Tucker House Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 1001 Wallace Street, Philadelphia, Pennsylvania 19123
- CMS Provider Number
- 395461
- Inspections on file
- 33
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Tucker House Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of breast cancer and cellulitis had a critical BNP lab value reported, but staff did not notify the ordering physician as required by facility policy. Documentation showed unsuccessful attempts to reach the physician, and there was no evidence that the prescriber was ever informed of the result.
The facility did not properly label or manage two residents' personal clothing, resulting in significant delays in returning laundry, mixing of personal items with bed linens, and multiple grievances about missing or delayed laundry. Laundry aides reported ongoing issues due to lack of labeling by nurse aides, and one family received a deceased resident's belongings in a wet condition.
The facility failed to maintain an effective pest control program, resulting in roach and mice infestations across three nursing floors. Observations revealed live and dead roaches in resident rooms, along with clutter and food waste. Residents reported frequent sightings of pests, and pest control reports recommended improved sanitation and decluttering, which were not adequately addressed.
The facility did not maintain the means of egress on one floor, as a designated exit door from the ground floor dining room was padlocked on the corridor side, despite being marked with an illuminated exit sign. This was confirmed by the administrator and other representatives during an interview.
The facility failed to maintain stairways according to NFPA 101 standards. The 3rd floor South stairtower door did not latch properly, and environmental services supplies were stored in the East stairtower on the ground floor. These issues were confirmed by facility representatives during an interview.
The facility failed to maintain proper safety measures for hazardous area doors on two of five floors. Observations revealed that doors to the basement level medical waste room and elevator equipment room did not latch properly, and the Business office on the ground floor had excess combustible storage without a self or automatic closing door. These issues were confirmed during an exit conference with facility representatives.
The facility failed to monitor the installation of alcohol-based hand rub dispensers, with one found directly over a light switch in the 3rd floor dining room, placing it too close to an ignition source. This was confirmed during an exit conference with the facility's administration and maintenance representatives.
The facility failed to maintain corridor doors on three floors, with several doors either not smoke tight or lacking proper latching. This was confirmed during an exit conference with facility representatives.
The facility failed to maintain smoke barrier doors on one of its floors. Observations revealed that the East corridor smoke barrier doors did not close smoke tight, as required for proper smoke containment. This issue was confirmed during an exit conference with the facility's administrator and representatives.
The facility did not maintain electrical outlets as required, with a missing outlet cover observed in the Nurse lounge on the 4th floor. This was confirmed during an exit conference with the administrator and other representatives.
The facility failed to develop comprehensive care plans for residents, including one with a contracted hand and another with vision issues, leading to unaddressed health needs. A resident with heel protectors ordered did not have this intervention documented in their care plan, highlighting a lack of person-centered planning.
The facility failed to update care plans for two residents. One resident with significant weight loss had an outdated care plan that did not reflect the current order for two house shakes daily. Another resident requiring two-person assistance for mobility had a care plan indicating only one person was needed. These discrepancies were confirmed by staff.
A facility failed to provide adequate nail care for a resident who was cognitively impaired and had hemiplegia and muscle weakness. The resident was dependent on staff for personal hygiene, as noted in their care plan, which included checking and trimming nails on bath day and as necessary. Despite receiving a bed bath, observations revealed that the resident's fingernails were significantly long and required trimming. The resident's left hand was contracted, making regular nail care essential.
The facility failed to address the nutritional needs of two residents, leading to significant weight loss that was not promptly managed. One resident with cognitive impairment and diagnoses of failure to thrive and dementia lost 7.9% of their weight in one week without timely intervention. Another resident, who was physically active and cognitively impaired, lost 5.19% of their weight over a month, with no prompt action taken by the Registered Dietitian. Both cases lacked timely documentation and intervention adjustments.
A facility failed to provide appropriate pain management for a resident with myalgia, as staff did not document the administration of Tylenol or conduct a required pain assessment. The resident was observed tearful and requesting pain medication, but the necessary documentation and evaluation of non-pharmacological interventions were missing, as confirmed by staff interviews.
A facility failed to identify possible triggers for re-traumatization in a resident's PTSD care plan. The resident, with a history of childhood abuse and diagnoses including PTSD, had a care plan that lacked identification of potential triggers. This deficiency was confirmed by interviews with the DON and a Regional nurse.
A facility failed to maintain effective infection control during a medication administration and a peg tube dressing change. A nurse handled medication without disinfecting hands, and another nurse did not use PPE or change gloves during a dressing change for a resident on Enhanced Barrier Precautions.
A facility failed to provide proper incontinence management for a resident with Neuromuscular Dysfunction of the Bladder. The resident was ordered a 16FR/10ML Foley catheter but was observed with an 18FR/10ML catheter instead. This error was confirmed by a Registered Nurse.
A facility failed to provide a resident with timely access to their personal funds after discharge, as required by policy. The resident's account was closed late, and a refund request was delayed and never received by the corporate office, resulting in a refund of $3,418.20 not being sent to the resident.
A facility failed to ensure ongoing collaboration with a dialysis center, resulting in a resident not receiving prescribed medications before and after hemodialysis sessions. The resident, with end-stage kidney disease, missed multiple doses of Lispro insulin, Phos lo, apixaban, and isosorbide mononitrate ER in March 2024, as confirmed by the DON.
Failure to Notify Physician of Critical Lab Result
Penalty
Summary
Facility staff failed to notify the ordering physician of a critical laboratory result for one resident. According to facility policy, staff are required to inform the prescriber of results that are outside clinical reference ranges and document this notification. In this case, a resident with diagnoses including breast cancer and cellulitis of the left lower limb had a critical BNP laboratory value reported. The clinical record showed that the critical result was received by a registered nurse, who documented unsuccessful attempts to reach the physician for review and indicated that further attempts would be made. Despite these efforts, there was no documented evidence that the physician was ever informed of the critical laboratory result. Interviews with facility leadership and the medical director confirmed a lack of clarity regarding why the nurse was unable to notify the physician. The clinical record review did not show any follow-up or confirmation that the prescriber was made aware of the critical value, as required by facility policy.
Failure to Properly Identify and Manage Residents' Personal Clothing
Penalty
Summary
The facility failed to ensure that residents' clothing was properly identified and managed, as required by facility policy. Specifically, two residents' personal clothing was not labeled with their names, resulting in delays and confusion in returning laundry. One resident and their relative reported waiting approximately two weeks for personal laundry to be returned. Interviews with laundry aides revealed that the lack of labeling by nurse aides led to ongoing delays, with personal items left unclaimed until complaints were made. Observations in the laundry room showed residents' clothing mixed with bed linens and a pile of unidentified clothing. Additionally, review of facility grievances over two months showed ten complaints related to laundry delays and missing items, and one report documented that a deceased resident's belongings were returned to family in a wet condition.
Pest Control Deficiency in Resident Care Areas
Penalty
Summary
The facility failed to maintain an effective pest control program across three nursing floors, as evidenced by multiple observations and interviews. In one resident room, live and dead roaches were found inside a nightstand drawer, along with what appeared to be pest droppings. The room was also noted to have trash and food particles on the floor. A resident reported seeing a mouse emerge from a hole in the baseboard and frequently observed roaches in his room. Another resident demonstrated a roach infestation problem by showing live roaches inside a dresser drawer. The room was cluttered, and food waste was present on the floor. Additionally, a resident had placed traps under the dresser, which caught numerous dead and live roaches. The pest control reports reviewed indicated ongoing issues with roach activity and recommended improvements in sanitation and decluttering in specific rooms and the kitchen area. The reports highlighted positive roach acceptance on monitors placed under the dishwasher area and recommended fixing leaks and improving sanitation practices. Despite these recommendations, the facility continued to experience pest issues, as evidenced by the observations and resident reports. The facility's failure to address these recommendations and maintain cleanliness contributed to the persistent pest problem.
Plan Of Correction
Rooms 218, 311, and 421 were cleaned and treated by pest control. Rooms 226, 232, 410, and 425 were cleaned, decluttered, and treated by pest control. The elevator and tracks were cleaned. The kitchen and dishwasher area were cleaned, leaks were fixed, and treated by pest control. Current residents' rooms were audited; targeted rooms were identified. Current staff were re-educated on the homelike environment and the process for pest management and control. The NHA or designee will conduct 5 random room audits per week to ensure rooms are cleaned, orderly, and free of debris and bugs per policy. Results will be reviewed during the facility's monthly QAPI meeting. The NHA or designee will conduct a weekly review of pest management reports to ensure recommendations are followed through. Results will be reviewed during the facility's monthly QAPI meeting.
Failure to Maintain Means of Egress
Penalty
Summary
The facility failed to maintain the means of egress on one of its five floors, as observed during a survey. Specifically, on December 12, 2024, at 11:22 a.m., it was noted that the right side exit door from the ground floor dining room was secured with a padlock on the corridor side. This door is designated as an exit and is marked with an illuminated exit sign within the dining room. During an interview at the exit conference on the same day, the administrator, maintenance representative, and regional facility representative confirmed that the exit was locked, preventing egress.
Plan Of Correction
Padlocks removed to ensure means of egress. NHA will educate the Maintenance Director on maintaining means of egress. An initial audit was completed to ensure means of egress throughout the facility. NHA/designee will audit weekly x 4, then monthly x 3. Findings will be reviewed in the monthly QAPI.
Stairway Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain stairways in compliance with NFPA 101 standards, as evidenced by two specific deficiencies observed during a survey. Firstly, on the 3rd floor, the South stairtower door was found to not latch properly in its frame when tested. This issue was confirmed during an interview with the administrator, maintenance representative, and regional facility representative. Secondly, environmental services supplies, including wet floor signs and various other items, were improperly stored in the East stairtower on the ground floor. This storage issue was also confirmed during the exit conference interview with the same facility representatives.
Plan Of Correction
Stair tower door fixed to ensure positive latch. Environmental supplies removed from stair tower. NHA educated the Maintenance Director on maintaining stair towers. An initial audit was completed to ensure maintenance of the stair towers. NHA/designee will audit weekly x 4, then monthly x 3. Findings will be reviewed in the monthly QAPI.
Deficient Hazardous Area Door Maintenance
Penalty
Summary
The facility failed to maintain proper safety measures for hazardous area doors on two of five floors. During an observation on December 12, 2024, it was noted that several doors to hazardous areas did not latch properly or lacked self-closing capabilities. Specifically, the basement level medical waste room and the basement level elevator equipment room had doors that failed to latch in their frames. Additionally, the Business office on the ground floor contained excess combustible storage and did not have a self or automatic closing door. These deficiencies were confirmed during an exit conference with the facility's administrator, maintenance representative, and regional facility representative.
Plan Of Correction
The doors observed were fixed to ensure self-closing and positive latching. NHA educated the Maintenance Director on maintaining doors to hazardous areas. An initial audit was completed to ensure self-closing and positive latching of doors to hazardous areas. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.
Improper Installation of ABHR Dispenser
Penalty
Summary
The facility failed to properly monitor the installation of alcohol-based hand rub dispensers (ABHR) on one of its five floors. During an observation on December 12, 2024, at 10:18 a.m., it was noted that an ABHR dispenser was installed directly over a light switch in the 3rd floor dining room. This placement is non-compliant with safety regulations, as it positions the dispenser too close to an ignition source. The issue was confirmed during an exit conference on the same day at 11:45 a.m. with the facility's administrator, maintenance representative, and regional facility representative.
Plan Of Correction
The hand sanitizer dispenser was removed. NHA educated the Maintenance Director on monitoring the location and installation of alcohol-based hand rub dispensers. An initial audit was completed to ensure location and installation of all alcohol-based hand rub dispensers. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.
Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility failed to maintain corridor doors on three of its five floors, as observed during a survey conducted on December 12, 2024. The survey revealed that several corridor doors were either not smoke tight when latched or failed to positively latch in the frame. Specifically, the door to room 419 on the 4th floor was not smoke tight, the 3rd floor nurse lounge door had no latch, and doors to rooms 203, 217, and 227 on the 2nd floor were either not smoke tight or lacked a latch. During an exit conference on the same day, the administrator, maintenance representative, and regional facility representative confirmed these deficiencies. The report highlights that the facility did not meet the requirements for corridor doors as outlined by the NFPA 101 standards, which are crucial for ensuring the safety and containment of smoke in the event of a fire.
Plan Of Correction
All the observed doors were fixed to ensure positive latch and smoke tightness. NHA educated the Maintenance Director on maintaining corridor doors. An initial audit was completed to ensure positive latch and smoke tightness of corridor doors. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.
Smoke Barrier Doors Not Closing Smoke Tight
Penalty
Summary
The facility failed to maintain smoke barrier doors on one of its five floors, as observed during a survey. On December 12, 2024, at 10:12 a.m., it was noted that the smoke barrier doors in the East corridor did not close smoke tight, which is a requirement for ensuring proper smoke containment. This deficiency was confirmed during an exit conference on the same day at 11:45 a.m. with the facility's administrator, maintenance representative, and regional facility representative, who acknowledged that the doors did not fit together smoke tight.
Plan Of Correction
The east corridor smoke barrier doors were fixed to close smoke tight. NHA educated the Maintenance Director on maintaining smoke barrier doors. An initial audit was completed to ensure smoke tightness of all smoke barrier doors. NHA/designee will audit weekly x 4, then monthly x 3.
Missing Outlet Cover in Nurse Lounge
Penalty
Summary
The facility failed to maintain electrical outlets in compliance with NFPA 101 standards in one of its smoke compartments. During an observation on December 12, 2024, at 9:56 a.m., it was noted that an outlet cover was missing in the Nurse lounge on the 4th floor. This deficiency was confirmed during an exit conference on the same day at 11:45 a.m. with the administrator, maintenance representative, and regional facility representative.
Plan Of Correction
An outlet cover was installed in the Nurse lounge on the 4th floor. NHA educated the Maintenance Director on maintaining electrical outlets. An initial audit was completed to ensure compliance of electrical outlets. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific health needs. Resident R65, who was cognitively impaired and diagnosed with hemiplegia and muscle weakness, had a contracted left hand that was not addressed in their care plan. Despite being dependent on staff for feeding assistance due to limited mobility, there was no documented evidence of a care plan to maintain or improve the resident's range of motion and mobility. Resident R1, diagnosed with glaucoma and cataracts, had a care plan that only addressed vision problems in the context of fall risk, without specific interventions for the new diagnoses. Additionally, Resident R102, who had chronic respiratory failure and other conditions, had an order for heel protectors that was not included in their care plan. The resident sometimes refused to wear the protectors, but this refusal was not documented in the care plan. These omissions indicate a failure to provide person-centered care plans as required by facility policy.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents were updated to reflect their specific care needs. Resident R85, who was admitted with conditions including diabetes mellitus, anxiety disorder, and dementia, experienced significant weight loss from June 2024 through November 2024. Despite an order dated October 8, 2024, for two house shakes a day to address the weight loss, the care plan only included one house shake daily. Additionally, the care plan's goal for weight stability was not revised to reflect the resident's current weight of 107.6 lbs, which was below the goal of maintaining within 3% of 115.8 lbs. The dietician confirmed the resident's current weight and the order for two shakes daily. Resident R89, admitted with diagnoses including thrombotic pulmonary embolism, muscle wasting, and lack of coordination, required two or more persons for physical assistance with bed mobility and transfer, as per the Minimum Data Set assessment dated October 14, 2024. However, the care plan inaccurately indicated that only one person was needed for assistance. A licensed nurse confirmed that the resident required two persons for assistance with repositioning in bed and transferring.
Failure to Provide Adequate Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a dependent resident, identified as Resident R65, who was cognitively impaired and had diagnoses of hemiplegia affecting the left side and muscle weakness. The resident was dependent on staff for personal hygiene, as noted in the quarterly Minimum Data Set (MDS) dated August 21, 2024. The comprehensive care plan, revised on August 25, 2021, indicated that the resident had a self-care performance deficit related to decreased mobility, with an intervention to check nail length and trim and clean on bath day and as necessary. Despite receiving a bed bath on November 14, 2024, observations on November 12 and November 15, 2024, revealed that Resident R65's fingernails on both hands were significantly long and required trimming. The resident's left hand was contracted, and they made a fist due to the contracture, which further emphasized the need for regular nail care. This deficiency was identified during an observation with Licensed Nurse, Employee E10.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to evaluate and address the nutritional needs of two residents, leading to significant weight loss that was not promptly addressed. Resident R84, who had moderate cognitive impairment and diagnoses of adult failure to thrive, muscle wasting, and dementia, experienced a 7.9% weight loss in one week. Despite this significant weight loss, there was no documented evidence that the Registered Dietitian was informed or that any interventions were reviewed or modified to address the resident's needs until a nutrition assessment was conducted months later. Similarly, Resident R107, who was cognitively impaired and had diagnoses of alcohol dependence and cognitive communication deficit, experienced a 5.19% weight loss over one month. The resident was noted to be physically active, often wandering and not sitting for full meals, which contributed to the weight loss. Despite these observations, there was no documented evidence that the Registered Dietitian was made aware of the weight loss or that any interventions were promptly reviewed or modified. The Registered Dietitian did not address the significant weight loss until a nutrition assessment was conducted two months later.
Failure in Pain Management Documentation and Assessment
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R70, who was cognitively impaired and diagnosed with myalgia of the head and neck. The facility's policy on administering pain medication required staff to assess the resident's level of pain, including location and intensity, before administering medication, and to document these assessments in the resident's electronic health record. However, on November 12, 2024, Resident R70 was observed tearful and requesting pain medication, but the Registered Nurse, Employee E11, did not document the administration of the as-needed Tylenol or conduct a pain assessment as required by the facility's policy. Further review of Resident R70's clinical record revealed no evidence that non-pharmacological interventions were implemented prior to administering pain medication, nor was there any documented follow-up to evaluate the effectiveness of the medication given. Interviews with Registered Nurse, Employee E11, and Regional Registered Nurse, Employee E3, confirmed the lack of documentation for the administration of Tylenol and the absence of a pain assessment. This deficiency was identified under 28 Pa. Code 211.9 (a)(1) Pharmacy services and 28 Pa. Code 211.12 (d)(5) Nursing services.
Failure to Identify PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to identify possible triggers that may cause re-traumatization for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted with diagnoses including suicidal ideations, major depressive disorder, and PTSD, had a history of sexual and physical abuse by his father during childhood. Despite having a care plan for PTSD, the plan did not include identification of potential triggers for re-traumatization. This deficiency was confirmed through interviews with the Director of Nursing and a Regional nurse, who acknowledged the omission in the resident's care plan.
Infection Control Deficiencies in Medication Administration and Dressing Change
Penalty
Summary
The facility failed to maintain an effective infection control program during a medication administration review and a peg tube dressing change. During the medication administration to Resident R85, a licensed nurse, Employee E5, was observed touching the medication cart drawer, computer mouse, and medication-blister-pack with bare hands. Without disinfecting her hands, Employee E5 then picked up medication tablets and placed them in a dispensing cup. This action was confirmed by Employee E5 at the time of the observation. In another instance, during a peg-site dressing change for Resident R98, who was on Enhanced Barrier Precautions due to tube feeding, a licensed nurse, Employee E6, did not wear the necessary Personal Protective Equipment (PPE) as required by the Enhanced Barrier Precautions. Additionally, Employee E6 failed to remove soiled gloves and did not put on clean gloves before placing a new dressing around the peg site. This lapse in protocol was also confirmed by Employee E6 at the time of the observation.
Incontinence Management Deficiency Due to Incorrect Catheter Size
Penalty
Summary
The facility failed to implement appropriate treatment and services for incontinence management for a resident with incontinence concerns. The resident, identified as having Neuromuscular Dysfunction of the Bladder, was admitted with a physician's order for a urinary Foley catheter size 16FR/10ML. However, during an observation, it was found that the resident had a Foley catheter of 18FR/10ML instead. This discrepancy was confirmed by a Registered Nurse at the facility.
Failure to Provide Timely Access to Resident's Personal Funds
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to their personal funds, as required by their policy. The policy stated that upon discharge, eviction, or death, the facility must convey the resident's funds and a final accounting within 90 days. Resident CL1 was discharged and transferred to another facility on November 30, 2023. However, the resident's account was not closed until February 1, 2024, and the refund request was sent to corporate on February 20, 2024. An interview with the business office confirmed the delay, and the Nursing Home Administrator revealed that the corporate office never received the refund request, resulting in the refund check not being sent to the resident. The facility still owed the resident $3,418.20.
Failure to Administer Prescribed Medications for Dialysis Resident
Penalty
Summary
The facility failed to ensure ongoing collaboration with the dialysis facility for the provision of medications as ordered by the physician for a resident requiring hemodialysis. The clinical record review revealed that the resident, who had a diagnosis of end-stage kidney disease, was scheduled for hemodialysis three times a week. However, the nursing staff did not administer the prescribed medications, including Lispro insulin, Phos lo, apixaban, and isosorbide mononitrate ER, at the required times before and after dialysis sessions on multiple occasions in March 2024. This failure was confirmed by the director of nursing during an interview. The facility's policies on administering medications and dialysis care emphasized the responsibility of the licensed nurse to administer and document medications according to physician orders and the need for effective communication and collaboration with the dialysis center. Despite these policies, the resident did not receive the necessary medications as ordered, leading to a deficiency in the provision of safe and appropriate dialysis care. The facility's contract with the dialysis center also required ongoing communication and collaboration, which was not adequately maintained in this case.
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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