Wesley Enhanced Living Pennypack Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 8401 Roosevelt Boulevard, Philadelphia, Pennsylvania 19152
- CMS Provider Number
- 395413
- Inspections on file
- 26
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 11
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.
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.
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.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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