Suburban Woods Health & Reha
Inspection history, citations, penalties and survey trends for this long-term care facility in Norristown, Pennsylvania.
- Location
- 2751 Dekalb Pike, Norristown, Pennsylvania 19401
- CMS Provider Number
- 395912
- Inspections on file
- 23
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Suburban Woods Health & Reha during CMS and state inspections, most recent first.
Surveyors found that multiple residents did not receive medications, including carvedilol, amlodipine, oxycodone, and insulin lispro, within the time frames ordered by physicians and required by facility policy. A resident with diabetes and hypertension had numerous late doses of carvedilol and sliding‑scale insulin, often given well outside the ordered windows, with MAR entries marked only as "charted late" and no documented reason or MD notification. Another resident with diabetes reported insulin being given long after meals, and MAR review showed repeated late pre‑meal insulin doses across morning, midday, and evening med passes, again without explanation or provider notification. A third resident reported consistently late morning and nighttime medications, and records showed antihypertensive and pain medications administered after the scheduled time ranges, with late entries documented but lacking rationale or evidence of physician contact, despite no reported issues with timely meal delivery.
A resident with severe visual impairment and diabetes, requiring staff supervision for ambulation, was left unsupervised after being dropped off by a contracted transportation service following a medical appointment. The resident was not escorted into the building or signed back into nursing care, resulting in the resident walking alone across a busy highway to obtain food, while facility staff were unaware of the resident's whereabouts for an extended period. Facility staff confirmed there were no procedures in place to ensure safe transfer of care after such outings.
Surveyors found that food service areas were not maintained according to professional standards, with trash present around the loading dock, dirty and stained floors in storage and refrigeration areas, peeling paint in the dish room, and heavy buildup of burned food and grease in the convection oven. These conditions were confirmed by the Food Service Director.
A resident who was able to request toileting assistance was told by a staff member to urinate in her brief instead of being assisted to the bathroom, resulting in the resident feeling degraded and embarrassed. The incident was witnessed by the resident's roommate and confirmed through facility investigation as mental abuse, leading to the staff member's termination.
A resident with severe cognitive impairment and dementia, known for daily wandering and refusal to wear a wander guard, was able to exit the facility unsupervised by following a family member out the front door. The resident was later found in the parking lot by the DON, with no injuries identified.
A resident with Huntington's disease refused an outside appointment related to their diagnosis. Although staff attempted to reschedule by leaving a message with the hospital, there was no documentation that a new appointment was arranged, and the DON confirmed that no rescheduling occurred.
Two residents had physician-ordered medications administered without the required documentation of diagnosis or reason for use. Orders for medications such as Metoclopramide, Systane Hydration, and Lidocaine cream were missing ICD-10 codes or any stated indication, as confirmed by the DON.
A resident with multiple medical conditions was given an antibiotic after a Nurse Practitioner reviewed lab results that were only weakly suggestive of infection, despite the resident denying urinary symptoms and pending culture results.
The facility did not ensure that MDS assessments accurately reflected the status of two residents. One resident on hospice care was not properly documented as receiving hospice services in the MDS, and another resident's cognitive status was not assessed due to incomplete interviews by social services, resulting in missing information.
The facility failed to serve meals according to resident preferences, with lunch being delayed up to 2:00 p.m. and breakfast served too early. Residents expressed dissatisfaction with the new meal delivery process, which has led to altered meal times. Staff confirmed the changes and the resulting resident upset.
The facility failed to maintain a safe, clean, and homelike environment on the second-floor nursing unit. Observations included a detached privacy curtain, ripped floor mat, chipped walls, and a slow-draining sink. A resident reported brown spots in the bathroom, a dusty dresser, and clothing on the floor. The hot water temperature was uncomfortable, and a call bell plate had exposed wires. Interviews confirmed the facility's lack of cleanliness, contributing to these deficiencies.
A facility failed to develop comprehensive care plans for a resident with diabetes and a history of alcohol abuse. The care plan did not address the resident's refusal of medication or provide support for maintaining sobriety, despite the resident's need to attend meetings outside the facility. Staff interviews confirmed these deficiencies, highlighting a lack of coordination in care and support for the resident's needs.
The facility failed to provide adequate assistance with ADLs for three residents who were unable to perform these tasks independently. One resident was observed with facial hair and long nails despite requesting grooming, while another had long nails and expressed a desire for them to be trimmed. A third resident requested to have his beard shaved multiple times but was not assisted due to staff time constraints.
The facility failed to provide adequate supervision during transfers, resulting in falls for two residents who required two-person assistance. One resident fell during a hoyer lift transfer attempted by a single aide, while another fell due to insufficient staff assistance. Additionally, the facility environment posed hazards, with industrial detergent lacking instructions and a window without a safety lock, indicating lapses in maintaining a safe environment.
The facility failed to ensure accessible call systems for residents, with reports of delayed responses and staff turning off call bells without providing assistance. Observations confirmed that call bells were often out of reach, highlighting a systemic issue with the facility's call system accessibility and staff responsiveness.
The facility failed to maintain a sanitary environment on the second-floor nursing unit, affecting several residents. Observations revealed a strong urine odor in various areas, confirmed by staff and a resident's family member. Additional maintenance issues included broken blinds, stained windows, walls, and privacy curtains, violating Pennsylvania codes.
Repeated Late Medication Administration and Poor Documentation of Insulin and Other Medications
Penalty
Summary
The deficiency involves the facility’s failure to administer medications within the time parameters ordered by physicians and outlined in facility policy for three cognitively intact residents. The facility’s undated "Administration of Medication" policy states that medications are to be given within 60 minutes before or after the designated administration time, with before‑meal medications given approximately 30 minutes before meals and after‑meal medications given no later than 30 minutes after meals. The facility’s meal delivery schedule shows defined breakfast, lunch, and dinner delivery windows, and the Food Director and Nursing Home Administrator both reported no concerns with late delivery of food trucks. There was no documented evidence of actual food delivery times. Despite this, multiple medication administration records (MARs) showed repeated late administrations without documented reasons or physician notification. For one resident with type 2 diabetes and hypertension, the MAR from late December showed numerous late administrations of carvedilol and insulin lispro. Carvedilol, ordered twice daily within specified time windows, was repeatedly given well after the ordered time ranges, including evening doses administered between approximately 8:18 p.m. and 9:21 p.m. when the ordered window was 5:00 p.m. to 7:00 p.m., and a morning dose given at 10:39 a.m. when the ordered window ended at 10:00 a.m. Insulin lispro ordered before meals and at bedtime was also frequently administered late, including morning, midday, afternoon, and bedtime doses given significantly after the scheduled times, some several hours after the ordered administration time. Documentation on the MAR typically noted "charted late" or similar brief comments, but there was no documented evidence of reasons for the delays or of physician notification. This resident reported that medications are often late. A second resident with a hip replacement and type 2 diabetes, cognitively intact, reported that insulin is often given long after meals, sometimes a few hours, despite being ordered to be given prior to meals. Review of this resident’s MAR for early to mid‑January showed repeated late administrations of scheduled pre‑meal insulin lispro doses. Morning, midday, and evening doses ordered within specific time ranges were frequently administered well after those ranges, including midday doses given more than an hour or several hours after the ordered window and morning doses given after the end of the scheduled time frame. Each late dose was documented as "charted late" with minimal comments such as "n/a" or similar, and there was no documented evidence of reasons for the late administration or physician notification. A third resident with a scapula fracture and type 2 diabetes, also cognitively intact, reported that morning medications are received late and that medications are always late, especially at night. Review of this resident’s MAR from late December through January showed late administration of antihypertensive and pain medications. Amlodipine ordered for morning administration within an 8:00 a.m. to 11:00 a.m. window was given after 11:00 a.m. on multiple occasions, and oxycodone ordered twice daily within specified morning and afternoon/evening windows was administered after the end of those windows, including doses given after 7:00 p.m. or later when the ordered window ended at 7:00 p.m. These late administrations were documented as "charted late" or "other" with comments such as "N/A" or "ok," and there was no documented evidence of reasons for the delays or of physician notification. The Director of Nursing confirmed that when medications are late they must be manually entered and documented as late, corroborating the pattern of late entries noted in the MARs.
Failure to Ensure Safe Return and Supervision of Visually Impaired Resident After Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with significant visual impairment and diabetes was not adequately supervised upon return from a medical appointment. The resident, who had a history of right eye exenteration for melanoma and a cataract in the left eye, required staff supervision for ambulation on both level and uneven surfaces, as documented in clinical and therapy assessments. Despite these needs, the resident was routinely transported to medical appointments by a contracted transportation company without evaluation for community mobility, and there were no procedures in place to ensure safe transfer of care back to facility staff upon return. On the day of the incident, the resident left the facility for a medical appointment with physician approval, which specified supervision by staff, family, or another authorized individual. However, after the appointment, the transportation driver dropped the resident off near the facility entrance but did not escort the resident into the building or sign them back into the care of nursing staff. Facility staff were unaware of the resident's whereabouts for an extended period and only realized the resident was missing after questioning and searching the building. The resident was later observed walking alone through the facility parking lot, having crossed a four-lane highway under construction to obtain food at a nearby restaurant. The resident had not received any food or a nutritious snack since leaving the facility that morning. Interviews with facility administration and nursing staff confirmed there were no policies or procedures to ensure residents were safely returned and signed back into the facility after outings with contracted transportation services.
Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service department related to the storage, preparation, and cleanliness of food service areas. Observations included significant trash accumulation around the loading dock near the dumpster, such as empty milk cartons, plastic juice cups, and paper. The dry storage area had a buildup of dust, dirt, and a black substance on the floor under shelves adjacent to the aluminum freezer walls. The walk-in freezer and cooler both had dirty floors with debris and stains under the shelves. In the dish room, the wall behind the high-pressure spray hose and scrap sink was dirty and had peeling paint. Additionally, the convection oven had a heavy buildup of burned-on food splatter and grease drippings on its interior surfaces. These findings were confirmed in an interview with the Food Service Director.
Failure to Protect Resident from Mental Abuse During Toileting Assistance
Penalty
Summary
A resident with a history of bipolar disorder, depression, muscle weakness, and scoliosis, who was continent of urine and able to request assistance, reported that after activating her call light to request help to use the bathroom, a staff member instructed her to urinate in her brief instead of assisting her to the toilet. The resident complied due to inability to hold her urine, and later expressed feelings of degradation and embarrassment about the incident. The event was corroborated by the resident's roommate, who overheard the aide expressing frustration and instructing the resident to go in her pants. Facility documentation and interviews confirmed that the resident was typically able to communicate her needs and receive assistance to the toilet. The facility's investigation substantiated the allegation of mental abuse, as the aide's actions constituted humiliation and deprivation, which are defined as mental abuse in the facility's policy. The aide involved was subsequently terminated following the investigation.
Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for a resident with severe cognitive impairment and a diagnosis of dementia. The resident was identified as being at risk for elopement, with documented daily wandering behavior and a history of removing his wander guard. The interdisciplinary team had previously placed the resident on 15-minute checks due to his refusal to wear the wander guard and continued wandering. On the date of the incident, the resident was last seen ambulating in the hallway and was found to be missing during a routine check. Staff initiated a search after the resident could not be located, and the Director of Nursing eventually found the resident in the parking lot. It was determined that the resident exited the facility through the front door, likely following a family member who was leaving the building. No injuries were identified upon assessment after the resident was returned to the facility.
Failure to Ensure Timely Rescheduling of Outside Professional Services
Penalty
Summary
The facility failed to ensure the timely provision of professional services by outside providers for one resident diagnosed with Huntington's disease. The resident was admitted with this neurological disorder and had an outside appointment scheduled related to their diagnosis. According to nursing documentation, the resident refused to attend the appointment, and staff attempted to reschedule by leaving a message with the hospital to arrange a new date and time. However, there was no documented evidence in the clinical record that the appointment was successfully rescheduled, and the Director of Nursing confirmed that no new appointment had been made.
Incomplete Documentation of Medication Orders
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not documenting the diagnosis or reason for use for several physician-ordered medications. For one resident, orders for Metoclopramide HCl and Systane Hydration did not include an ICD-10 diagnosis or any reason for use, with the diagnosis field marked as 'N/A.' For another resident, an order for Lidocaine HCl cream also lacked a documented diagnosis or reason for use, with the diagnosis field left blank. These omissions were confirmed during an interview with the Director of Nursing, who acknowledged that all medication orders are required to list the diagnosis or reason for use to be considered complete.
Antibiotic Prescribed Without Adequate Indication
Penalty
Summary
A deficiency was identified when a resident with a history of bipolar disorder, depression, muscle weakness, and scoliosis was administered an antibiotic without adequate indication for use. The resident's clinical record showed an abnormal urinalysis and an improving white blood cell count, but the resident denied any urinary symptoms. Despite the lack of clear symptoms, a Nurse Practitioner ordered Bactrim DS for three days after reviewing the laboratory results. The physician's note indicated that the urinalysis was only weakly suggestive of infection and that further culture results were pending at the time the antibiotic was prescribed.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident admitted with Parkinson's Disease and placed on hospice care per physician order, the Significant Change MDS assessment indicated a life expectancy of less than six months in Section J, but Section O did not document that the resident was receiving hospice services. This discrepancy was confirmed by the MDS Coordinator, who acknowledged that Section O should have been completed for hospice. For another resident, a Quarterly MDS assessment had Section C: Cognitive Pattern marked as not assessed, as interviews for mental status were not completed in time by the social services department, resulting in the section being coded as no information.
Delayed Meal Service and Resident Dissatisfaction
Penalty
Summary
The facility failed to serve meals in accordance with resident preferences on both the 1st and 2nd floor nursing units. Interviews with residents revealed that lunch, which was previously served at noon, has been consistently delayed, sometimes being served as late as 2:00 p.m. Observations confirmed that lunch trucks were delivered late, with the last residents on the 1st floor receiving their meals at 1:42 p.m. Additionally, residents reported that breakfast is being served too early, often before they are awake, and dinner is also served later than preferred, with one resident noting dinner was served at almost 7:00 p.m. the previous night. Staff interviews indicated a recent change in the process of delivering meal trays, which has resulted in the altered meal times. A nurse aide confirmed that the 1st floor nursing unit was waiting for additional food trucks and that the new schedule has upset many residents. A resident council meeting further corroborated these issues, with multiple residents expressing dissatisfaction with the timing of breakfast and lunch. The facility's failure to adjust meal service to meet resident needs and preferences constitutes a deficiency in care.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the second-floor nursing unit. Observations revealed several issues, including a privacy curtain partially detached due to missing hooks, a ripped and stained floor mat, and chipped walls. A resident reported a slow-draining bathroom sink, scrapped walls, brown spots on bathroom walls and around the toilet, and a dusty dresser with spilled sugar. The air conditioning unit was dusty with brown spots from old spills. Clothing was found in large bags on the floor, and the bathroom had brown spots and a broken hot water handle, preventing the water from being turned off. The floor was dirty, and there was unrolled toilet paper on the floor. The hot water temperature in the shower room was between 95 F and 99 F, which was not comfortable for residents. Interviews with residents and family members confirmed the facility's lack of cleanliness, with reports of a urine smell and dry stool in a restroom that had to be cleaned by a family member. Maintenance and housekeeping staff confirmed the observations, including exposed wires from a call bell plate that had fallen off the wall. The facility's failure to adhere to its cleaning policy and maintain a sanitary environment contributed to these deficiencies, as evidenced by the observations and interviews conducted during the survey.
Failure to Develop Comprehensive Care Plans for Medication and Sobriety Support
Penalty
Summary
The facility failed to develop comprehensive care plans for a resident, identified as R50, specifically related to medication administration and the management of a history of alcohol abuse. The facility's policy requires a comprehensive, person-centered care plan for each resident, including measurable objectives and timetables to address medical, nursing, mental, and psychosocial needs identified in comprehensive assessments. However, the care plan for Resident R50 did not address the resident's refusal of medication, education for the resident and staff, or any plan for managing hypoglycemia. The resident, who has a diagnosis of diabetes mellitus, routinely refused blood glucose tests and insulin, yet the care plan only included a goal to be free of signs and symptoms of hypoglycemia without addressing the refusal of medication. Additionally, the care plan did not include the resident's history of alcohol abuse or support for maintaining sobriety, despite the resident's expressed need to attend meetings twice a week outside the facility. Interviews with staff and the resident confirmed these deficiencies. The Director of Nursing also confirmed the findings, indicating a lack of coordination in care and support for the resident's needs, including assistance with preparing and traveling to group meetings outside the facility.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide appropriate assistance with Activities of Daily Living (ADL) for three residents who were unable to perform these tasks independently. Resident R19, who was dependent on staff for personal hygiene, transfer, and toileting, was observed with facial hair and long nails, despite expressing a desire to have them trimmed. The Unit Manager confirmed this observation. Resident R29, also dependent on staff for personal hygiene, transfer, toileting, dressing, and bed mobility, was observed with long nails and expressed a desire to have them trimmed, which was confirmed by a Licensed Nurse. Resident R75, who required extensive assistance from one to two staff members for personal hygiene, bathing, and toileting, requested to have his beard shaved multiple times over several days. Despite his requests, the task was not completed due to staff time constraints, as confirmed by a grievance investigation and a statement from a Certified Nursing Assistant. These deficiencies were observed and confirmed by various staff members, indicating a failure to adhere to the facility's policy on personal care, which mandates daily morning care to promote resident comfort and cleanliness.
Inadequate Supervision and Environmental Hazards in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision during resident transfers, leading to falls for two residents. Resident R84, who was cognitively intact and required total dependence on two-person assistance for transfers, fell during a transfer with a hoyer lift. The incident occurred because a nurse aide, Employee E4, attempted the transfer alone, contrary to the resident's care plan and facility policy requiring two-person assistance. The hoyer lift tipped during the transfer, resulting in the resident falling to the floor. Similarly, Resident R30, who had a history of falls and required two-person assistance for transfers, fell while being transferred by only one employee. The resident confirmed the fall during an interview, and facility documentation revealed discrepancies in staff accounts of the transfer process. Employee E20 was terminated for not following the care plan appropriately, as the resident was transferred without the required assistance, leading to the fall. Additionally, the facility environment posed accident hazards due to improper handling and storage of cleaning agents and unsecured windows. The laundry room contained industrial detergent without proper instructions or measuring tools, posing a risk to residents using it. A resident reported skin sensitivity after using the detergent. Furthermore, a window in the dementia unit lacked a safety lock, allowing it to open widely, which was against safety protocols. The Maintenance Director was unaware of this issue, indicating a lapse in maintaining a hazard-free environment.
Inaccessible Call Systems and Poor Staff Response
Penalty
Summary
The facility failed to ensure that the call systems were accessible and functional for 11 residents, as required by their policy. Observations and interviews revealed that residents were unable to reach their call bells, and when they did, the response from staff was inadequate. For instance, Resident R75 reported a delay of one hour in response to their call bell, and often had to use their phone to contact the nursing station. Additionally, during a resident council meeting, several residents reported that staff would turn off call bells without providing assistance, often stating they were not assigned to the resident and failing to return. Specific observations highlighted the inaccessibility of call bells for residents. Resident R49's call bell was found underneath the bed and on the floor, making it unreachable, which was confirmed by staff members. Similarly, Resident R29's call bell was placed on a dresser, out of reach, and a nurse mentioned the need for a clip to attach it to the sheets. These deficiencies were observed and confirmed by facility staff, indicating a systemic issue with the accessibility and responsiveness of the call system in the facility.
Sanitation and Maintenance Deficiencies on Second-Floor Nursing Unit
Penalty
Summary
The facility failed to maintain a functional and sanitary environment on the second-floor nursing unit, affecting six out of ten residents reviewed. The facility's policy requires daily cleaning of occupied resident rooms and mandates housekeeping to report any maintenance issues. However, observations revealed a persistent strong urine odor in various areas of the second-floor nursing unit, including near the dining room and specific resident rooms. These observations were confirmed by both a licensed nurse and the Maintenance and Housekeeping Director. Additionally, a family member of a resident reported frequent urine odors and unsanitary conditions, further corroborating the findings. Further observations on the second-floor nursing unit revealed additional maintenance issues. Resident rooms were found with broken blinds, stained windows, walls, and privacy curtains. These deficiencies were confirmed by the Maintenance Director during the survey. The facility's failure to address these issues is in violation of several Pennsylvania codes, including the Administrator's responsibility, management, and window maintenance regulations.
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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