Maximum Smoke Compartment Size
Penalty
Summary
The facility failed to maintain smoke compartments within the required square footage, affecting three out of nine smoke compartments. During a document review and interview conducted on January 23, 2025, it was found that smoke compartments one, two, and five exceeded the maximum allowable area of 22,500 square feet. Specifically, smoke compartment one included Katharine, Drexel, and St. Anthony Avenue (300 & 400 Wings), smoke compartment two included St. Elizabeth's Garden and All Saints Boulevard (500 & 600 Wings), and smoke compartment five contained the Chapel and Administration offices, which are non-patient care areas. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Emergency Preparedness Plan Lacks Key Components
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included comprehensive policies and procedures addressing the resident population, particularly persons at-risk, the types of services the facility could provide during an emergency, and the continuity of operations, including delegations of authority and succession plans. This deficiency was identified during a document review conducted on January 23, 2025, at 8:30 a.m., which revealed that the plan did not adequately cover these critical areas. During an exit interview with the Administrator and Maintenance Director on the same day at 11:45 a.m., it was confirmed that there was a lack of documentation supporting the inclusion of these necessary components in the Emergency Preparedness Plan. This oversight affects the entire facility, as it leaves the facility unprepared to effectively manage emergencies, particularly concerning the care and safety of at-risk residents.
Plan Of Correction
1. Policy on person at risk was reviewed and education done with staff. 2. Policy available in Emergency Preparedness binder.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility was found to be deficient in its emergency preparedness communication plan. During a document review on January 23, 2025, it was discovered that the plan did not include a method for providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or a designee. This omission affects the entire facility, as it lacks a crucial component of emergency preparedness. An exit interview with the Administrator and Maintenance Director on the same day confirmed the absence of this documentation. The deficiency highlights a gap in the facility's ability to communicate effectively during emergencies, which is a requirement under federal regulations. The lack of a comprehensive communication plan could potentially hinder the facility's response in emergency situations.
Plan Of Correction
1. At risk resident list with mobility status was available as of 1-22-2025 and failed to give to inspector at inspection. 2. NHA will ensure the list is maintained in the emergency prepared book.
Failure to Revise Behavioral Health Care Plan
Penalty
Summary
St. John Neumann Center for Rehab & Healthcare was found to be non-compliant with the requirements for comprehensive care plans as outlined in 42 CFR Part 483. The facility failed to review and revise the behavioral health care plan for a resident who was cognitively impaired and had multiple diagnoses, including dementia, anxiety disorder, depression, and manic depression. The resident was receiving antipsychotic medication routinely but had a history of refusing medications and care, which was not adequately addressed in the care plan. Despite multiple incidents of agitation, confusion, and physical altercations with a roommate, the care plan was not updated to reflect these behaviors or the resident's refusal of medications. The resident's clinical records revealed several instances where the resident expressed dissatisfaction with the facility, refused medications, and exhibited aggressive behavior. Notably, the resident was involved in physical altercations and expressed a desire to die, yet the care plan lacked documentation of any revisions to address these significant behavioral issues. The facility's failure to update the care plan in response to these events was a key factor in the deficiency identified during the survey.
Plan Of Correction
1. Facility conducted a thorough review of the resident, and updated CP to reflect refusals of care and/or medicine. 2. Using the PCC dashboard alerts, the Director of Nursing, and/or designee, will review the resident behaviors and/or refusal of care in the past 30 days and update the behavior care plans of residents that refuse care and/or medicine. 3. Education provided for facility IDT on requirement to update care plan with behaviors. 4. Using the PCC dashboard alerts, audits will be conducted weekly for 4 weeks then monthly for 2 months for any residents who have refusal behaviors and assure interventions are initiated/updated in Care Plans. 5. Results of these audits will be reported and reviewed with the Quality Assurance Performance Improvement Committee to ensure ongoing compliance.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse in the area where food and laundry are received. During an inspection, the dumpster was observed to be leaking a creamy colored, foul-smelling liquid through its sides, which spread over the floor around the dumpster. The floor in this area was irregularly covered with dark, greasy substances. This observation was confirmed by the Director of Environmental Services present at the time.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident R24, who has a seizure disorder and dementia, did not receive their prescribed Vimpat medication on three consecutive days due to a lack of a new prescription. The medication administration record (MAR) indicated the absence of the medication, and nursing notes confirmed the need for a new script. However, there were no nursing notes on the subsequent days to address the missed doses. The resident was monitored for seizure activity due to the missed doses, and the physician and family were notified. Resident R101, diagnosed with atrial fibrillation and dementia, did not receive their prescribed nitroglycerine transdermal patch on a specific day because the patch was unavailable. The MAR confirmed the absence of the medication, and a nursing note indicated the unavailability of the patch. An interview with the Director of Nursing confirmed that the medications were not available for administration to the residents.
Failure to Implement Pressure Ulcer Prevention Plan
Penalty
Summary
The facility failed to address the potential for developing a pressure ulcer and did not develop or implement a care plan to prevent pressure ulcers for a resident identified as at risk. The resident, who was cognitively intact, had diagnoses of muscle weakness and malnutrition, and required partial/moderate assistance with mobility, was admitted to the facility. The resident's Minimum Data Set (MDS) and Braden Scale assessments indicated a risk for skin breakdown, yet there was no documented evidence of a comprehensive person-centered care plan to address this risk. A skin/wound note revealed that a licensed nurse identified a new intact blister on the resident's right heel, which was later assessed by a wound care physician as a Stage 2 pressure ulcer. Despite these findings, the Director of Nursing confirmed that no comprehensive care plan had been developed for the resident's identified risk of skin breakdown, indicating a deficiency in the facility's care planning and implementation processes.
Medication Mismanagement and Safety Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for Resident R153, as evidenced by the presence of medication at the resident's bedside. The facility's Medication Administration Policy requires that licensed nursing professionals administer medications according to a prescribed schedule, with any deviations requiring physician notification and documentation. Additionally, the Self-Medication Administration Policy mandates that only residents assessed and deemed capable of managing their own medications can do so, with proper documentation maintained. However, there was no physician order or indication that Resident R153 was authorized to self-administer medication. Resident R153, who was admitted with a diagnosis of dementia and had a BIMS score of 6 indicating severe cognitive impairment, was observed with a medication cup containing four pills on their bedside table. This observation was made in a shared room with another resident. The Assistant Director of Nursing, Employee E11, confirmed that the medication should not have been left at the bedside, as it is against facility policy. Employee E11 was unable to identify the pills or determine which staff member left them there, highlighting a lapse in adherence to medication administration protocols.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. Resident R141, who was admitted with a diagnosis of dependence on renal dialysis, had a physician order dated September 19, 2024, which required checking the Permacath at the right chest wall and ensuring that caps were secure, clamps were closed, and an emergency clamp was at the bedside. However, during an observation and interview on September 27, 2024, it was found that there was no emergency equipment or emergency clamp at the resident's bedside. This deficiency was confirmed by the Unit Manager, a licensed nurse, on the same day.
Failure to Administer Medication Due to Lack of Procedure
Penalty
Summary
The facility failed to develop and implement procedures to ensure the accurate acquiring, receiving, dispensing, and administering of medications for a resident diagnosed with anxiety. The resident, who was cognitively impaired, had a physician's order to receive diazepam twice daily for anxiety. However, the medication administration record for September 2024 indicated that the evening doses on two consecutive days were not administered, with one dose marked as 'Hold/See Nurses Note' and the other as 'medication not available.' There was no corresponding nurse's note explaining the reason for holding the medication on the first day, and no documentation was found to indicate that the physician was informed of the missed doses or that alternative treatments were requested. Additionally, there was no evidence that the licensed nurse investigated the reason for the medication's unavailability or attempted to obtain it. An interview with a regional support employee revealed that the facility lacked a written procedure for handling pharmacy services or medication unavailability.
Delayed Physician Response to Drug Regimen Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician timely reviewed and documented actions taken to address identified irregularities in the drug regimen reviews for two residents. For Resident 117, the consultant pharmacist identified that the use of olanzapine for Major Depressive Disorder (MDD) triggered inappropriate antipsychotic use per CMS guidelines. The physician did not acknowledge the pharmacist's report until several months later and ordered a psychiatric consult, which was not conducted until months after the initial recommendation. Additionally, the physician did not provide a clinical rationale for disagreeing with a recommendation for a gradual dose reduction (GDR) of temazepam. Similarly, for Resident 144, the consultant pharmacist recommended a GDR for clonazepam and Klonopin. The physician delayed acknowledging the pharmacist's reports and did not document any clinical rationale for disagreeing with the recommendations. An interview with a licensed nurse revealed that there was a backlog of pharmacy reviews that had not been addressed by the physician, indicating a systemic issue in the timely review and documentation of drug regimen irregularities.
Failure to Document Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper documentation for the use of a psychotropic medication, olanzapine, for a resident identified as R117. The resident, who was cognitively impaired and diagnosed with anxiety and depression, was receiving olanzapine, an antipsychotic medication. During a monthly medication regimen review, the consultant pharmacist recommended further review of the diagnosis for olanzapine, as it could trigger a quality indicator for inappropriate antipsychotic use. However, the physician did not acknowledge these recommendations until nearly three months later and disagreed with them, opting instead to order a psychiatric consultation. Despite the physician's order for a psychiatric consultation, the clinical record for Resident R117 lacked documentation of a specific diagnosed condition justifying the use of olanzapine. This oversight indicates a failure in the facility's process to ensure that psychotropic medications are prescribed based on a documented need for a specific diagnosed condition, as required by regulations. The absence of such documentation suggests non-compliance with the standards for medication management and nursing services.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by errors observed during medication administration for two residents. On September 26, 2024, a Licensed Nurse, Employee E13, administered an incorrect dosage of Vitamin D3 to Resident R29, providing 10 MCG 400 IU instead of the prescribed 25 MCG (1000 UT). This discrepancy was confirmed by the nurse at the time of observation. Additionally, Employee E14, another Licensed Nurse, was observed preparing to crush an extended-release Metoprolol Succinate ER tablet for Resident R151, which could have resulted in an improper dosage delivery. The nurse was stopped before the tablet was crushed, and the error was acknowledged during the interview. These incidents contributed to the facility's medication error rate of 7.41%.
Failure to Obtain Laboratory Services for Resident
Penalty
Summary
The facility failed to obtain necessary laboratory services for a resident, identified as Resident R10, who was diagnosed with schizophrenia and had a potential for episodes of anxiety related to their condition. The resident's care plan included psychological consultation and treatment as needed. On April 2, 2024, a physician ordered Divalproex 500 mg every 12 hours to treat schizoaffective disorder, bipolar type, and recommended checking valproic acid levels in two weeks. However, a review of the resident's clinical record revealed no documented evidence that the valproic acid levels were drawn as recommended by the psychiatrist. This was confirmed during an interview with the Unit Manager, Employee E9, who acknowledged that the valproic acid levels were not drawn per the psychiatrist's recommendations.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident, identified as R97, who was experiencing dental pain. According to the facility's policy on dental services, residents requiring dental care should be referred to a dental provider within three days of identification, and their care plan should be updated accordingly. However, despite a nursing note dated February 18, 2024, indicating that the family requested dental services for R97 due to tooth pain, and a care conference note on February 22, 2024, reiterating this request, the resident was not seen by a dentist until June 13, 2024. This delay in providing dental care was confirmed by the mobile dentist office contracted by the facility, which reported that the resident had only been seen on that date. The deficiency was further highlighted by the lack of documentation regarding the resident's dental history, which the facility failed to provide upon request. Interviews with the resident's family and the mobile dentist office corroborated the delay in dental services. The facility's inaction in addressing the resident's dental pain in a timely manner, as per their own policy, resulted in a failure to meet the required standards for dental services, as outlined in the relevant state codes.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program during medication administration for four of the six residents observed. Specifically, the facility's staff did not adhere to established infection control procedures, such as hand hygiene and proper cleaning techniques for medical equipment. During medication administration, a Licensed Nurse, identified as Employee E15, used a sphygmomanometer and a pulse oximeter on multiple residents without disinfecting the equipment between uses. This occurred with Resident 155 and Resident 46, and the nurse confirmed the oversight at the time of the findings. Additionally, another Licensed Nurse, identified as Employee E14, failed to perform hand hygiene during medication administration for Residents 8 and 24. After touching various surfaces, including a drawer, medication cart, computer, and medication-blister-pack, E14 handled medication tablets with bare hands without disinfecting her hands. This breach of protocol was confirmed by E14 during the observations. These actions were in violation of the facility's policy on hand hygiene and enhanced barrier precautions, which require decontamination of reusable equipment and proper hand hygiene during medication administration.
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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