Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wesley Enhanced Living Pennypack Park during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and multiple pressure ulcers did not have required wound care documentation completed on several occasions. The facility's records lacked details of wound treatments for multiple wound sites, contrary to its own wound care policy and professional standards.
Food Storage and Cooling Deficiencies: The FSD was observed with multiple food safety issues, including undated and unlabeled ground beef and hot dogs, uncovered and undated hashbrowns, expired cheese and onions, and diced potatoes cooling in an undated deep pan. The FSD confirmed the findings during the kitchen tour.
Improper garbage disposal was observed in the receiving and dumpster area during a food delivery. Three uncovered trashcans were present, one contained foul-smelling refuse exposed to open air, and a white milky liquid was pooling on the floor and spreading into walking and delivery zones used to transport food into the kitchen. The Food Service Director confirmed the observations.
Failure to maintain confidentiality during medication administration. An LPN administered meds in a dining room with multiple residents and staff present, spoke audibly about the resident's meds, and left a computer screen open on the med cart displaying PHI to passersby. The DON confirmed the screen should have been covered and privacy should have been maintained during med pass.
The facility failed to provide written notice to a resident and/or the resident’s representative explaining hospital transfers and the reasons for the moves in a language and manner they understand. Records showed one resident was transferred twice for hospital evaluation and another resident was transferred after a fall, but documentation of the required written notices was not found. The administrator and DON confirmed this was not facility practice, including notice of bed-hold duration.
An LPN administered tacrolimus ER to a resident while the resident was eating breakfast, despite FDA guidance that the medication be taken once daily on an empty stomach, preferably in the morning. The resident had an order for tacrolimus ER for anti-rejection, and the Unit Manager later stated the medication time would be changed to the appropriate time.
Incomplete clothing inventory records were found for two residents after a cognitively intact resident reported that multiple clothing items belonging to his wife were missing and could not be located by staff. Interviews showed the social worker learned of the issue from laundry staff, the only inventory sheet on file did not list any clothing, and the Administrator and DON confirmed that nursing staff had not completed inventory sheets for either resident’s belongings.
A resident with severe obesity, dementia, and muscle weakness, who required two staff for mechanical lift transfers, was transferred by a single CNA in violation of policy and care plan. During the transfer, the resident fell, sustaining multiple skin tears and bruising, and experienced severe pain requiring hospital evaluation. Investigation found no equipment defect and confirmed only one staff member was present during the transfer.
A resident who was dependent on staff for transfers was moved using a mechanical lift by a single nurse aide, despite facility policy and physician orders requiring two staff for such transfers. During the transfer, the resident fell, sustaining multiple skin tears, bruising, and severe pain, which required hospitalization. Investigation confirmed the lift equipment was not defective and the incident was due to inadequate staffing during the transfer.
A nurse aide did not receive a required annual performance review, and a resident was injured during a transfer when the aide used a mechanical lift alone, against facility policy requiring two staff for such transfers. The DON confirmed there was no process for completing employee performance evaluations.
A facility failed to re-admit a resident after hospitalization, despite the resident being medically stable and off restraints. The resident, with a history of aggressive behavior and multiple medical conditions, was initially sent to the hospital due to increased aggression. The facility's DON and NHA refused re-admission, citing inadequate documentation, and did not collaborate with the hospital to address the resident's needs, leading to a deficiency.
A facility failed to create a person-centered care plan for a resident with complex medical and psychological needs, including anxiety and hallucinations. The resident exhibited challenging behaviors such as aggression and medication refusal, yet no comprehensive plan was in place to manage these issues. The Unit Manager confirmed the absence of such a plan, highlighting a deficiency in regulatory compliance.
A resident with a history of UTI and delirium was admitted with acute encephalopathy and exhibited aggressive behaviors. Despite repeated recommendations from a psychiatric nurse practitioner to conduct lab tests, including a urine analysis, the facility failed to follow through. The resident's condition worsened, leading to hospitalization for an acute kidney injury and a UTI.
A resident with diabetes exhibited aggressive behaviors and refused meals and medications. Despite recommendations from an endocrinologist and a psychiatric nurse practitioner to consult endocrinology and monitor blood sugar levels, the facility failed to schedule an appointment or contact the endocrinologist. The DON confirmed the endocrinologist was not contacted regarding the resident's diabetes management.
The facility failed to maintain an effective pest control program, leading to the presence of pests such as mice and roaches. Observations noted an air gap in the kitchen doors and a mouse in the second floor kitchenette. Pest control reports from June to October 2024 indicated repeated treatments but highlighted issues like food debris and water on kitchen floors, suggesting inadequate pest control measures.
A facility failed to update a resident's care plan regarding their activities of daily living. The resident, with diagnoses of muscle weakness, dementia, and mobility issues, had a physician's order for physio-therapy. Despite this, the care plan was not revised to reflect the resident's current status, as confirmed by the DON.
A resident with a history of alcohol abuse eloped from the facility unsupervised, returning with alcohol. Despite being cognitively intact, the resident left without using her usual mobility aids, which went unnoticed by staff. The facility's elopement prevention policy was not effectively implemented, leading to a lapse in supervision.
A facility failed to follow physician orders for a resident's indwelling urinary catheter. The resident, with a history of UTI, cognitive communication deficit, and depression, had an order for a 16FR/10ML Foley catheter. However, the catheter in use lacked size markings, preventing verification of compliance with the order. This was confirmed by an RN.
A resident experienced significant weight loss and developed pressure sores, yet the facility failed to conduct a comprehensive nutritional assessment as required by its policies. Despite a low albumin level indicating malnutrition and the resident's need for assistance with eating, there was no documentation of nutritional interventions or consideration of food preferences and adaptive utensils.
A resident with multiple health conditions was found to be receiving oxygen at 4.5 liters per minute, contrary to the physician's order of 2 liters per minute for pulse oxygen levels below 92%. The oxygen tubing was also not dated, and there were no orders for the frequency of tubing changes, as confirmed by staff interviews.
A facility failed to document the clinical rationale for continuing an antipsychotic medication and did not attempt a gradual dose reduction (GDR) for a resident. The resident, admitted with dementia and muscle weakness, was prescribed Quetiapine Fumarate for psychosis. The facility's policy requires a GDR unless clinically contraindicated, but no evidence of a GDR attempt or rationale documentation was found. The DON confirmed these findings.
A resident's medications were found unattended on a bedside table, left by a nurse without explanation. The resident, with multiple health conditions, confirmed the medications were his. A nurse verified the medications were left unattended, indicating a failure in secure storage and administration protocols.
A resident experienced prolonged mouth pain due to decaying teeth, as the facility failed to provide timely dental services despite a policy ensuring routine and emergency care. A dental examination confirmed the need for extractions and dentures, but staff delayed arranging these services, acknowledging awareness of the required follow-up care.
A facility failed to ensure accurate physician orders for a resident's oxygen therapy. The resident was observed without the prescribed oxygen device, and both the resident and their MDS indicated no need for oxygen therapy. A nurse confirmed the inaccuracy of the orders.
A facility failed to maintain an effective infection control program when an RN examined a resident's urinary Foley catheter without wearing PPE, despite the resident being suggested for Transmission Based Precautions. The facility's policy requires PPE to prevent exposure to body fluids, which was not adhered to in this instance.
The facility did not provide education on the benefits and potential side effects of the influenza vaccine to residents before administering it for the 2024-2025 flu season. This was confirmed through clinical record reviews and staff interviews, indicating a lapse in compliance with Pennsylvania Code requirements.
Essential equipment in the dietary services department was not fully operational, with dish machines in the main kitchen and nursing unit kitchenettes failing to meet the manufacturer's specifications for sanitizing temperatures. The main kitchen's dish machine required a booster heater repair, while the second floor B wing, first floor A wing, and C wing kitchenettes had dish machines with insufficient rinse temperatures.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure complete documentation of wound care treatments for one resident with multiple pressure ulcers. According to the facility's own wound care policy, specific information must be recorded in the medical record after each wound treatment, including the type of care given, date and time, resident positioning, the name and title of the caregiver, assessment data, resident tolerance, and any problems or refusals. However, review of the clinical record for a resident diagnosed with hemiplegia, hemiparesis, and stage 4 sacral pressure ulcer revealed missing documentation for wound treatments on several dates for multiple wound sites, including the right buttock, right heel, sacrum, left ischial, and lateral ankle. The absence of required documentation was noted on multiple occasions, with no records of wound care being completed for the specified areas on the identified dates. The facility's failure to document these treatments is not in accordance with accepted professional standards and the facility's own policy, as required by regulation. The findings were based on a review of clinical records and facility-provided documentation.
Food Storage and Cooling Deficiencies
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the Food Service Department, five packages of ground beef and two packages of beef hot dogs were found undated and unlabeled, three trays of hashbrowns were uncovered and undated, and a container of provolone cheese, American cheese, and cut-up onions were expired and dated 9/6. In addition, diced potatoes cooling in the refrigerator for a salad were undated and placed in a 1/3 size, 4-inch-deep steel steam table pan. The Food Service Director confirmed these findings during the kitchen tour.
Improper Garbage Disposal in Receiving Area
Penalty
Summary
Garbage and refuse were not disposed of properly in the facility’s receiving and dumpster area. During a food delivery on September 8, 2025, staff were observed walking boxes of food into the kitchen storage areas through the receiving zone while three large grey trashcans were uncovered. One trashcan contained trash with a foul odor and refuse exposed to open air. A foul, white, milky liquid was observed pooling across the receiving area floor, appearing to leak from the trash compactor and spreading into multiple walking and delivery zones used by staff to transport food into the facility. A strong, pervasive odor consistent with decomposing waste was present throughout the receiving area. The Food Service Director, Employee E8, confirmed the observations of the receiving and dumpster area during the tour.
Failure to Maintain Confidentiality During Medication Administration
Penalty
Summary
The facility failed to keep residents' personal health information confidential during medication administration for two residents. During observation of medication administration for one resident, the nurse prepared and administered medications in the dining room while 9 other residents and other staff were present, and the nasal spray was administered after the pills while the nurse spoke to the resident audibly across the room. During observation of medication administration for another resident, the nurse left the medication cart with the computer screen open, displaying the resident's information and medications to anyone passing through the hallway, and then prepared and administered medications in the dining room where 9 other residents and other staff were sitting. The eye drop was administered after the pills and was visible to other staff and residents. The DON confirmed that the computer screen containing personal health information should have been covered when the nurse was away from the medication cart and that privacy should have been provided during medication administration.
Failure to Provide Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that the resident and/or the resident’s representative received written notice of transfers and the reasons for the moves in a language and manner they understand. Review of Resident R122’s medical record showed that the resident was transferred to the hospital for evaluation on July 3, 2025, and for an emergency evaluation on June 20, 2025, but the record did not contain documentation of written notification to the resident or representative explaining the transfers and the reasons for them. Review also showed that Resident R8 was transferred to the hospital due to a fall on July 1, 2025. During interview, the facility administrator confirmed that written notice of the reason for transfer had not been provided, and the administrator and DON confirmed that it was not facility practice to provide written notice specifying the duration of the bed-hold policy or the reasons for transfer in writing and in a language and manner they understand.
Medication Administered With Breakfast Instead of Empty Stomach
Penalty
Summary
The facility failed to administer medications according to professional standards of practice for one of three residents reviewed, Resident R32. The clinical record showed an order dated July 5, 2023, for Tacrolimus ER Oral Tablet Extended Release 24 Hour 1 MG, with instructions to give 3 tablets by mouth once daily for anti-rejection. FDA guidance reviewed in the report stated that tacrolimus extended-release tablets should be taken once daily with fluid, preferably water, on an empty stomach, at least 1 hour before or at least 2 hours after a meal, and at the same time each day, preferably in the morning. During observation of medication administration by an LPN on September 9, 2025, at 8:58 a.m., the nurse prepared and administered tacrolimus extended-release tablet to Resident R32 while the resident was eating breakfast. During interview on September 10, 2025, the Unit Manager stated she spoke to the pharmacy and that it was recommended by the family the medication should be taken on an empty stomach. The Unit Manager also stated the medication time would be changed to the appropriate time.
Incomplete Clothing Inventory Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate inventory records for two residents, a cognitively intact resident with a BIMS score of 15 and his wife, who had severe cognitive impairment and a BIMS score of 99. The report states that the wife’s clothing items were missing, including undershirts, T-shirts, shirts, and dress blouses, and that the resident reported he had given the clothing to the facility months earlier for review, but no action had been taken and the items could not be located. The resident also stated that the facility offered reimbursement, but he said the clothing had special value and cost more than the amount offered. Facility staff interviews showed that the social worker first learned of the missing clothing after laundry staff reported it, and that the only inventory sheet found was dated March 24, 2025 and did not list any clothing. The social worker stated that administration needed to review the system error that resulted in the lack of documentation, and no inventory sheet was produced for the wife during the survey. The facility’s admission process required nursing staff to complete an inventory sheet when family brought in personal belongings, but the Administrator and DON confirmed that inventory sheets had not been completed for either resident’s clothing.
Failure to Provide Sufficient Staff During Mechanical Lift Transfer Resulting in Resident Harm
Penalty
Summary
Facility staff failed to follow established protocols requiring two nursing assistants to perform a mechanical lift transfer for a resident with morbid obesity, dementia, and muscle weakness. The resident was assessed as dependent for bed mobility and transfers, with care plans and physician orders specifying the need for extensive assistance of two staff members during transfers using a stand-up lift. Despite these requirements, a nurse aide conducted a transfer alone, contrary to facility policy and the resident's care plan. During the transfer, the resident fell from the mechanical lift. The nurse aide initially reported that the sling broke during the transfer, but subsequent inspection by staff and interviews revealed no evidence of damage or defect to the sling. The incident resulted in the resident sustaining multiple skin tears to the left forearm, hand, and wrist, as well as bruising to the head and face. The resident experienced severe pain, with pain levels reported as high as 10 out of 10, and required transfer to the hospital for further evaluation and treatment. Documentation and interviews confirmed that only one staff member was present during the transfer, in violation of facility policy, the resident's care plan, and physician orders. There was no evidence that the equipment was defective, and the failure to have sufficient staff directly led to the resident's fall and subsequent injuries.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with morbid obesity, dementia, and muscle weakness, who was dependent on staff for all transfers, was transferred using a mechanical stand-up lift by a single nurse aide, contrary to facility policy, care plan, and physician orders that required the assistance of two staff members. The nurse aide performed the transfer alone, and during the process, the resident fell from the lift. The incident resulted in the resident sustaining multiple skin tears to the left forearm and hand, bruising to the head and face, and experiencing severe pain, which ultimately required hospitalization for evaluation and treatment. Facility documentation and staff interviews confirmed that the mechanical lift and sling were not defective or broken, and the failure was attributed to the lack of a second staff member during the transfer. The resident's care plan and physician orders clearly specified the need for two-person assistance with all mechanical lift transfers, and the facility's policy reinforced this requirement. Despite these directives, the nurse aide proceeded with the transfer alone, leading to the resident's fall and subsequent injuries. The investigation further revealed that the environment was not maintained free from accident hazards, as required by regulation, due to the improper use of the mechanical lift and lack of adequate supervision. The resident reported significant pain following the incident, and clinical observations documented active bleeding and multiple wounds. The facility's failure to ensure adherence to safe transfer techniques and supervision directly resulted in actual harm to the resident.
Failure to Complete Annual Performance Review and Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to complete a performance review for a nurse aide at least once every 12 months, as required by policy. Review of personnel files showed no documented evidence that the nurse aide had a performance evaluation for the years 2024 and 2025. The Director of Nursing confirmed that there was no process in place for completing performance evaluations for employees, including the nurse aide in question. Additionally, an incident occurred in which a resident fell while being transferred from a wheelchair to a bed using a mechanical lift. The nurse aide performed the transfer alone, contrary to facility policy requiring two staff members for all Hoyer lift transfers. The resident sustained an injury as a result of the fall. Inspection of the mechanical lift sling revealed no issues, and the Director of Nursing confirmed that the injury occurred due to the nurse aide transferring the resident independently.
Facility Fails to Re-Admit Resident Post-Hospitalization
Penalty
Summary
The facility failed to re-admit a resident after a change in condition, which was identified as a deficiency. The resident, who had a history of morbid obesity, transient cerebral ischemic attack, hypertension, cognitive communication deficits, diabetes, and a urinary tract infection, exhibited aggressive behaviors such as kicking, scratching, yelling, and refusing meals and medications. On March 3, 2025, the resident was sent to the hospital due to increased aggression and was later diagnosed with an acute kidney injury and treated for a urinary tract infection. Despite the hospital's report that the resident no longer required Haldol or physical restraints, the facility refused to re-admit the resident. The hospital social worker documented that the resident had been off restraints for over 60 hours and was medically stable for discharge. However, the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) expressed concerns about the resident's stability and refused re-admission, citing inadequate documentation of the resident's condition. The facility did not provide documentation to support their decision not to re-admit the resident, nor did they collaborate with the hospital to address the resident's needs. Interviews with the DON and NHA confirmed the lack of documentation and collaboration, which contributed to the deficiency. The facility's actions were not in compliance with the regulatory requirements for permitting residents to return after hospitalization.
Plan Of Correction
The facility does and shall ensure to permit residents to return to the facility after hospitalization/therapeutic leave. The facility does and shall ensure to follow the bed hold policy permitting residents to return to the facility after hospitalization/therapeutic leave. The facility does and shall ensure to document conversations with the hospital and family regarding transfer back to the facility. Monitoring/random review will be conducted by admission director or designee and social services 1 time weekly for 3 months with findings reported to the CQI Committee for a period deemed appropriate by the CQI Committee.
Failure to Develop Person-Centered Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who exhibited various challenging behaviors and refused medications. The resident, who had multiple diagnoses including morbid obesity, transient cerebral ischemic attack, hypertension, cognitive communication deficits, diabetes, and a urinary tract infection, was also being treated for anxiety, visual hallucinations, and disorientation. Despite these complex medical and psychological needs, the facility did not create a comprehensive care plan to address the resident's behaviors and medication refusals. The resident displayed a range of behaviors from January to March 2025, including kicking, scratching, yelling, screaming uncontrollably, refusing meals and medications, and exhibiting increased anxiety. The resident also attempted to climb out of bed, removed clothing, and was combative with staff. These behaviors were documented in nursing notes, which detailed incidents of the resident being anxious, confused, lethargic, and aggressive, often requiring staff intervention and, at times, hospitalization. Despite these documented behaviors, the facility did not have a plan of care in place to manage the resident's behaviors effectively. The Unit Manager confirmed the absence of a person-centered care plan to address and manage the resident's behaviors, which was a significant oversight given the resident's complex needs and the frequency of behavioral incidents. This lack of a comprehensive care plan was a deficiency in meeting the regulatory requirements for developing and implementing person-centered care plans.
Plan Of Correction
The facility does and shall develop and implement comprehensive person-centered care plans for each resident, that includes measurable objectives and timeframes also consistent with the residents' rights to meet resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The facility does and shall ensure that comprehensive care plan is culturally competent. All residents' comprehensive care plans will be reviewed to ensure they are comprehensive and include any interventions deemed necessary. All nursing staff have/will be educated on proper comprehensive care planning and the importance of ongoing care plan updates to ensure the most effective and contemporary care. Monitoring/random review of comprehensive care plans will be conducted 1 time weekly for 3 months with findings reported to the CQI Committee for a period deemed appropriate by the CQI Committee. Monitoring/random review of comprehensive care will be conducted 1 time weekly for 3 months with findings reported to the CQI Committee for a period deemed appropriate by the CQI Committee.
Failure to Follow Lab Test Orders for Resident with UTI and Behavioral Issues
Penalty
Summary
The facility failed to ensure that physician orders and recommendations for laboratory tests were followed for a resident who was admitted with acute encephalopathy and a urinary tract infection. The resident, who had a history of UTI with delirium, exhibited various behaviors such as increased anxiety, hallucinations, and aggression. Despite the psychiatric nurse practitioner's repeated recommendations to obtain a urine analysis and other lab tests to rule out infectious or metabolic causes of the resident's altered mental status, these tests were not conducted. The resident's clinical records showed ongoing behavioral issues, including aggression towards staff and other residents, refusal of meals and medications, and attempts to leave the facility. The psychiatric nurse practitioner made multiple visits and consistently recommended lab tests to assess the resident's condition, but these recommendations were not addressed by the facility. The resident's condition did not improve, and he was eventually transferred to the hospital, where he was diagnosed with an acute kidney injury and treated for a urinary tract infection. Interviews with the Unit Manager confirmed that the urine analysis ordered by the physician and recommended by the nurse practitioner on several occasions was not completed. This oversight in following medical orders and recommendations contributed to the resident's continued behavioral issues and eventual hospitalization.
Plan Of Correction
The Facility does and shall ensure that routine and emergency Lab services were provided for all residents to meet their health needs. All residents will be reviewed for Lab orders to meet health needs. Education has been done. All nursing staff have/will be educated regarding timely lab services for all residents. Monitoring and random check will be conducted by supervisors/Unit Managers once a day for 2 weeks and 1 time a week for 6 weeks. Findings and on-going monitoring will be reported to the CQI Committee for a period deemed appropriated by the CQI Committee. Monitor: Unit Managers/shift Supervisor/DON
Failure to Address Endocrinology Consultation for Resident
Penalty
Summary
The facility failed to ensure that a recommendation for a resident to be seen by an endocrinologist was addressed. The resident, who had a history of diabetes, was seen by the facility endocrinologist, who recommended a follow-up in 2-4 weeks and advised the facility to contact them sooner if there were any concerns or changes in the resident's health status related to diabetes. Despite this, there was no evidence in the clinical record that the nursing staff scheduled an appointment or contacted the endocrinologist, even after a psychiatric nurse practitioner noted that the resident's behaviors might be linked to low blood sugar levels and advised consulting endocrinology. The resident exhibited various behaviors, including aggression towards staff and other residents, refusal of meals, and medication non-compliance, which were documented in multidisciplinary notes. The psychiatric nurse practitioner highlighted that the resident's condition worsened when blood sugar levels were low and recommended frequent blood sugar checks and a urinalysis to rule out other medical causes. However, these recommendations were not acted upon, and the Director of Nursing confirmed that the endocrinologist was not contacted regarding the resident's diabetes management concerns.
Plan Of Correction
The Facility does and shall ensure that endocrinologist services were provided for all residents to meet their spatialized health needs. All nursing staff have/will be educated regarding timely dental services for all residents. Monitoring and random checks will be conducted by supervisors/Unit Managers once a day for 2 weeks and 1 time a week for 6 weeks. Findings and ongoing monitoring will be reported to the CQI Committee for a period deemed appropriate by the CQI Committee. Monitor: Unit Managers/shift Supervisor/DON
Inadequate Pest Control Measures in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests within the building. Observations revealed that the main kitchen had a set of double doors leading to a concrete dock, which did not seal completely, creating an air gap that allowed easy access for pests and rodents. Additionally, a large metal dumpster was located just below the dock, where garbage and refuse were stored, potentially attracting pests. On the second floor B wing nursing unit kitchenette, a mouse was observed running across the floor into a hole beneath the wooden cabinets, which showed signs of water damage. This kitchenette was equipped with a dish machine and sink used for residents dining in the area. The pest control operator's reports from June to October 2024 indicated repeated treatments for common household pests, including mice and roaches, within the building. The reports highlighted issues such as food debris and excess water on the kitchen floors, and the need for cleaning floor drains to ensure proper drainage. Despite these treatments, the presence of pests persisted, indicating that the facility's pest control measures were inadequate. The facility's management and licensee were found to be responsible for these deficiencies under the relevant Pennsylvania Code sections.
Failure to Revise Care Plan for Resident's ADLs
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident R32, regarding their activities of daily living. Resident R32 was admitted to the facility with diagnoses including muscle weakness, dementia, and abnormalities of gait and mobility. A physician's order dated March 13, 2024, indicated a need for a physio-therapy evaluation and treatment. However, the care plan, which was initiated on January 16, 2024, and had a target date of September 8, 2024, was not updated to reflect the resident's current status or improvements in activities of daily living. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan had not been revised to reflect the resident's current condition.
Resident Elopement and Alcohol Possession
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident R80, who was able to leave the facility without staff knowledge. The facility's policy on elopement, effective since December 12, 2016, was not effectively implemented in this case. Resident R80, who was cognitively intact with a BIMS score of 15, left the facility unsupervised and returned with alcohol, despite having a history of alcohol abuse. The resident was not using her usual mobility aids, which might have alerted staff to her unsupervised departure. The incident occurred when a CNA discovered Resident R80 missing during a routine check. Despite a search by staff and security, the resident was not found until she returned to her room. Upon her return, staff noticed the smell of alcohol on her breath and discovered bottles of alcohol in her possession. The resident claimed to have attended a party and purchased alcohol, which was confirmed by the presence of a shopping bag containing alcohol bottles. The front desk staff did not notice anything unusual when the resident left, as she had not previously shown any signs of elopement risk. Interviews with staff confirmed the sequence of events, and it was noted that the resident frequently left the facility with family members, which may have contributed to the oversight. The facility's failure to recognize and address the potential for elopement, despite the resident's history of alcohol abuse and her verbal indications of wanting to leave, highlights a lapse in supervision and adherence to the facility's elopement prevention policy.
Failure to Follow Physician Orders for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that physician orders were followed for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including a urinary tract infection, cognitive communication deficit, and depression, had a physician order dated August 23, 2024, for a 16FR/10ML Foley catheter due to urinary retention. On October 24, 2024, it was observed that the Foley catheter in use for the resident did not have the size marked, preventing verification that the correct catheter size was used as per the physician's order. This finding was confirmed by a registered nurse at the facility.
Failure to Monitor and Assess Nutritional Status
Penalty
Summary
The facility failed to adequately assess and monitor the nutritional status of a resident, identified as Resident R27, which led to a deficiency in maintaining acceptable nutritional parameters. The facility's policy required that any weight change of less than five pounds should prompt the nursing staff to notify the dietitian, who would then conduct a nutritional assessment and provide necessary interventions. However, despite a significant weight loss of seven pounds in one month and a total of twenty-one pounds over six months, there was no documentation indicating that a comprehensive nutritional assessment was conducted for Resident R27. Additionally, the resident's clinical records showed a low albumin level, indicative of malnutrition, and the development of an arterial wound and a new sacral pressure sore, yet no nutritional assessment was documented following these changes in the resident's condition. Observations during a breakfast meal revealed that Resident R27 required assistance with eating and was consuming warm cooked cereal with milk. There was no evidence that the resident's food preferences, nutritional supplementation, or the use of adapted utensils were considered to enhance food consumption and eating abilities. Interviews with the registered nurse, nursing aide, and registered dietitian confirmed the absence of a documented nutritional assessment for the month of October, despite the resident's ongoing weight loss and the development of pressure sores. This lack of assessment and intervention highlights the facility's failure to adhere to its own policies and ensure the nutritional well-being of Resident R27.
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen as ordered by the physician for a resident, identified as Resident R22. Resident R22 was admitted with multiple diagnoses, including Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis, obesity, Essential Hypertension, and an unspecified fracture of the left lower leg. A physician's order dated September 26, 2024, specified that oxygen should be administered at 2 liters per minute via nasal cannula when the resident's pulse oxygen level was below 92% on room air. However, during an observation on October 21, 2024, it was found that Resident R22 was receiving oxygen at 4.5 liters per minute, contrary to the physician's order. Additionally, the oxygen tubing was not dated, and there were no orders specifying the frequency of tubing changes. Interviews with the Unit Manager and Director of Nursing confirmed these findings.
Failure to Document Rationale for Antipsychotic Use and Attempt GDR
Penalty
Summary
The facility failed to provide documentation of a clinical rationale for the continued administration of an antipsychotic medication and did not attempt a gradual dose reduction (GDR) for a psychoactive drug for one resident. According to the facility's policy on Medication Monitoring and Management, a GDR should be attempted in two separate quarters within the first year of antipsychotic therapy, unless clinically contraindicated. After the first year, a GDR must be attempted annually. The policy also states that a GDR is clinically contraindicated if target symptoms return or worsen after the most recent attempt, and the physician must document the clinical rationale for not attempting further dose reductions. Resident R32 was admitted with diagnoses including dementia and muscle weakness. The resident had a physician order for Quetiapine Fumarate, an antipsychotic medication, for psychosis in the absence of dementia. However, the clinical record lacked evidence of a physician review for a GDR or documentation of the rationale for continuing the medication. The Director of Nursing confirmed these findings during an interview, indicating a failure to adhere to the facility's policy and regulatory requirements.
Failure to Securely Store and Administer Medications
Penalty
Summary
The facility failed to ensure the safe storage of drugs and biologicals for one resident, identified as Resident R36. The resident was admitted with multiple diagnoses, including Atherosclerosis Heart Disease, Type 2 Diabetes Mellitus, and Essential Hypertension, among others. The physician's orders for Resident R36 included several medications such as Aspirin, Lasix, Metoprolol Tartrate, Plavix, and Metformin HCl ER, with specific administration times. However, during an observation, it was found that these medications were left unattended on the resident's bedside table in a medication cup. The resident confirmed that the medications were his and that they were left by a nurse without any explanation of what they were. A licensed nurse, identified as Employee E9, confirmed that the medications were indeed left unattended on the bedside table. This incident indicates a failure in the facility's protocol to ensure that medications are securely stored and properly administered, as required by professional principles and regulations.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident R56, who was cognitively intact and experiencing mouth pain and discomfort due to decaying teeth. The facility's policy, dated December 2016, stated that routine and emergency dental services should be provided to all residents, with a dentist contracted to visit monthly and as needed. However, despite a dental examination on August 28, 2024, confirming the need for dental care, including extractions and fitting for dentures, the resident reported waiting several months for the nursing staff to arrange these services. Interviews with the resident and staff, including a registered nurse and a social worker, confirmed the delay in providing timely dental services. The staff acknowledged awareness of the dental evaluation and the recommended follow-up care but failed to act promptly. This inaction resulted in the resident continuing to experience pain and discomfort, highlighting a deficiency in the facility's adherence to its dental services policy and the responsibilities of the social worker in assisting with dental appointments and transportation arrangements.
Inaccurate Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of physician orders for a resident, identified as Resident R32. A review of the physician order dated March 13, 2024, indicated that Resident R32 was to have their oxygen tubing changed weekly and their pulse oximetry checked every shift, with oxygen administered as needed if their pulse oximetry reading fell below 92% on room air. However, during an observation on October 24, 2024, it was noted that Resident R32 did not have an oxygen device in place as ordered. An interview with Resident R32 revealed that they had not been receiving or needing oxygen therapy for a long time. The Minimum Data Set (MDS) for Resident R32, dated September 3, 2024, also indicated that the resident was not receiving oxygen therapy. Employee E9, a Registered Nurse, confirmed that the physician orders related to oxygen for Resident R32 were not accurate.
Infection Control Deficiency: Failure to Use PPE
Penalty
Summary
The facility failed to maintain an effective infection control program related to Transmission Based Precautions for one resident. The facility's policy, effective October 2018, requires the use of Transmission Based Precautions when measures more stringent than Standard Precautions are necessary to prevent infection spread. This includes wearing Personal Protective Equipment (PPE) to prevent exposure to body fluids. On October 24, 2024, a Registered Nurse (RN), identified as Employee E9, examined the urinary Foley catheter of a resident who was suggested for Transmission Based Precautions without wearing PPE. Employee E9 confirmed the failure to wear PPE during the examination.
Failure to Educate Residents on Flu Vaccine
Penalty
Summary
The facility failed to provide education related to influenza vaccines to six residents before administering the vaccine for the 2024-2025 flu season. Clinical record reviews and staff interviews revealed that residents were offered and received the flu vaccine without documented evidence of being informed about the benefits and potential side effects. The Director of Nursing confirmed that the residents did not receive the necessary education prior to vaccination, which is a requirement under the relevant Pennsylvania Code sections.
Deficient Dish Machine Temperatures in Dietary Services
Penalty
Summary
Essential mechanical equipment used for the food and nutrition services department in the facility was found to be not fully operational and safe. Observations in the main dietary kitchen revealed a dish machine that did not meet the manufacturer's recommendations for safe operation, which required hot water for cleaning and sanitizing dishes, utensils, bowls, cups, and everyday china. The director of Dietary Services, Employee E3, confirmed that the booster heater needed mechanical equipment, specifically a pressure reducing valve, and repair to maintain the dish machine safely and in accordance with the manufacturer's specified final rinse temperature of 180 degrees Fahrenheit. Further observations in the nursing unit kitchenettes revealed similar deficiencies. The dish machine in the second floor B wing nursing unit kitchenette was not maintained according to the manufacturer's specifications, with a final water rinse temperature of only 86 degrees Fahrenheit, far below the required 180 degrees Fahrenheit. Additionally, dish machines in the first floor A wing and C wing nursing unit kitchenettes were also not maintained properly, with final rinse temperatures of 157 and 165 degrees Fahrenheit, respectively, instead of the required 180 degrees Fahrenheit. These deficiencies were confirmed with the director of dietary services, Employee E3.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines At Philadelphia Rehab And Healthcare Ctr | 0.1 mi | ★★★★★ | 1 | 0 |
| Deer Meadows Rehabilitation Center | 0.1 mi | ★★★★★ | 21 | 0 |
| Transitional Care Unit At Nazareth Hospital | 0.3 mi | ★★★★★ | 0 | 0 |
| Roosevelt Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 24 | 0 |
| Immaculatemarycenter For Rehabilitation&healthcare | 0.8 mi | ★★★★★ | 26 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.