Wesley Enhanced Living At Stapeley
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 6300 Greene Street, Philadelphia, Pennsylvania 19144
- CMS Provider Number
- 395715
- Inspections on file
- 24
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Wesley Enhanced Living At Stapeley during CMS and state inspections, most recent first.
A resident with a history of CVA and parkinsonism, who used a manual wheelchair and required staff assistance to stand, was pushed by a CNA down a hallway on the back wheels of a wheelchair without leg rests, with the front wheels elevated so the resident’s feet could not touch the floor, contrary to the care plan for safe transport. The resident verbally objected to being taken to the room, was later found crying, reported that someone had bent her hand, and subsequently was found to have a fracture of the left 4th proximal phalanx of unknown origin while under facility care. A CNA witness did not report the alleged abuse to nursing staff as required by the facility’s abuse-prevention and reporting policies, and there was no documentation of the probable cause of the serious injury.
Two residents did not receive care that maintained their dignity and comfort: one had medication applied in a public hallway without privacy by an LPN, and another was left lying on a bare mattress for over an hour after care, despite clean linens being available. Staff interviews and observations confirmed these lapses in providing necessary privacy and basic necessities.
A resident was transferred to a hospital for evaluation, but the required notification to the Office of the State Long-Term Care Ombudsman was not made until over two months later. Facility documentation and staff interviews confirmed the delay in notification following the facility-initiated emergency transfer.
A resident admitted with dementia did not have a baseline care plan developed and implemented within 48 hours of admission, as required by facility policy. The absence of this plan was confirmed by the DON during review.
Three residents with severe cognitive and physical impairments did not receive timely assistance with grooming tasks such as nail care, haircuts, and shaving. These residents, who were dependent on staff for ADLs, were observed or reported to have unmet hygiene needs, which were confirmed by staff and family interviews.
The facility did not ensure that medically-related social services, specifically routine care plan meetings, were provided as required for several residents. Care conferences were not held at the required quarterly intervals, and staff shortages contributed to these delays. Family members reported dissatisfaction with communication, and the Social Service Director confirmed the lapses in care planning.
A resident with multiple neurological and mobility diagnoses was prescribed Diclofenac gel for arthritis pain. During a pharmacy review, the pharmacist recommended clarifying the administration directions by specifying the gram strength for Voltaren Gel. The facility did not implement these recommendations, and the omission was confirmed by the DON.
Surveyors observed that medication carts on one nursing floor were repeatedly left unlocked and unattended by multiple nurses, and refrigerated medications were found wet and stored at improper temperatures due to a malfunctioning refrigerator. These findings were confirmed by staff and were not in accordance with facility policy.
The facility did not ensure that meals were palatable, attractive, or served at safe and appetizing temperatures. Multiple residents reported that food was often cold, difficult to chew, and lacked flavor, leading them to request alternatives. Observations and test tray evaluations confirmed that hot foods were served below required temperatures, planned menu items were not provided, and delays in meal delivery occurred. The dietary director confirmed that recipes and menus were not followed as required.
Several residents were found to have personal refrigerators containing food brought by family or visitors that were not labeled or monitored for temperature, and staff did not provide guidance on safe food storage practices, resulting in improper storage and handling of perishable items.
A resident was diagnosed and treated for bacterial conjunctivitis on two occasions, but the infection was not recorded in the facility's infection tracking logs for two consecutive months, despite clear documentation in the clinical record and physician orders. The Infection Preventionist confirmed the omission and was unable to explain how it occurred, resulting in a failure to follow the facility's infection surveillance policy.
Surveyors found that essential kitchen equipment, including the dish machine, booster heater, water softener, three compartment sinks, garbage disposal, grease trap, and exterior doors, were not maintained in safe or functional condition. The dish machine failed to reach required sanitizing temperatures, sinks and plumbing were leaking, the garbage disposal and grease trap were inoperable, and exterior doors did not seal properly, all of which were confirmed by interviews with facility staff.
The facility did not maintain an effective pest control program, as evidenced by unrepaired kitchen flooring with water and food debris from leaking equipment, and exterior doors near the kitchen that did not seal properly, leaving gaps that could allow pests to enter. Pest control reports confirmed ongoing issues with pests and rodents, and the director of maintenance and housekeeping acknowledged the need for repairs and cleaning.
A resident's grievance regarding alleged abuse or neglect was not properly filed or tracked according to facility policy. The responsible social worker did not add the incident to the grievance log and was unaware of the grievance policy, while the administrator could not provide knowledge of such a policy. The facility's failure to document and resolve the grievance as required led to noncompliance with established procedures.
A resident with significant medical conditions reported falling during a Hoyer lift transfer by a nurse aide, who then discouraged reporting the incident. The event was not immediately reported to the state health department as required, and documentation was incomplete, resulting in a deficiency for failure to ensure timely reporting of suspected abuse or neglect.
A resident with significant medical conditions reported falling during a Hoyer lift transfer performed by a nurse aide, who then asked the resident not to report the incident. The facility did not complete a thorough investigation, failing to interview the alleged staff member, other staff on relevant shifts, or other residents, and left investigation documentation incomplete.
A resident with osteoporosis was injured during a transfer from bed to chair due to the facility's failure to follow the care plan requiring a mechanical lift. Two nurse aides, unfamiliar with the resident's specific needs, conducted the transfer improperly, resulting in the resident's left leg twisting and sustaining a femur fracture.
The facility was found to have deficiencies in food safety and sanitation practices. Observations revealed that the kitchen area was heavily soiled with dust, dirt, and food debris, with stained ceiling tiles and dead pests in light fixtures. The garbage disposal was malfunctioning, causing water to spew into the sink area, and the floor drains were obstructed. Additionally, a metal door leading outside did not seal properly, allowing potential pest entry near the dry food storage area. The director of dietary services confirmed the lack of routine sanitation and proper food handling practices.
A resident with a complex medical history did not receive timely diagnostic services as ordered by their physician. The facility failed to conduct an ABI test, which was necessary for the resident's follow-up care. The Unit Manager confirmed the test was not completed, resulting in a deficiency in meeting the resident's needs.
The facility failed to protect two residents' property from theft. One resident reported $110 missing from her wallet, and another reported $30 missing from his desk drawer. Neither resident was provided with lockable storage for their belongings, contrary to facility policies. Interviews confirmed the lack of secure storage options in their rooms.
A facility failed to create a care plan for a resident with edema, who has severe cognitive and physical impairments. Despite physician orders to keep the resident's right arm elevated to manage swelling, the resident was observed with the arm not elevated. The facility lacked a care plan addressing this intervention.
The facility failed to complete neurological assessments for a resident with multiple unwitnessed falls and did not obtain a physician's order for a hand splint for another resident. Despite the protocol for immediate assessments after falls, no documentation was found for a resident on anticoagulants. Another resident was observed with a splint without an active order or skin assessments, as confirmed by the Nursing Home Administrator.
A resident with hemiplegia and cognitive impairment fell from bed during personal care due to inadequate supervision and assistance. The resident required two-person assistance for bed mobility, but a nurse aide attempted to turn the resident alone, resulting in a fall and minor injuries.
The facility failed to adhere to infection control practices, as staff did not follow hand hygiene protocols during wound care and medication administration for two residents. One resident with a G-Tube did not receive proper enhanced barrier precautions, and an LPN improperly handled a cup during medication delivery.
A facility failed to ensure proper administration of medications for a resident with end-stage renal disease, pseudoseizure disorder, and hypotension. The resident was entrusted to transport medication to the dialysis center without being assessed for the ability to do so, leading to missed doses and hospitalizations. Interviews confirmed the lack of policies to ensure medication delivery and administration, resulting in the resident not receiving critical medications as prescribed.
Failure to Prevent and Report Physical and Mental Abuse Resulting in Hand Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and mental abuse and to ensure mandated reporting of alleged abuse. Facility policies stated that residents have the right to be free from abuse, neglect, corporal punishment, involuntary seclusion, and improper restraint, and that all employees are mandated reporters required to immediately report alleged abuse to a supervisor and administration. The administrator was responsible for implementing abuse-prevention policies, ensuring staff training, and identifying, assessing, investigating, and reporting all possible incidents of abuse within required timeframes. The resident involved had a history of CVA and parkinsonism, used a manual wheelchair, and was dependent on staff to stand. A quarterly MDS indicated the resident could understand and be understood, had no functional limitations in upper or lower extremities, and used a wheelchair for mobility, though a PT assessment documented that the resident could not propel the wheelchair 150 feet and was not capable of operating the wheelchair with full purpose due to decreased cognitive skills. The care plan included use of leg rests as needed for safe transportation while seated in the wheelchair. Observation showed the resident could slowly self-propel a short distance. On the date of the incident, a CNA (Employee E6) was observed on camera pushing the resident from the lounge/activity area down the hallway on the back wheels of a manual wheelchair without leg rests, with the front wheels elevated and the chair reclined so the resident’s feet dangled and could not touch the floor, restraining the resident from normal use of the wheelchair. A CNA witness (Employee E5) reported that the resident verbally expressed not wanting to go to her room while being pushed and was later found crying in her room, stating that someone had bent her hand and threatening to kill Employee E6 if that staff member returned to care for her. This alleged abuse was not reported by Employee E5 to an RN or LPN on either the day or evening shift as required by policy. Later that evening, an RN was called to assess the resident’s painful, swollen left hand, the physician ordered an x-ray and pain medication, and subsequent imaging revealed a fracture of the left 4th proximal phalanx of unknown origin while under facility care. The physician indicated being unaware that the resident had fallen or sustained trauma, and there was no documentation of the probable cause of the serious injury.
Failure to Maintain Resident Dignity and Provide Basic Comfort
Penalty
Summary
The facility failed to maintain resident dignity and provide necessary care and comfort for two residents. In one instance, a licensed nurse administered a topical medication to a resident's shoulders in a public hallway, without providing privacy. This occurred near the activity room where other residents were present and in view, and while other residents were passing by for breakfast. The resident had moderate cognitive impairment and required moderate assistance with activities of daily living. In another instance, a resident who was dependent for activities of daily living and used a wheelchair was observed lying on a bare plastic mattress without sheets, blanket, or pillowcase for over an hour after care was provided. The nurse aide assigned to the resident stated she was unable to make the bed due to a perceived lack of linens, although other staff and a tour of the linen storage areas confirmed that clean linens were available on the unit and in the laundry room. The resident reported that the bed was stripped and left unmade after morning care.
Failure to Notify Ombudsman of Emergency Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding a facility-initiated emergency transfer of a resident to the hospital. Review of the clinical record showed that the resident was transferred to the local hospital for evaluation, as documented in a nursing progress note. However, documentation provided by the Nursing Home Administrator confirmed that the required notification to the Ombudsman was not made until more than two months after the transfer occurred. An interview with the Nursing Home Administrator further confirmed that the Ombudsman was not informed at the time of the resident's hospital transfer.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one of two new admissions reviewed. According to facility policy, a baseline plan of care is required to address each resident's immediate health and safety needs within forty-eight hours of admission. Review of the clinical record for a resident admitted with a diagnosis of dementia showed that while a comprehensive care plan was initiated several days after admission, there was no evidence of a baseline care plan specifically addressing dementia. This was confirmed by the Director of Nursing during an interview, who acknowledged the absence of a baseline care plan for the resident.
Failure to Provide Timely Grooming Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) related to grooming for three residents with significant cognitive and physical impairments. One resident with dementia, muscle weakness, and osteoarthritis was observed to have long nails and expressed a desire to have them cut, which was confirmed by the unit manager. Another resident, who was nonverbal, dependent on staff for all care, and receiving hospice services, was reported by a family member to be in need of a haircut and nail care, with delays in both being addressed despite prior notification to the facility. The unit manager confirmed the observations of long nails and hair for this resident. A third resident with parkinsonism, mobility issues, and severe cognitive impairment was observed to have facial hair and expressed a desire to be shaved, which was also confirmed by the unit manager. Clinical records and care plans for these residents indicated a need for staff assistance with grooming and hygiene tasks due to their cognitive and physical limitations. Despite these documented needs, the facility did not consistently provide timely grooming care, resulting in unmet personal hygiene needs for these residents.
Failure to Provide Timely Social Services and Care Plan Meetings
Penalty
Summary
The facility failed to provide medically-related social services as required, specifically in relation to the scheduling and conducting of routine care plan meetings for four out of eight residents reviewed. Facility policy requires that baseline care plans be developed and updated as needed until a comprehensive care plan is created, with care conferences to be held quarterly. Clinical record reviews showed that care conferences for several residents were not held at the required intervals, with significant gaps between meetings. For example, one resident's last care plan meeting was over six months prior, and there was no upcoming meeting scheduled. Interviews confirmed these findings, with a family member expressing dissatisfaction with the lack of social service communication and the absence of timely care plan meetings. The Social Service Director acknowledged that care conferences had been delayed due to staffing shortages in the department. These failures were found to be non-compliant with state regulations regarding the provision of social services and the responsibilities of the licensee.
Failure to Implement Pharmacy Recommendations for Medication Administration
Penalty
Summary
The facility failed to act on pharmacy recommendations in a timely manner for one of three residents reviewed. Resident R78, who had a medical history including transient ischemic attack, cerebral infarction, dementia, difficulty walking, muscle weakness, and unsteadiness, was prescribed Diclofenac sodium gel for arthritis pain. During a drug regimen review, the pharmacist recommended specifying the gram strength in the administration directions for Voltaren Gel, advising 4 grams for lower extremities and 2 grams for upper extremities. Despite this recommendation, the facility did not implement the suggested changes, as confirmed by the Director of Nursing, and the recommendation remained unaddressed.
Medication Storage and Security Deficiencies
Penalty
Summary
Facility staff failed to ensure that medication carts were kept locked and that refrigerated medications were stored properly on the second floor. Multiple observations revealed that medication carts assigned to different licensed nurses were left unlocked and unattended. Specifically, one nurse left the cart unlocked while coming out of a resident's room, another was unaware her cart was unlocked, and a third left the cart unlocked while retrieving supplies from the kitchen. These incidents were confirmed by interviews with the involved staff and the nursing supervisor. Additionally, the medication refrigerator in the second floor medication room was found to have a temperature reading of 50 degrees, with the top of the refrigerator frozen and water dripping onto the medications, resulting in all contents being wet. These conditions were observed and confirmed by the nursing supervisor. Facility policies require that all medications and biologicals be stored in locked compartments and under proper temperature conditions, but these requirements were not met during the survey.
Failure to Provide Palatable, Attractive, and Safe-Temperature Meals
Penalty
Summary
The facility failed to provide foods and drinks that were palatable, attractive, and at a safe and appetizing temperature to residents, as required by policy. Observations during meal service revealed that the main hot entrée, country fried steak, was overcooked or held hot for an extended period, making it difficult for residents and staff to cut and chew. Additionally, the planned cream gravy was not served, and residents requested substitute food items due to the unpalatable and unappetizing nature of the meal. A review of the menus showed that all diet types were supposed to receive cream gravy, but this was not provided. Residents reported during a group meeting that food was often served cold, difficult to chew, lacked flavor, and was not seasoned, leading them to frequently request alternative menu items. A test tray evaluation confirmed that foods and fluids were not consistently served at safe and appetizing temperatures, with hot foods such as corned beef and cabbage and mashed potatoes being served well below the required 135 degrees Fahrenheit. Delays in meal tray delivery were observed, and the director of dietary services confirmed both the delays and the failure to meet temperature standards. Further review of the menu revealed multiple discrepancies between the planned and served items, including substitutions and omissions. The director of dietary services acknowledged that recipes and menus were not followed as planned on the observed dates.
Failure to Ensure Safe Storage and Handling of Resident Food Brought by Visitors
Penalty
Summary
The facility failed to ensure the safe and sanitary storage and handling of personal food products brought in by family and visitors for three residents. Observations revealed that one resident had Chinese takeout food in a Styrofoam container, red paper, and a peach stored in a personal refrigerator without a temperature log, and the resident had not received any guidance from the facility on maintaining food safety. Another resident had three food containers in a personal refrigerator, none of which were labeled with dates, and there was no temperature log present. This resident also reported that the facility had not provided any instructions on how to safely store food. Interviews with the unit manager and the administrator confirmed that several residents were allowed to have personal refrigerators without being given guidance on food safety standards. One resident expressed frustration that her food items were frozen due to the refrigerator being set at a freezing temperature. The facility's policy requires perishable foods to be stored in resealable containers with tightly fitting lids, labeled with the resident's name, the items, and the use-by date, and for safe food handling practices to be explained to families and visitors, but these procedures were not followed.
Failure to Track and Document Resident Infection in Surveillance Logs
Penalty
Summary
The facility failed to implement appropriate tracking and surveillance of infections for two of the three months reviewed, specifically in April and May 2025. According to the facility's own infection prevention and control policy, the program is required to perform surveillance, use infection reports to improve processes, and take corrective actions as indicated. However, documentation review revealed that a resident developed eye drainage and was subsequently diagnosed and treated for bacterial conjunctivitis with antibiotic eye drops on two separate occasions during the review period. Despite these documented infections and treatments, the facility's infection tracking records for April and May did not include this resident's infection. An interview with the Infection Preventionist confirmed that the resident was diagnosed and treated for bacterial conjunctivitis, but the infection was not recorded in the facility's infection tracking logs for the relevant months. The Infection Preventionist was unable to explain how this omission occurred. This failure to accurately track and document infections is not in accordance with the facility's infection prevention and control policy and the requirements for ongoing surveillance as outlined in regulatory guidelines.
Unsafe and Non-Functional Kitchen Equipment and Infrastructure
Penalty
Summary
Essential equipment in the food and nutrition services department was found to be in unsafe and non-functional condition. The dish machine was not reaching the required final rinse temperature of 180 degrees Fahrenheit, with observed readings at only 150 degrees. The booster heater for the dish machine was confirmed to be non-functional, and the water softener had not been working for months. The three compartment sinks were in disrepair, with one well unable to hold water and leaking from the stopper, piping, and mechanisms underneath. The garbage disposal adjacent to the sinks was not operating according to manufacturer specifications, spewing water onto the floor, which had deep grooves and missing grout due to water damage. The grease trap in the same area was out of commission and covered with soggy plywood, further saturated by continuous leaks and water from the broken disposal. Additionally, the metal doors leading directly outdoors from the kitchen hallway were not sealing properly, leaving visible gaps at the threshold. These deficiencies were confirmed through interviews with the administrator and the director of dietary services, who acknowledged that the dish washer, booster heater, water softener, garbage disposal, three compartment sink, grease trap, and metal doors were not maintained in safe mechanical and operational condition. No information about residents' medical history or condition was provided in the report.
Deficient Pest Control Program and Environmental Maintenance
Penalty
Summary
The facility failed to maintain an effective pest control program in the food and nutrition services department. Environmental observations revealed that the main kitchen had flooring in need of repair, with missing and worn grouting due to water damage in the three compartment sink area. Pooling water and food debris were present as a result of leaking and inoperable equipment, including the sink, garbage disposal, and grease trap, providing nutrients for pests and rodents. Additionally, metal doors near the main kitchen that led directly outdoors did not seal properly, leaving one-inch gaps at the threshold, which could allow pests to enter from the driveway where the dumpster was located. Pest control operator reports confirmed ongoing treatment for common household pests and rodents in the facility, including the main kitchen. The director of maintenance and housekeeping confirmed the need for repairs and cleaning to address these issues.
Failure to File and Track Grievance Related to Alleged Abuse/Neglect
Penalty
Summary
The facility failed to ensure that a grievance regarding alleged abuse or neglect was properly filed, tracked, and promptly resolved for one resident. According to the facility's own policy, upon receipt of a grievance or complaint, the grievance officer is required to review and investigate the allegations, submit a written report to the administrator within five working days, and coordinate actions with appropriate agencies as necessary. However, review of the facility's grievance log for the relevant months showed no entry for the resident's grievance in April, despite a Grievance Form being filled out for a reportable incident. The social worker responsible for the grievance log admitted that the incident was not added to the log and also stated she was unaware of the facility's grievance policy during her employment. Further, the social worker explained that she was covering for another staff member on leave and that both she and the absent employee were responsible for the grievance log. The administrator, when asked, was unable to provide knowledge of a grievance policy beyond what was included in the admissions packet. The social worker became aware of the situation during a clinical meeting and conducted an interview with the resident involved, but did not interview other residents associated with the alleged perpetrator, as they were deemed non-interviewable. These actions and omissions resulted in the facility not following its own grievance procedures and failing to document and resolve the grievance as required.
Failure to Timely Report Alleged Abuse/Neglect Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health as required. A resident with hemiplegia, morbid obesity, and atherosclerosis reported falling to the ground while being transferred with a Hoyer lift by a nurse aide. The resident stated that after the fall, the aide asked her not to report the incident, expressing concern about losing her job. The resident eventually reported the incident due to ongoing pain and learning that the aide had resigned. Facility records showed that the incident was documented in a grievance form, but the date of completion was left blank, and the report was not entered into the Pennsylvania Electronic Event Reporting System immediately upon receiving the allegation. Staff interviews confirmed that the administrator was aware of the requirement to report but did not follow up to ensure the report was submitted. This resulted in a failure to comply with state regulations regarding timely reporting of suspected abuse or neglect.
Failure to Thoroughly Investigate Alleged Abuse/Neglect Incident
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of abuse/neglect involving a resident with hemiplegia, morbid obesity, and atherosclerosis. The resident reported falling to the ground while being transferred from bed to wheelchair using a Hoyer lift by a nurse aide. The incident was not immediately reported by the staff involved, and the resident only disclosed the fall later due to ongoing pain and after learning the aide had resigned. Documentation showed that the resident described the fall and the aide's request to keep the incident quiet, fearing job loss. The facility's investigation records were incomplete, lacking evidence that the alleged perpetrator (the nurse aide) was contacted or interviewed. There was also no documentation of attempts to interview other licensed nurses, nurse aides across relevant shifts, or other residents who may have been under the care of the involved aide. The investigation section of the grievance form was left incomplete, and the date of completion was not recorded. These omissions indicate that the facility did not follow its abuse prevention policy or ensure a comprehensive investigation into the reported incident.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, who was diagnosed with osteoporosis, was transferred according to their care plan using a mechanical lift from bed to chair. This deficiency resulted in actual harm to the resident, whose left leg was bent and twisted during the transfer, leading to a fracture of the left femur. The facility's policy on using a mechanical lifting machine, which includes preparing the environment and checking the stability of attachments, was not followed during the transfer. The incident involved two nurse aides, neither of whom were familiar with the resident's specific care needs related to transfers. One of the aides was on orientation at the time of the incident. During the transfer, the resident's left leg twisted inward, causing pain and subsequent injury. The resident, who was visually impaired and had cognitive impairments, required substantial assistance with transfers, as noted in their care plan. Despite these requirements, the transfer was not conducted with the necessary precautions, leading to the resident's injury.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have deficiencies in the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. During an environmental tour of the main kitchen, it was observed that the area where cleaned dishes were stored was heavily soiled with dust, dirt, and food debris. The ceiling tiles were stained and water-damaged, and the light fixtures contained dead pests. The fan and ceiling vent in the area were also covered in dirt and dust. Additionally, the wall surrounding the three-compartment sink was soiled with dried food debris, and the garbage disposal was malfunctioning, causing water to spew into the sink area. The floor beneath the sink and garbage disposal was wet, with drains obstructed by food debris and dirt. Furthermore, the metal door leading outside to the trash area did not seal properly, leaving a gap that could allow pests and rodents to enter. This door was located near the dry food storage area, posing a risk to food safety. The director of dietary services confirmed the lack of routine sanitation and proper food handling practices, which could lead to foodborne illnesses. These observations indicate a failure to maintain a clean and safe environment for food preparation and storage, as required by professional standards and state regulations.
Failure to Provide Timely Diagnostic Services
Penalty
Summary
The facility failed to provide timely x-ray services or arrange for them through an approved provider, as required by their policy, for Resident R62. The resident, who was alert and oriented, had a complex medical history including a fracture, coronary heart disease, high blood pressure, diabetes mellitus, a stroke with one-sided weakness, and an unstageable pressure ulcer. After a fall at home resulting in a broken ankle and subsequent heart attack and stroke, the resident was admitted to the facility. The physician ordered specific diagnostic tests, including ankle-brachial pressure indices (ABIs), a left arterial duplex ultrasound, and a left venous reflux ultrasound, to be conducted before a follow-up appointment. Despite the physician's orders and the facility's policy requiring the arrangement of such tests, the ABI test was not conducted. The Unit Manager confirmed that the facility does not perform ABI tests and acknowledged that the test was not completed. This oversight was identified during a review of the resident's clinical records, which showed no evidence of the ABI test being performed, leading to a deficiency in meeting the resident's diagnostic needs as per the physician's orders.
Failure to Protect Residents' Property from Theft
Penalty
Summary
The facility failed to ensure the protection of residents' property from loss or theft, as evidenced by incidents involving two residents. Resident R27 reported missing $110 from her wallet after returning from a dialysis center. It was confirmed through interviews and observations that Resident R27 was not provided with a drawer or cabinet in her room that could be locked to secure her personal belongings. Similarly, Resident R88 reported $30 missing from his desk drawer, which was a piece of furniture he brought from home and could not be locked. The facility did not provide any furniture with locking capabilities to secure personal belongings for Resident R88. The facility's policies, including the abuse policy and room furnishings policy, were reviewed. The abuse policy defined misappropriation of property as a form of abuse and outlined the facility's responsibility to investigate missing property. The room furnishings policy indicated that residents should be provided with lockable storage for their belongings. Interviews with social workers confirmed that neither resident was offered or provided with lockable storage, which contributed to the loss of their personal property.
Failure to Develop Care Plan for Edema
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with edema. The resident, who has severe cognitive impairment, physical impairments on one side of the body, and is dependent on staff for mobility and personal care, was observed with a swollen right hand. Physician orders required the resident's right upper extremity to be elevated at all times to manage the edema. However, during an observation, the resident was found in bed with the right arm by her side, not elevated, contrary to the physician's orders. The facility did not have a care plan in place addressing the resident's edema, including the necessary intervention of elevating the extremity.
Failure to Complete Neurological Assessments and Obtain Splint Order
Penalty
Summary
The facility failed to ensure that neurological assessments were completed for a resident who experienced multiple unwitnessed falls. Resident R85, who was severely cognitively impaired and at high risk for falls due to impaired cognition and atrial fibrillation, experienced unwitnessed falls on several occasions. Despite the facility's protocol to perform neurological assessments immediately after a fall, there was no documented evidence that these assessments were completed on the specified dates. The Medical Director confirmed the importance of these assessments, especially given the resident's use of anticoagulant medication, which increases the risk of bleeding. Additionally, the facility did not obtain a physician's order for the use of a hand splint for Resident R42, who was assessed with severe cognitive and physical impairments. The resident was observed wearing a splint on her left hand, but the order for the splint had been discontinued, and there was no evidence of an active order or skin assessments while the splint was in use. The Nursing Home Administrator confirmed the lack of an order and the absence of skin assessments, indicating a failure to provide appropriate care according to the resident's needs.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, identified as Resident R38, who was at risk of falling due to significant medical conditions. Resident R38 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, dysphagia, muscle weakness, and morbid obesity. The resident was cognitively impaired and required extensive assistance with bed mobility, specifically needing two-person physical assistance for rolling left and right. Despite these needs being documented in the resident's care plan, the facility did not ensure compliance with this requirement during personal care. An incident occurred where a nurse aide, identified as Employee E20, turned Resident R38 on their left side without the required assistance, resulting in the resident falling from the bed. The fall caused the resident to sustain a small amount of bleeding around the mouth and complaints of pain in the face and right leg. The resident was subsequently assisted back to bed using a Hoyer lift, and medical personnel were notified. The facility's failure to adhere to the care plan and provide the necessary two-person assistance directly led to the resident's fall and injury.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by observations and staff interviews. The infection control policy, revised in August 2012, requires hand hygiene after removing gloves, before handling dressings, and before moving from a contaminated to a clean body site during resident care. Additionally, the Enhanced Barrier Precautions Policy, updated in August 2024, mandates the use of personal protective equipment during high-contact activities for residents with indwelling medical devices. However, during an observation on August 5, 2024, a Licensed Practical Nurse (LPN) and Nursing Assistants failed to follow these precautions while providing wound care to a resident with a G-Tube, as the LPN did not clean hands before donning new gloves. Another incident involved improper hand hygiene during medication administration. On August 7, 2024, an LPN was observed holding a resident's cup with a hand on top of the cup and palm resting on the rim while delivering a drink. These actions are contrary to the facility's infection control policies, which require hand hygiene before handling medications. The residents involved in these incidents included one with severe cognitive and physical impairments, dependent on staff for mobility and personal care, and another resident during medication administration.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice before and during dialysis treatment for a resident with end-stage renal disease, pseudoseizure disorder, and hypotension. The resident was prescribed Levetiracetam and Carvedilol, with specific instructions for the Levetiracetam to be administered at the dialysis center. However, the resident was entrusted to transport the medication to the dialysis center without being assessed or care planned for the ability to self-administer or transport medications. This led to instances where the resident did not receive the medication as prescribed, including an incident where the resident experienced a pseudoseizure and was sent to the hospital from the dialysis center. Additionally, there was no documentation indicating that the director of nursing or the physician were notified of the resident's refusal to take medications on a specific date, which resulted in the resident being transferred to the hospital due to unresponsiveness and syncope. Interviews with the Director of Nursing and licensed nursing staff confirmed that there were no policies and procedures in place to ensure that the resident arrived at the dialysis center with the prescribed medication. The facility and the dialysis center had no record of what was happening with the medication during the entire months of March and April 2024. The Director of Nursing confirmed that the facility failed to ensure that the resident received medications as ordered by the physician according to professional standards of practice for safe administration and security of medications on hemodialysis days. The facility's policy required licensed nursing staff to administer medications in a safe and timely manner as prescribed by the physician, with supervision by the director of nursing services. Medications were to be administered within one hour of their prescribed time, and the administration was to be recorded in the medication administration record with the date, time, and signature of the licensed nurse. The facility's failure to adhere to these policies and procedures resulted in the resident not receiving critical medications as prescribed, leading to adverse health events and hospitalizations.
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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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