Statesman Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Levittown, Pennsylvania.
- Location
- 2629 Trenton Road, Levittown, Pennsylvania 19056
- CMS Provider Number
- 395259
- Inspections on file
- 26
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Statesman Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility discontinued blood sugar monitoring for several insulin-dependent residents without documenting the clinical reasoning in their progress notes. Interviews with nursing leadership and the Medical Director confirmed there was no facility policy guiding this practice, and the required documentation was not completed when blood sugar checks were stopped for residents with diabetes receiving insulin.
The facility failed to maintain its fire alarm system, with deficiencies identified in the September 2024 inspection report remaining uncorrected. Issues included out-of-sync A-wing strobes, failed batteries in the Main FACP, and overdue sensitivity testing. These were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain its automatic sprinkler system components, impacting the entire facility. A document review revealed that the October sprinkler inspection report listed an uncorrected deficiency: the absence of a required FDC hydrotest. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not perform the required annual fire door inspection as per NFPA standards. A document review revealed the absence of documentation confirming the inspection, which was acknowledged by the Administrator and Maintenance Director during an exit interview.
The facility failed to maintain required testing of emergency generator components, lacking documentation for monthly battery conductance testing and the 3-year 4-hour load test. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain emergency exit doors, as observed on multiple occasions. The C wing hallway emergency exit door next to the boiler room and the B wing hallway emergency exit next to the storage room did not release after 15 seconds as required. Additionally, the therapy front entrance emergency exit door next to the clinical reimbursement office also failed to release in the specified time. These issues were confirmed during an exit interview with the facility's administration and maintenance personnel.
The facility did not maintain hazardous areas according to NFPA 101 standards, as observed when the B wing storage room door failed to latch smoke tight. This affected one of four smoke compartments and was confirmed during an exit interview with the Administrator and Maintenance Director.
A facility failed to provide a necessary emergency tool kit for a resident with End Stage Renal Disease receiving hemodialysis. Despite a physician's order requiring the kit to be available at all times, an observation revealed its absence, confirmed by both the resident and a nurse.
A significant medication error occurred when a nurse administered Furosemide 40 mg, one tablet instead of the prescribed two tablets, to a resident with Obstructive and Reflux Uropathy. This error was confirmed through observation, interview, and clinical record review, resulting in a medication error rate of 3.85%.
The facility failed to involve two residents in the development and implementation of their person-centered care plans. Despite being alert and oriented, both residents and their responsible parties were not notified or involved in care plan meetings. The social worker confirmed the absence of documentation for such meetings, indicating a lapse in ensuring residents' rights to participate in their care planning.
A resident with lower extremity impairments and requiring maximal assistance for bathing was not provided with suitable adaptive equipment, leading to discomfort and lack of proper care. The resident's wheelchair was too tight, and the mechanical lift sling caused skin irritation. Additionally, the resident was not accommodated with a shower for several months due to the facility's inadequate equipment and lack of a care plan addressing these needs.
A facility failed to update a resident's care plan after the discontinuation of an anticoagulant medication. The resident, with multiple health issues including deep vein thrombosis, had their Eliquis held due to low hemoglobin levels, as noted in a hospital discharge summary. Despite this, the care plan was not revised to reflect the medication change or to include necessary interventions, as confirmed by the DON.
A facility failed to implement an effective discharge plan for a resident with complex medical needs, including end-stage renal disease requiring dialysis. Despite the resident's mother's efforts to facilitate a transfer closer to family, there was no documented discharge plan or follow-up communication from the facility, as confirmed by the social worker.
A resident with multiple health conditions did not consume any meals and had limited fluid intake on a particular day. The facility failed to notify the physician of this significant change in condition, as required by their policy. The registered nurse supervisor was not informed by the previous unit or the assigned nurse aide about the resident's lack of meal consumption, leading to the deficiency.
The facility did not notify the State LTC Ombudsman of emergency transfers and discharges as required. The DON confirmed the absence of documentation for the past six months, despite attempts to send notifications via email and fax.
Failure to Document Rationale for Discontinuing Blood Sugar Monitoring in Insulin-Dependent Residents
Penalty
Summary
The facility failed to provide a documented rationale for discontinuing blood sugar monitoring for six residents who were insulin dependent. Clinical record reviews and staff interviews revealed that blood sugar check orders were discontinued for these residents while they continued to receive insulin, without any documentation in the residents' progress notes explaining the clinical reasoning for this decision. Both the Assistant Director of Nursing and the Director of Nursing confirmed that there was no facility policy regarding the discontinuation of blood sugar checks for residents with diabetes who are on insulin, and that practitioners are required to document the clinical reasoning when discontinuing such orders, which was not done in these cases. Further, the Medical Director was not aware that blood sugar check orders were being discontinued for residents with standing insulin orders and stated that regular blood sugar checks are necessary regardless of trends. The Facility Administrator also confirmed that a progress note should have been placed when modifying or discontinuing blood sugar checks after reviewing and confirming the orders with the physician. The lack of documentation and absence of a facility policy led to the deficiency, as there was no evidence in the clinical records to support the discontinuation of blood sugar monitoring for these insulin-dependent residents.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system, as evidenced by the document review and interview conducted during the survey. The annual fire alarm inspection report from September 2024 identified several deficiencies that remained uncorrected by the time of the survey in December 2024. Specifically, the A-wing strobes were out of synchronization, requiring immediate investigation and correction. Additionally, the two 12V9AH batteries in the Main Fire Alarm Control Panel (FACP) failed and needed replacement as soon as possible. Furthermore, the system was overdue for sensitivity testing, which also required prompt attention. These deficiencies were confirmed during the exit interview with the Administrator and Maintenance Director.
Plan Of Correction
A wing strobes adjusted to be in synchronization, batteries in the main FACP replaced, and sensitivity testing completed. Maintenance Staff and vendor educated to timely repairs following inspections. Maintenance Director will schedule all repairs with vendor immediately following inspections so repairs will be made timely.
Failure to Maintain Sprinkler System Components
Penalty
Summary
The facility failed to maintain automatic sprinkler system components, affecting the entire facility. During a document review on December 3, 2024, it was discovered that the October 2024 sprinkler inspection report listed a deficiency that had not been corrected by the time of the survey. Specifically, there was no record of a Fire Department Connection (FDC) hydrotest, which was required to be conducted on July 19, 2024, and September 16, 2024. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
0353 FDC hydrotest completed. Maintenance Staff and vendor educated to timely repairs following inspections. NHA will audit that Maintenance Director schedules all repairs with vendor immediately following inspections so repairs will be made timely.
Failure to Conduct Annual Fire Door Inspection
Penalty
Summary
The facility failed to conduct the required annual fire door inspection as mandated by NFPA 101 and NFPA 80 standards. During a document review on December 3, 2024, it was discovered that there was no documentation available to confirm that an annual fire door inspection had been performed. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the necessary documentation.
Plan Of Correction
0761 Annual Fire Door Inspection completed and doors adjusted/repaired as needed. Maintenance staff educated that Annual Fire Door Inspection must be completed annually. NHA will audit that Maintenance staff will routinely inspect 3 Fire Doors weekly x 90 days to assure they are closing and latching properly.
Failure to Maintain Emergency Generator Testing
Penalty
Summary
The facility failed to maintain the required testing of emergency generator components, specifically affecting one generator. During a document review on December 3, 2024, it was discovered that the facility did not have verifying documentation for monthly battery conductance testing and the 3-year 4-hour load test. These tests are essential to ensure the generator's capability to supply service within 10 seconds, as required by NFPA standards. The deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the necessary documentation. This lack of documentation indicates that the facility did not adhere to the maintenance and testing protocols outlined in NFPA 101, NFPA 110, and NFPA 111, which are critical for the proper functioning of the emergency power systems in the facility.
Plan Of Correction
Monthly battery conductance testing completed. 3 year 4 hour generator load test completed. Maintenance staff educated that a 3 year 4 hour load test must be completed on the generator. Maintenance will schedule the next 3yr 4 hour load test with vendor immediately following the completion of load test.
Failure to Maintain Emergency Exit Doors
Penalty
Summary
The facility failed to maintain emergency exit doors as required by NFPA 101 standards, affecting multiple emergency exit doors. During observations on December 3, 2024, it was noted that the C wing hallway emergency exit door next to the boiler room and the B wing hallway emergency exit next to the storage room did not release after 15 seconds as indicated on the posted signs. This failure was confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, another deficiency was observed on the same day at the therapy front entrance emergency exit door next to the clinical reimbursement office, which also failed to release after 15 seconds as indicated on the sign. This issue was similarly confirmed during the exit interview with the facility's administration and maintenance personnel. These deficiencies indicate a failure to comply with the required egress door standards, potentially impacting the safety and rapid evacuation of occupants in an emergency.
Plan Of Correction
C and B wing hallway doors adjusted to release after 15 seconds. Maintenance Staff educated that emergency exit doors must release after 15 seconds. Maintenance staff will test 3 emergency exit doors weekly to assure they release after 15 seconds x 90 days. Any doors that do not release will be adjusted/repaired.
Failure to Maintain Smoke-Tight Hazardous Area
Penalty
Summary
The facility failed to maintain hazardous areas as required by NFPA 101 standards. During an observation on December 3, 2024, at 10:46 a.m., it was noted that the door to the B wing storage room did not latch smoke tight, which is a requirement for hazardous areas. This deficiency affected one of the four smoke compartments in the facility. The issue was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:00 p.m.
Plan Of Correction
B wing storage door adjusted to latch smoke tight. Maintenance staff educated that storage room doors must latch smoke tight. Maintenance staff will audit 3 storage room doors to assure each door latches smoke tight and adjust/repair as necessary.
Failure to Provide Emergency Tool Kit for Dialysis Resident
Penalty
Summary
The facility failed to ensure the availability of a necessary emergency tool kit for a resident receiving hemodialysis. The clinical record review revealed that the resident was admitted with a diagnosis of End Stage Renal Disease and had a physician's order to receive dialysis three times a week. The order also specified that an emergency tool kit, including a clamp, gauze, and tape, should be available with the resident at all times during every shift. However, during an observation and interview, it was found that there was no emergency tool kit located in the resident's room or with the resident, and no emergency clamp was present at the bedside. This absence was confirmed by both the resident and a licensed nurse.
Significant Medication Error in Administration
Penalty
Summary
The facility failed to administer medications correctly in accordance with physician orders, resulting in a significant medication error for one of the seven residents observed. On November 6, 2024, at 10:28 a.m., a Registered Nurse, identified as Employee E12, administered Furosemide 40 mg, one tablet by mouth to Resident R21. However, the physician's order for Resident R21 required the administration of two tablets of Furosemide 40 mg by mouth. This medication is prescribed for Obstructive and Reflux Uropathy, a condition where urine cannot drain through the urinary tract, potentially leading to acute kidney injury or chronic kidney disease. The error was confirmed through observation, interview with Employee E12, and clinical record review. The facility's medication error rate was calculated at 3.85%.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident R61 and Resident R71, had the right to participate in the development and implementation of their person-centered plan of care. Resident R61, who was admitted with multiple diagnoses including muscle weakness, seizures, and end-stage renal disease, was reported by his mother to have not been involved in any care plan meetings since his admission. Despite her efforts to communicate with the facility's social worker and Director of Nursing about transferring her son closer to home, she received no response or notification of any care plan meetings. The clinical records lacked documentation of any such meetings or notifications. Similarly, Resident R71, who was alert and oriented and had diagnoses including diabetes and respiratory failure, reported not having had a care plan meeting in a while. A review of her clinical records from February to November 2024 showed no evidence of care plan meetings or notifications. The social worker confirmed that there was no documentation to show that either resident was invited to participate in care plan meetings, thus failing to uphold their right to be involved in their care planning process.
Failure to Accommodate Resident's Mobility and Bathing Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of Resident R10, who was cognitively intact but had impairments in both lower extremities, requiring maximal assistance for showering and bathing, and used a wheelchair for ambulation. The resident experienced discomfort and skin irritation due to the use of a mechanical lift sling that was too small, and the wheelchair provided was too tight, causing improper positioning. Despite the resident's complaints, the facility did not provide a suitable wheelchair or address the issue of the mechanical lift sling. Additionally, Resident R10 had not been accommodated with a shower for several months because the facility's shower room doorways could not accommodate the bariatric shower chair required for the resident. The nursing and physical therapy staff informed the resident that he would not fit through the doorway into the central shower room, and the facility did not have a bariatric-designed shower chair available on the C wing nursing unit. This lack of accommodation was confirmed by interviews with nursing staff and observations of the facility's equipment. The clinical records revealed that there was no care plan developed to address the accommodation of medical and physical needs for adaptive equipment to enhance mobility and bathing for Resident R10. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the absence of a care plan for the adaptive equipment and a restorative exercise program for the resident. The facility's failure to develop and implement a care plan contributed to the deficiency in providing reasonable accommodations for Resident R10's needs.
Failure to Update Care Plan for Anticoagulant Discontinuation
Penalty
Summary
The facility failed to develop a person-centered plan of care for a resident with a history of deep vein thrombosis and who was on anticoagulant medication. The resident, identified as R61, had multiple diagnoses including muscle weakness, seizures, pancreatitis, anemia, paraplegia, heart failure, deep vein thrombosis, and end-stage renal disease. The resident was prescribed Eliquis, an anticoagulant, which was later held due to low hemoglobin levels as noted in a hospital discharge summary. The hospital recommended follow-up with the resident's primary care physician regarding the management of Eliquis. Despite these changes, the resident's care plan was not updated to reflect the discontinuation of the anticoagulant treatment or to include any new services, treatments, or interventions related to the change in the resident's medication orders. This oversight was confirmed during a discussion with the Director of Nursing, who acknowledged the absence of a person-centered plan of care addressing the discontinuation of the anticoagulant. The deficiency was cited under specific Pennsylvania Code regulations related to nursing services.
Failure in Discharge Planning for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for Resident R61, as required by their Discharge Planning Policy. The policy mandates the identification of discharge needs, the development of a discharge plan focusing on the resident's goals, and the involvement of the interdisciplinary team. However, there was no evidence of such a plan in Resident R61's clinical record or person-centered plan of care. The resident, who had multiple complex medical conditions including muscle weakness, seizures, pancreatitis, anemia, paraplegia, heart failure, deep vein thrombosis, and end-stage renal disease requiring hemodialysis, was admitted to the facility with the expectation of being transferred closer to his family. Despite the resident's mother's efforts to facilitate the transfer by providing a list of potential facilities and dialysis centers, and her repeated attempts to contact the social worker and the DON for updates, there was no documented follow-up or communication from the facility. The social worker confirmed that the discharge plan was to transfer the resident closer to his family and connect him to a dialysis center, but admitted there was no documentation of any discharge planning activities in the resident's records.
Failure to Notify Physician of Resident's Change in Meal and Fluid Consumption
Penalty
Summary
The facility failed to notify the physician regarding a significant change in a resident's meal and fluid consumption. The resident, identified as R61, was admitted with multiple diagnoses including muscle weakness, seizures, pancreatitis, anemia, paraplegia, heart failure, deep vein thrombosis, and end-stage renal disease requiring hemodialysis. On a specific day, the resident did not consume any meals and only consumed a limited amount of fluids and supplements. Despite this significant change in the resident's condition, there was no evidence in the clinical record that the physician was notified to provide further instructions or assessments. The facility's policy on Change in Condition requires that the physician be notified of significant changes in a resident's condition, which includes changes in meal and fluid intake. However, the registered nurse supervisor, Employee E14, reported not being informed by the previous unit or the assigned nurse aide, Employee E15, about the resident's lack of meal consumption. This lack of communication and failure to follow the facility's policy resulted in the deficiency noted by the surveyors.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges as required. This deficiency was identified through a review of facility documentation and staff interviews. On October 1, 2024, the Director of Nursing (DON) was asked to provide documentation of such notifications for the past six months. A follow-up call with the Administrator confirmed that they were working on the request. However, during a telephone interview on October 2, 2024, the DON admitted that the facility did not have documentation to prove that notifications had been sent. The facility had been sending notifications electronically by email until January 2024, and switched to faxing in February 2024, but lacked confirmation pages to verify the transmissions.
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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