Wallingford Skilled Nursing And Rehabilitation Cen
Inspection history, citations, penalties and survey trends for this long-term care facility in Wallingford, Pennsylvania.
- Location
- 115 South Providence Road, Wallingford, Pennsylvania 19086
- CMS Provider Number
- 395685
- Inspections on file
- 30
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Wallingford Skilled Nursing And Rehabilitation Cen during CMS and state inspections, most recent first.
A resident with bilateral heel DTIs had physician orders for specific wound care, including cleansing, skin prep, and later Betadine treatments. Documentation showed that the initial treatment orders were followed and that the updated Betadine and dressing treatment for the right heel was provided. However, the ordered Betadine treatment for the left heel, to be applied and left open to air, was not carried out over an extended period, as evidenced by gaps in the TAR. The DON later confirmed that the left heel treatment order had been missed and not followed.
Surveyors identified expired and undated medications, including insulin pens and vaccines, as well as expired medical supplies in two medication rooms and two medication carts. Staff, including the DON, RN, and LPNs, confirmed the presence of these items, which were not removed or disposed of as required by facility policy.
Surveyors found that dietary staff did not consistently use required hair and beard restraints, and food items in the kitchen were improperly stored, lacking necessary labeling and dating. Uncovered equipment, leaking water onto food, and improper storage practices in both the cooler and freezer were observed and confirmed by facility leadership.
The facility did not document the resolution of grievances for several residents, leaving key sections of grievance forms incomplete and failing to provide required notifications. Review of records and staff interviews confirmed that the grievance process was not properly followed or documented, in violation of facility policy and resident rights regulations.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Four residents with cognitive impairment and incontinence were found in soiled briefs and unchanged clothing, and the facility did not conduct a required investigation into allegations of neglect. Despite staff reporting the issue and the implicated CNA being removed from future assignments, there was no documented follow-up to determine if other residents were affected, if the supervising nurse had concerns, or if skin checks were performed.
Surveyors found that the facility did not maintain an effective pest control program on two nursing units, as evidenced by multiple residents reporting frequent sightings of mice in their rooms, the observation of fruit flies, and confirmation from the NHA of a bat incident. The DON and Administrator in Training acknowledged the ongoing pest issues.
A resident with schizophrenia, autism, and excoriation disorder reported that an RN verbally abused him during wound care by yelling and making statements perceived as threats regarding his ability to return to his group home. The RN admitted to raising her voice and referencing the resident's discharge status. Facility leadership confirmed this constituted verbal abuse and that policies to protect residents from abuse were not properly implemented.
A resident did not receive necessary dental services, as the facility failed to provide or obtain appropriate dental care.
A treatment cart was observed to have medications and treatment supplies stored haphazardly, without separation by resident or route of administration. An LPN confirmed the cart was in daily use and that this practice could result in cross-contamination. The DON and Administrator in Training acknowledged the failure to follow infection control practices for medication storage.
Two residents who required assistance with dressing were left exposed in their rooms with doors and privacy curtains open, resulting in a lack of privacy and dignity. Both residents were cognitively intact and needed staff help for dressing due to medical conditions, but staff failed to ensure their privacy during these activities.
The facility failed to implement enhanced barrier precautions for four residents, including those with indwelling catheters and gastrostomy tubes, as required by their policy. Observations revealed the absence of necessary signage and PPE setup in or outside the residents' rooms, which was confirmed by staff interviews.
A resident with CHF experienced a significant weight gain of 14.48% in one month, but the facility failed to notify the physician as required by policy. The weight was not rechecked until six days later, and the physician was still not informed, as confirmed by a nurse interview.
A facility failed to follow a physician's order to maintain ear protectors on a resident's oxygen tubing, leading to an abrasion behind the resident's ear. Despite staff signing off that the protectors were in place, a nurse's note revealed the absence of protectors, resulting in redness and swelling. The issue was treated with antibiotics and resolved within a few weeks.
A resident with cognitive impairment and physical disabilities fell during care due to inadequate supervision. The resident, who required two-person assistance, was being attended by only one staff member when they lunged off the bed and fell to the floor. The incident highlights a failure in providing necessary supervision and assistance.
A facility failed to document consistent and adequate catheter care for a resident with an indwelling urinary catheter. The facility's procedure requires catheter care to be performed twice daily and documented, but a review of the resident's records showed no evidence of routine care. This deficiency was confirmed with the Nursing Home Administrator.
A facility failed to monitor and address significant weight loss in a resident. Despite a policy requiring re-weighing and notifying a dietitian for significant weight changes, the resident experienced notable weight loss over two months without documented intervention or communication with the dietitian. The care plan and order summary lacked interventions to address the weight loss, and there was no evidence of communication with the dietitian.
A resident did not receive their prescribed diabetes medication, Trulicity, on three occasions due to pharmacy delivery issues. This led to a significant increase in the resident's HbA1c levels, indicating poor blood sugar control.
A facility failed to consistently implement non-pharmacological interventions (NPIs) and document appropriate indications for the use of PRN Lorazepam for a resident. The resident received the medication multiple times without NPIs being attempted or appropriate indications documented, as confirmed by the Director of Nursing.
The facility failed to properly store and label medications on the 1 North Unit. Observations revealed loose tablets, unlabeled glucose gel, and improperly stored suppositories. Staff confirmed the medications were not in their original containers, violating storage protocols.
A newly admitted resident with a history of hypotension and syncope was inaccurately assessed as not being at risk for falls, despite hospital documentation indicating deficits in ambulation, balance, and strength. The facility failed to develop a care plan or interventions to prevent falls, resulting in the resident experiencing a fall with significant injuries requiring hospitalization.
The facility did not ensure physician action on medication irregularities for several residents. Recommendations for dose reductions and medication evaluations were not addressed for residents with severe cognitive impairments and multiple diagnoses, as confirmed by the DON.
The facility failed to perform gradual dose reductions (GDR) and periodic evaluations for psychotropic medications for three residents. One resident was on Aripiprazole for depression without any GDR attempts or physician rationale documented. Another resident was on Klonopin, Lexapro, and Haloperidol without GDR attempts or rationale. A third resident with severe cognitive impairment was on Haloperidol, Olanzapine, and Mirtazapine, with no documented GDR attempts or evaluations despite recommendations.
A resident was found with a hip fracture, but the facility failed to conduct a thorough investigation into the injury's cause. The investigation did not include interviews with staff from the relevant shifts, leaving the timeline and cause of the injury undetermined. The DON confirmed the investigation was incomplete.
A facility failed to administer Calcium Acetate to a resident with Chronic Kidney Failure and Dependence on Hemodialysis as prescribed. The medication was not given at 12:30 p.m. on multiple occasions because the resident was out for dialysis, and the physician was not informed of the missed doses until later. This was confirmed through clinical records and a DON interview.
The facility failed to monitor and address significant weight changes for two residents. One resident was not weighed since April, with no documented refusal or care plan, despite a functional scale. Another resident with a PEG tube experienced a significant weight gain, but a reweight was not obtained as required by the care plan. The DON could not explain the lack of reweighting, indicating a failure to follow care plan interventions.
A facility failed to administer enteral nutrition as ordered for a resident with a PEG tube. The physician's order specified Jevity 1.5 at 65 ml per hour, totaling 1040 ml daily, but records for three months showed no documentation of this being provided. The DON confirmed the absence of evidence for the prescribed nutrition.
A facility failed to document non-pharmacological interventions (NPIs) before administering as-needed oxycodone to a resident. Despite a physician's order requiring NPIs to be attempted and documented prior to giving the medication, the resident's MARs for several months showed multiple administrations of oxycodone without such documentation. The Director of Nursing confirmed this oversight, which violated state regulations on clinical records and resident care policies.
A resident with epilepsy did not receive a timely Depakote level test as ordered by a physician. The test, initially scheduled for early May, was not completed until late June, as confirmed by the DON. This delay indicates a failure to meet the resident's medical needs.
A resident's DEXA scan was delayed twice due to transportation issues and the inability to transfer from a wheelchair to the examination table. Despite being sent with an escort, the resident could not complete the procedure, as confirmed by the DON.
Failure to Follow Physician’s Wound Care Orders for Heel DTI
Penalty
Summary
The facility failed to follow a wound care physician’s orders for treatment of a resident’s left heel deep tissue injury (DTI). On January 15, 2026, the resident was documented as having a right heel DTI measuring 2.5 x 3.5 cm and a left heel DTI measuring 2.5 x 2.3 cm, with an order to cleanse both heels with soap and water, apply skin prep, and leave them open to air daily; review of the January 2026 Treatment Administration Record (TAR) showed this initial skin prep order was followed. On January 22, 2026, the wound physician documented that the right heel DTI had worsened to 3.7 x 6.0 cm and the left heel DTI measured 0.3 x 0.3 cm, and issued new orders to apply Betadine-soaked gauze with a dressing to the right heel and to apply Betadine to the left heel and leave it open to air. TAR review confirmed that the right heel treatment was carried out, but the left heel Betadine treatment was not documented as provided from January 23, 2026, through February 8, 2026. In an interview on March 31, 2026, at 1:00 p.m., the DON confirmed that the left heel DTI order from the wound physician had been missed and therefore not followed, resulting in noncompliance with 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Expired and Improperly Stored Medications and Supplies Identified
Penalty
Summary
The facility failed to ensure that drugs, biologicals, and medical supplies were properly stored and disposed of in accordance with facility policy and professional standards. During observations in two medication rooms (Two South and Two North) and two medication carts (Two South Long Hall and Two South Short Hall), surveyors found multiple expired medical supplies, including debridement trays, oxygen tubing, safety needles, urinary catheter securement devices, sterile gloves, luer access devices, dressing change trays, ostomy lubricating deodorant, blood collection needles, and IV catheters. Additionally, expired or undated medications, such as Lantus and insulin lispro injection pens, Fluzone High Dose influenza vaccines, and tuberculin solution, were found in use or available for use. Staff interviews with the DON, RN, and LPNs confirmed the presence of these expired or undated items. The facility's policy required that medications and biologicals be stored properly and that outdated, contaminated, discontinued, or deteriorated medications and supplies be immediately removed from stock and disposed of according to procedures. Despite this, surveyors observed that expired items remained in medication rooms and carts, and some insulin pens were either undated or past their in-use expiration period. Facility leadership, including the DON and Administrator in Training, acknowledged the failure to ensure proper storage and disposal of these items.
Failure to Maintain Proper Food Storage and Staff Hygiene in Kitchen
Penalty
Summary
The facility failed to adhere to its dietary policies regarding personal hygiene and food storage in the Main Kitchen. Observations revealed that dietary staff did not consistently wear required hair or beard restraints while in food preparation areas, with one employee only donning a hairnet after the surveyor's arrival and another with a beard not wearing a beard net because they were locked in the manager's office. Additionally, uncovered equipment such as the industrial food mixer and slicing machine were noted in the food preparation area. Food storage practices were also found to be deficient. Multiple food items in the main cooler, including deli meats, cheeses, pureed foods, butter, and prepared omelets, were wrapped or stored without proper labeling or dating. Some items were past their use-by dates, and a ceiling fan was observed leaking condensed water onto food items. In the freezer, an open box of fish filets was left exposed to air, a personal drink was stored on a shelf, and boxes of food were stacked directly on the floor. These findings were confirmed by facility leadership during interviews.
Failure to Document Grievance Resolutions
Penalty
Summary
The facility failed to properly document the resolution of grievances for four out of six residents, as required by its own grievance policy. The policy designates the Administrator as the Grievance Officer, responsible for overseeing the grievance process, tracking grievances to their conclusion, and issuing written decisions to residents. However, review of grievance forms revealed missing documentation in several key areas, including whether the grievance was resolved, the date of resolution, notification to the resident or representative, and the staff member who received the grievance. Specifically, grievances filed on behalf of multiple residents lacked information in the 'Resolution of Grievance/Concern' section, with some forms left entirely blank regarding resolution details. Interviews with the DON and Administrator in Training confirmed that the facility did not institute corrective actions or resolve the grievances for these residents. The lack of documentation and follow-through on the grievance process was identified through review of facility documents and staff interviews, indicating non-compliance with both facility policy and state regulations regarding management and resident rights.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Investigate Allegations of Neglect for Multiple Residents
Penalty
Summary
The facility failed to fully investigate allegations of neglect for four residents who were incontinent and dependent on staff for care. According to the facility's own policy, an investigation into any allegation of abuse or neglect should be initiated within 24 hours, including a clinical examination for injuries, assessment of causative factors, and implementation of interventions to prevent further harm. However, after a grievance was filed by staff noting that four residents were found in soaked briefs and unchanged clothing at the start of a shift, the facility did not conduct a thorough investigation. The residents involved had significant cognitive impairments and were frequently or always incontinent, as documented in their clinical records and Minimum Data Set (MDS) assessments. Despite the grievance indicating that the responsible nurse aide was from an agency and would not be allowed to return, the facility did not document any investigation into whether the supervising licensed nurse had concerns about the aide's performance, whether other residents assigned to the aide received appropriate care, or whether skin checks were completed to assess for injuries related to prolonged exposure to soiled briefs. The Director of Nursing and Administrator in Training confirmed that no such investigation was completed, resulting in a failure to respond appropriately to the alleged neglect as required by facility policy and state regulations.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on two of four nursing units, as required by its preventive maintenance and infection control policies. Multiple residents reported seeing mice in their rooms, with one resident specifically indicating that mice entered through a hole in the PTAC unit and were also seen running from beneath the soda machine. Fruit flies were observed in a resident room during a surveyor's observation. Additionally, the Nursing Home Administrator confirmed the presence of a bat in the facility, which had been disposed of by staff. Interviews with several residents revealed ongoing issues with mice, with some stating they had seen mice frequently and even had multiple mice in their rooms. The Director of Nursing and the Administrator in Training confirmed the facility's failure to maintain an effective pest control program on the affected units. These findings were based on facility policy review, direct observations, and interviews with residents and staff.
Failure to Protect Resident from Verbal Abuse by RN
Penalty
Summary
A deficiency occurred when a resident with schizophrenia, autism disorder, and excoriation disorder reported being verbally abused by an RN during wound care. The resident, who had a moderate cognitive impairment, filed a grievance stating that the RN yelled at him and told him that if he continued picking at his wounds, he would never be able to go back home. The RN admitted to raising her voice and telling the resident that his group home would not take him back until his wound was healed, referencing the group home's inability to provide the necessary level of care. The resident expressed fear that the RN would say or do something to prevent his return home and preferred not to interact with her. Facility leadership, including the DON and Administrator in Training, confirmed that the RN spoke negatively to the resident about a symptom of his diagnosed medical condition and that her actions constituted verbal abuse as defined by facility policy. The facility failed to implement policies and procedures to protect the resident from abuse, as required by regulation, resulting in a deficiency for not safeguarding residents from all forms of abuse, including verbal abuse.
Failure to Provide or Obtain Dental Services
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident. This deficiency was identified during the survey process, indicating that the required dental care was not arranged or delivered as needed for the resident in question. No additional details regarding the resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Maintain Proper Infection Control in Medication Storage
Penalty
Summary
During a review of the facility's medication storage policy, it was found that medications should be stored with separation based on route of administration, specifically keeping internally administered medications apart from those used externally, such as ointments and creams. However, an observation of the treatment cart in the Two North Medication room revealed that treatment supplies and medications were stored haphazardly, without separation by resident or route of administration. Items such as Santyl ointments, zinc oxide paste, Voltaren cream, various gauze and dressing supplies, wound cleansers, antifungal sprays and powders, and other personal care items were intermixed in the drawers of the cart. An LPN confirmed that the treatment cart was in daily use and acknowledged the lack of separation in storage, which could lead to cross-contamination between residents. The DON and Administrator in Training also confirmed the failure to maintain infection control practices in the storage of medications and biologicals for one of two treatment carts. The deficiency was cited under relevant Pennsylvania Codes for responsibility of the licensee, management, and resident care policies.
Failure to Maintain Resident Privacy and Dignity During Dressing
Penalty
Summary
Two residents were not provided with adequate privacy and dignity during dressing and undressing activities. One resident, who was cognitively intact and dependent on staff for upper and lower body dressing due to a fractured humerus, schizophrenia, and muscle weakness, was observed lying in bed with only a brief on and the door to the room open. The resident reported feeling uncomfortable because staff did not close the door when leaving the room. Another resident, also cognitively intact and requiring supervision or assistance with dressing due to congestive heart failure, rhabdomyolysis, and muscle weakness, was observed sitting on the bed with the lower body exposed and no brief on, while the door to the room remained open. This resident confirmed needing assistance with lower body dressing. A CNA confirmed that the resident requires help with dressing and that the door should have been closed for privacy. Both residents had their doors and privacy curtains open, exposing their bodies to anyone passing by.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for four residents, as required by their policy based on CDC guidance. Resident 11, who was admitted with sepsis and had an indwelling Foley catheter due to neurogenic bladder, did not have an order for EBP, nor was there any signage or PPE located in or outside of his room. This was confirmed by the Director of Nursing during an interview. Similarly, Resident 59, who had a gastrostomy tube for protein calorie malnutrition, and Resident 64, also with a gastrostomy tube, lacked EBP signage and PPE setup in or outside their rooms during observations conducted over several days. Resident 164, admitted with small bowel cancer and having a PICC line, Foley catheter, and gastrostomy tube, also did not have EBP signage or PPE setup. An interview with a licensed nurse revealed that residents requiring EBP should have signage by the door and PPE set up outside their rooms, which was not done for Residents 64 and 164. The absence of EBP implementation for Residents 59, 64, and 164 was confirmed by the Regional nurse and Director of Nursing.
Failure to Notify Physician of Significant Weight Change
Penalty
Summary
The facility failed to notify the physician of a significant weight change for a resident diagnosed with Congestive Heart Failure (CHF). According to the facility's policy, a significant weight change is defined as a 5% change in one month or a 10% change in six months, and such changes require notification of the physician and dietitian. Resident 114 experienced a 14.48% weight gain in one month, increasing from 131.2 pounds to 150.2 pounds. Despite this significant change, the clinical records did not show any assessment or notification to the physician. The resident's weight was not rechecked until six days later, on December 11, 2024, when it had further increased to 154.2 pounds. Again, there was no documentation of physician notification. An interview with a licensed nurse confirmed that the physician was not informed of the significant weight change. This oversight is a violation of the facility's policy and state regulations regarding resident care policies, clinical records, and nursing services.
Failure to Follow Physician's Orders for Oxygen Tubing
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident, specifically regarding the use of ear protectors on oxygen tubing. The resident had a physician's order dated March 7, 2024, to maintain ear protectors on the oxygen tubing at all times. However, despite staff signing off on the Treatment Administration Records that the ear protectors were maintained, a nurse's note on August 28, 2024, indicated that the resident had an abrasion behind the left ear caused by the nasal cannula without the required ear protectors. The resident experienced significant redness and swelling behind the left ear, as noted in a practitioner's visit on August 28, 2024. The practitioner prescribed antibiotics and hydrocortisone cream to treat the condition. The issue was resolved by September 19, 2024, as per the practitioner's note. The deficiency was confirmed with the Nursing Home Administrator on December 12, 2024.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate assistance to prevent a fall for a resident with a history of cerebral infarction, contracture, falls, and intellectual disabilities. The resident, who had moderate cognitive impairment and required extensive assistance with two-person help for bed mobility, was found on the floor after an incident where only one staff member was present during care. The resident was dependent on toileting and personal hygiene and had impairments to one side of the upper and lower extremities. On the day of the incident, the resident was observed lying on the floor in a side-lying position, with no visible signs of pain. The unlicensed staff member, Employee E10, reported that while providing care, the resident lunged to the side of the bed and landed on the floor. The Nursing Home Administrator confirmed that only one staff member was present during the fall, which was contrary to the resident's care requirements for two-person assistance.
Inadequate Documentation of Catheter Care
Penalty
Summary
The facility failed to provide documented evidence of consistent and adequate catheter care for a resident with an indwelling urinary catheter. According to the facility's procedure, catheter care should be performed twice daily and as needed, with documentation in the clinical record. However, a review of the resident's physician's orders, Medication Administration Records, Treatment Administration Record, and care plan did not reveal any evidence of routine catheter care being provided. This deficiency was confirmed with the Nursing Home Administrator.
Failure to Address Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in a resident, identified as Resident 130, who was reviewed for nutrition. According to the facility's procedure, if a resident's body weight is not as expected, a re-weigh should be conducted, and significant weight changes should be reviewed by a licensed nurse. The nurse is responsible for notifying the provider and dietitian, documenting the notification, and informing the physician of any recommendations made by the dietitian. However, Resident 130 experienced a 5.86% weight loss from September 6, 2024, to October 3, 2024, and a further 5.45% loss by November 8, 2024, without any documented intervention or communication with the dietitian. The resident's care plan and order summary did not reflect any interventions to address the weight loss, and there was no evidence in the progress notes or assessments that the weight loss was communicated or addressed by the dietitian. These findings were confirmed with the Nursing Home Administrator.
Failure to Administer Diabetes Medication
Penalty
Summary
The facility failed to ensure that medication for treating diabetes was consistently available for a resident. Specifically, Resident 13 had a physician's order for Trulicity, a medication used to lower blood sugar levels in individuals with type 2 diabetes, to be administered subcutaneously once a week. However, a review of the Medication Administration Record revealed that Trulicity was not administered on three occasions: October 9, October 30, and November 13, 2024. Nursing progress notes for these dates indicated that the medication was not administered because it was not delivered from the pharmacy, as confirmed by an interview with Employee E9. The resident's medical records showed a significant increase in HbA1c levels, from 8.1% in April 2024 to 11.5% in November 2024, indicating poor blood sugar control. The physician's progress notes from November 21, 2024, highlighted that the resident's HbA1c was very high, and the lack of three doses of Trulicity was noted as a contributing factor. This deficiency in pharmaceutical services resulted in the resident not receiving necessary medication to manage their diabetes effectively.
Failure to Implement NPIs and Document Indications for PRN Psychotropic Medication
Penalty
Summary
The facility failed to implement consistent non-pharmacological interventions (NPIs) and provide appropriate indications for the use of as-needed psychotropic medication for Resident 164. The resident had a physician's order for Lorazepam, an anti-anxiety medication, to be administered twice daily and as needed every six hours for anxiety. However, from December 1, 2024, to December 12, 2024, the resident received the PRN Lorazepam six times in 12 days without consistent NPIs being attempted prior to medication administration. Additionally, the clinical records review revealed that the PRN Lorazepam was administered four times without any NPIs being attempted beforehand and six times without appropriate indications documented. An interview with the Director of Nursing confirmed these findings, indicating a failure in the facility's protocol to ensure NPIs were provided and appropriate indications were documented before administering the anti-anxiety medication.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications on the 1 North Unit. During an observation of the short hall medication cart, it was found that there were five white tablets in a medication cup, 12 loose Allegra tablets, and five loose Famotidine tablets, all not in their original containers. Employee E6, who was present during the observation, confirmed that the white tablets were Acetaminophen taken from another cart but could not explain why Allegra and Famotidine were not in their original containers. Further observations on the long hall medication cart revealed 53 loose tablets of various colors and sizes scattered in a drawer, an uncovered glucose gel tube without a pharmacy label, and a vial of used Lantus insulin dated from October. Additionally, in the medication room refrigerator, 23 Acetaminophen suppositories and 22 Bisacodyl suppositories were found stored in a zip-lock bag without a pharmacy label. Employee E8 confirmed that these suppositories should have been in their original containers. These findings were communicated to the Nursing Home Administrator.
Failure to Assess Fall Risk Leads to Resident Injury
Penalty
Summary
The facility failed to accurately assess and identify a newly admitted resident as a fall risk, leading to a fall that caused actual harm. Upon admission, the resident, who had a history of hypotension and syncope, was not assessed as having any risk factors for falls despite hospital documentation indicating ambulation, balance, and strength deficits. The facility's policy required a nursing assessment within 24 hours of admission, but the resident's assessment did not reflect the fall risk factors present in their medical history. As a result of the inaccurate assessment, no care plan or interventions were developed to prevent falls for the resident. This oversight led to the resident experiencing a fall, resulting in significant injuries that required hospitalization. The incident was documented in the resident's progress notes, indicating that the resident was found on the floor with facial lacerations and swelling, necessitating emergency medical services.
Failure to Address Medication Irregularities
Penalty
Summary
The facility failed to ensure that medication irregularities identified during monthly drug regimen reviews were addressed by a physician for four out of five residents reviewed. For Resident 16, a recommendation for a trial dose reduction of Aripiprazole was not acted upon by the physician. Similarly, for Resident 29, recommendations for dose reduction evaluations of Clonazepam, Haloperidol, and Escitalopram were not addressed. Resident 77's recommendation to limit Xanax to a 14-day duration was delayed in being addressed by the physician. Resident 137, who was admitted with severe cognitive impairment and multiple diagnoses including dementia with agitation and depression, had several medication regimen reviews with recommendations for dose reductions and reevaluation of antipsychotic use. These recommendations were not documented as being addressed by the attending physician. Interviews with the Director of Nursing confirmed the lack of physician response to the pharmacist's recommendations for all these residents.
Failure to Perform Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications by not attempting gradual dose reductions (GDR) and not periodically reevaluating psychotropic drug usage for three residents. Resident 16 was prescribed Aripiprazole for Major Depressive Disorder, but there was no attempt to perform a GDR or documentation of a physician's rationale for not doing so. Similarly, Resident 29 was on Klonopin, Lexapro, and Haloperidol for anxiety, depression, and dementia with behavioral disturbances, respectively, but the facility did not attempt GDRs or document any rationale for not attempting them. Resident 137, who had severely impaired cognition and multiple diagnoses including dementia with agitation and psychosis, was prescribed Haloperidol, Olanzapine, and Mirtazapine. Despite recommendations for semi-annual dose reduction evaluations and trial dose reductions, there was no documented evidence that these were performed. Additionally, there was no documentation of periodic evaluations for dual antipsychotic drug usage. The Director of Nursing confirmed the lack of attempts and documentation for GDRs and evaluations for all three residents.
Incomplete Investigation of Resident's Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as Resident 264. According to the facility's policy on accidents and incidents, the Administrator, Director of Nursing (DON), or their designee is required to make every effort to determine the cause of an accident or incident by conducting witness interviews with all staff and visitors who may have knowledge of the event. However, in this case, the investigation was incomplete as it did not include interviews with staff who cared for the resident on the shift when the injury was identified or the previous night shift staff assigned to the resident. This lack of thorough investigation left the facility unable to determine a timeline or cause for the injury. The incident involved Resident 264, who was found to be non-mobile and in pain during rounds, leading to a nurse practitioner ordering immediate x-rays. The x-rays revealed a moderately displaced intertrochanteric fracture of the left hip, and the resident was subsequently sent to the emergency room. The incident report noted that the resident was ambulating normally the previous evening, according to statements from an LPN and a CNA who worked the 3-11 shift. However, these statements did not provide any information regarding the possible cause of the injury. The Director of Nursing confirmed that the investigation into the resident's hip fracture was not thoroughly completed.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that medication ordered by the physician was administered to a resident with Chronic Kidney Failure and Dependence on Hemodialysis. The resident was prescribed Calcium Acetate, a phosphate binder, to manage elevated phosphorus levels, with specific administration times set for 8:30 a.m., 12:30 p.m., and 5:00 p.m. However, the medication was not given at 12:30 p.m. on several occasions due to the resident being out of the facility for dialysis. The missed doses occurred on June 4, 6, 15, 18, and 20, 2024, and the physician was not notified of these missed doses until June 24, 2024. This oversight was confirmed through a review of clinical records and an interview with the Director of Nursing.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor and address significant weight changes for two residents, leading to deficiencies in nutritional care. For one resident, there was a lack of monthly weight monitoring since April, and despite a dietitian's note indicating the absence of an updated weight due to the resident's refusal and a broken scale, there was no documented evidence of the refusal or a care plan addressing the issue. An interview with the Director of Nursing confirmed the absence of weight monitoring, and the Nursing Home Administrator later verified that the scale was functional, indicating a failure to obtain the resident's weight for proper nutritional evaluation. For another resident with a PEG tube and identified as at risk for nutritional alterations, the facility failed to act on a significant weight gain recorded over two days. The resident's care plan required weight reviews and physician notification of significant changes, but despite a noted 7% weight gain, a reweight was not obtained to confirm the change. The Director of Nursing could not provide an explanation for the lack of reweighting, indicating a failure to follow through on the care plan's interventions for monitoring and addressing the resident's nutritional status.
Failure to Administer Prescribed Enteral Nutrition
Penalty
Summary
The facility failed to provide enteral nutrition as ordered by the physician for a resident who returned from the hospital with a PEG tube. The physician had ordered Jevity 1.5 to be administered at 65 ml per hour from 5 p.m. to 9 a.m., totaling 1040 ml per day. However, a review of the resident's Medication Administration Record for April, May, and June 2024 showed no documentation that the resident received the prescribed amount of tube feeding. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documented evidence that the resident received the ordered nutrition.
Failure to Document Non-Pharmacological Interventions Before Administering Pain Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions (NPIs) were attempted and documented prior to the administration of as-needed narcotic pain medication for a resident. The resident had a physician's order for oxycodone, a narcotic pain reliever, to be given every four hours as needed, with a requirement to document all NPIs before administering the medication. However, a review of the resident's Medication Administration Records (MARs) for April, May, and June 2024 revealed that the resident received oxycodone multiple times without any documentation of NPIs being attempted prior to its administration. An interview with the Director of Nursing confirmed the facility's failure to document NPIs before administering the as-needed pain medication. This deficiency was identified during a clinical record review and was in violation of specific Pennsylvania Code regulations related to clinical records, resident care policies, and nursing services.
Failure to Perform Timely Laboratory Services
Penalty
Summary
The facility failed to perform necessary laboratory services for a resident diagnosed with epilepsy, who was prescribed Depakote. A physician's order dated April 29, 2024, required a Depakote level test to be conducted on May 1, 2024. However, the clinical records did not show that this test was completed on the specified date or on May 23, 2024, when it was reordered. An interview with the Director of Nursing on June 24, 2024, confirmed that the Depakote level test was not completed until June 22, 2024. This delay in conducting the required laboratory test constitutes a failure to meet the resident's medical needs as per the physician's orders.
Delay in DEXA Scan Due to Transportation and Transfer Issues
Penalty
Summary
The facility failed to ensure timely radiological diagnostic studies for a resident, resulting in a delay of a DEXA scan. The resident, who had a doctor's recommendation for a DEXA scan to assess bone density, experienced multiple scheduling issues. Initially, the resident was unable to attend the appointment due to transportation issues, as the transport company could not provide a stretcher and the resident could not be transferred from a wheelchair to the examination table. Subsequent attempts to complete the DEXA scan were also unsuccessful due to similar transportation and transfer issues. Despite being sent with an escort, the resident was unable to undergo the procedure on two separate occasions. The Director of Nursing confirmed that the delays were due to the resident's inability to transfer from the wheelchair to the examination table, highlighting a failure in coordinating appropriate transportation and ensuring the resident's needs were met for the diagnostic procedure.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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