West Chester Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Chester, Pennsylvania.
- Location
- 800 West Miner Street, West Chester, Pennsylvania 19382
- CMS Provider Number
- 395740
- Inspections on file
- 33
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Chester Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to include residents or their responsible parties in the care planning process for three residents. Despite completing MDS assessments, there was no evidence that these individuals were invited to participate in their care plan meetings. This was confirmed by the Nursing Home Administrator.
The facility failed to include the required Interdisciplinary Team (IDT) in care plan meetings for 15 residents. Federal regulations mandate that care plans be prepared by an IDT, including the attending physician, a registered nurse, a nurse aide, and a member of food and nutrition services staff. However, the meetings were attended by limited staff, such as social services, therapy, nursing, dietary, and respiratory staff, without the full IDT participation.
The facility did not ensure that four staff members completed the required 12 hours of annual training. Documentation review and interviews confirmed the deficiency, which was previously cited under state code.
A resident with ESRD, Heart Failure, and Diabetes experienced a significant weight gain over a short period, but the facility failed to notify the physician. Despite the weight increase being identified, it was not communicated, indicating a lapse in required notification procedures.
The facility failed to follow physician orders for two residents. One resident with chronic kidney disease and hyponatremia was not monitored for fluid intake as per the physician's order, leading to excess fluid consumption. Another resident received incorrect dosages of Morphine Sulfate due to a transcription error, although no adverse effects were reported. These deficiencies were confirmed with the facility's administration.
A resident with spinal stenosis and chronic back pain was administered Oxycodone HCL 10 mg 11 times despite having a pain level rating of 0, indicating no pain. The clinical record lacked an explanation for this administration, and the issue was reported to the DON.
The facility failed to properly label and store medications on two medication carts, with insulin pens found used and undated, and loose medications scattered in drawers. Staff interviews revealed insulins were placed in zip-lock bags, and scattered medications resulted from accidental popping out from blister packages.
The facility failed to provide timely pain medications for a resident, leading to severe pain and hospital transfer. The resident, with conditions like Postlaminectomy Syndrome, did not receive prescribed MS Contin and acetaminophen due to pharmacy delays. Another resident missed doses of Donepezil, Tamsulosin, and Levetiracetam due to similar issues, as confirmed by the ADON.
A resident with a physician's order for full life-sustaining interventions, including CPR, was found unresponsive and not breathing. The RN Supervisor did not initiate CPR, citing the resident's hospice status and a conversation with the resident's daughter, despite the resident's documented full code status and facility policy requiring CPR to be initiated unless a DNR order was in place.
The facility failed to follow physician's orders for pre and post-dialysis weight monitoring and to maintain communication with the dialysis center for four residents with ESRD. Multiple instances of missing weight documentation were found, and the Nursing Home Administrator confirmed the lack of compliance.
The facility failed to ensure that CPR was provided in accordance with the facility policy and procedures for a resident who was a FULL CODE. The NHA and DON did not effectively manage the facility to ensure compliance with federal and state guidelines and regulations, resulting in the failure to administer CPR as required.
The facility failed to notify the physician of significant weight changes in two residents with ESRD and dependent on Hemodialysis. One resident had a 13.8% weight gain over five days, and another had a 29.78% weight gain over four days, with delays in notifying the physician confirmed by the DON.
A resident with severe cognitive impairment and multiple health issues experienced bilateral hip fractures of unknown origin. Despite the resident denying trauma or falls, the facility failed to conduct necessary staff interviews, leading to a deficiency in management and nursing services.
The facility did not notify the State LTC Ombudsman's office when a resident was transferred to the hospital due to being unresponsive, as confirmed by the Nursing Home Administrator.
The facility failed to develop a comprehensive care plan for a resident with Dementia, Bipolar Disorder, and Anxiety Disorder, who had a history of psychiatric hospitalizations and previous attempts to hurt self. The care plan did not address the resident's behavior related to self-harm, as confirmed by the Nursing Home Director.
The facility failed to ensure consistent wound treatment for a resident with a surgical wound and did not follow the wound consultant's recommendations. The resident's wound treatment was missed on several occasions, and a new treatment recommendation was not implemented due to a lack of communication with the physician.
A resident continued to receive an unnecessary psychotropic medication despite recommendations from a psychiatrist to taper the dose. The resident experienced increased daytime sleepiness and low energy levels, and the facility did not follow the psychiatrist's recommendations in a timely manner.
The facility failed to obtain and monitor weights for two residents, leading to significant unaddressed weight changes. Despite the facility's policy requiring monthly weights and reweighs for significant changes, the Registered Dietitian did not review the records or request reweighs for these residents.
The facility failed to accurately assess and monitor a resident's sacral wound, leading to its progression to an unstageable stage with undermining. Despite being identified as high risk for pressure sores, the wound was inconsistently documented and miscommunicated to the physician, resulting in inadequate treatment.
A resident with a physician's order for Gabapentin 300mg for neuropathy did not receive the medication for four days due to a delay in delivery from the pharmacy. This resulted in the resident missing four doses, as confirmed by clinical and pharmacy record reviews and an interview with the DON.
Failure to Include Residents in Care Planning Process
Penalty
Summary
The facility failed to include residents or their responsible parties in the comprehensive care planning process for three out of five sampled residents. For Resident 1, an annual Minimum Data Set (MDS) assessment was completed on January 27, 2025, but there was no evidence that the resident or their responsible party was invited to the care plan meeting. Similarly, for Resident 2, a quarterly MDS was completed on January 7, 2025, without evidence of an invitation to the care plan meeting. Resident 3's annual MDS assessment was completed on December 9, 2024, and again, there was no documentation of an invitation to the care plan meeting. An interview with the Nursing Home Administrator confirmed the lack of documented evidence of invitations for these residents or their responsible parties to participate in their care plan meetings.
Failure to Include Interdisciplinary Team in Care Plan Meetings
Penalty
Summary
The facility failed to include the Interdisciplinary Team (IDT) in care plan meetings for 15 out of 15 resident care plan meetings reviewed. According to federal regulations, resident care plans should be prepared by an interdisciplinary team that includes the attending physician, a registered nurse, a nurse aide, a member of food and nutrition services staff, and other appropriate staff or professionals as determined by the resident's needs. However, the review of clinical records and interviews revealed that the care plan meetings lacked the required IDT participation. The care plan meetings for residents, including those with health conditions that precluded their attendance, were attended by limited staff such as social services, therapy, nursing, dietary, and respiratory staff. The absence of a comprehensive IDT, including the attending physician and other necessary professionals, was consistent across all reviewed cases. This deficiency was confirmed with the Regional Director, the Nursing Home Administrator, and the Director of Nursing.
Failure to Complete Required Annual Training
Penalty
Summary
The facility failed to ensure that four out of five reviewed staff members completed the required 12 hours of annual training. This deficiency was identified through a review of training documentation for Employees E3, E4, E5, and E6, which did not show evidence of completion of the mandated training. An interview with the Nursing Home Administrator and Director of Nursing confirmed that these employees did not fulfill the annual training requirement. This issue was previously cited on May 6, 2024, under 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
Failure to Notify Physician of Significant Weight Change
Penalty
Summary
The facility failed to notify the physician of a significant weight change for a resident with multiple serious health conditions. The resident, who has End Stage Renal Disease (ESRD), Heart Failure, and Diabetes, experienced a notable weight gain over a short period. Specifically, the resident's weight increased from 309 pounds to 322.7 pounds within a week, and further to 330.6 pounds over the course of less than a month, totaling a 21.6-pound gain. Despite these significant changes, the clinical records did not show any notification to the physician regarding the weight fluctuations. An interview with a licensed employee confirmed that the significant weight change was identified but not communicated to the physician. This oversight represents a failure in the facility's responsibility to ensure timely physician notification of significant changes in a resident's condition, as required by regulations.
Failure to Follow Physician Orders for Fluid Restriction and Medication Administration
Penalty
Summary
The facility failed to adhere to the physician's order for fluid restriction for Resident 13, who has chronic kidney disease and hyponatremia. The physician's order specified a daily fluid restriction of 1500 ml, with specific allocations for dietary and nursing shifts. However, the clinical records did not show that Resident 13's fluid intake was monitored to ensure compliance with this restriction. Observations revealed that Resident 13 had access to more fluids than allowed, including a 16-ounce cup of water on the side table and two 16-ounce cups on the bedside table. Interviews with the resident and a licensed nurse indicated a lack of awareness and monitoring of the fluid restriction, contributing to the deficiency. For Resident 419, the facility failed to follow the physician's orders for administering Morphine Sulfate Oral Solution. The orders included specific dosages for different conditions, but the medication was incorrectly transcribed and administered. The resident received incorrect dosages, including a 20 ml dose for air hunger, which was not per the physician's order. The facility's narcotic logbook and medication incident details confirmed the administration of incorrect doses due to a transcription error. Despite the error, no adverse effects were reported for Resident 419. The deficiency was confirmed with the Nursing Home Administrator and the Director of Nursing.
Unnecessary Medication Use for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication use. Resident 21, who has a diagnosis of spinal stenosis and chronic back pain, was prescribed Oxycodone HCL 10 mg to be taken as needed for moderate pain. However, a review of the resident's Medication Administration Record for September 2024 revealed that the medication was administered 11 times despite the resident having a pain level rating of 0, indicating no pain. The clinical record did not provide an explanation for the administration of Oxycodone under these circumstances. This issue was communicated to the Director of Nursing on October 3, 2024.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on two medication carts, as observed during a survey. The facility's policy, revised in February 2023, mandates that medications and biologicals be stored in their original packaging and that multi-dose vials be dated and discarded within 28 days unless otherwise specified by the manufacturer. However, during the observation of Medication Cart 4, a Lispro pen and a Basaglar pen were found used and undated, along with 97 loose medications scattered in the drawers. Similarly, Medication Cart 5 contained a Lispro pen, an Admelog pen, and a Lantus pen, each placed in a zip-lock bag with the resident's name written in pen, and 50 loose medications scattered in the drawers. Additionally, a used and undated Lidocaine vial with no name was observed. Interviews with staff revealed that the pharmacy sent multiple insulins for residents, and the original containers were left in the medication refrigerator while the insulins in use were placed in zip-lock bags. The scattered medications were attributed to accidental popping out from blister packages. These findings were communicated to the Director of Nursing, highlighting the facility's failure to adhere to its medication labeling and storage policy, as well as the manufacturer's guidelines for insulin storage.
Failure to Provide Timely Medication Administration
Penalty
Summary
The facility failed to provide necessary pain medications timely for Resident 2, resulting in significant pain and the need for emergent medical intervention. Resident 2, who was admitted with conditions including Postlaminectomy Syndrome, spinal fusion, and Cauda Equina injury, had physician orders for MS Contin, oxycodone, hydromorphone, and acetaminophen to manage chronic and breakthrough pain. However, the July 2024 Medication Administration Record (MAR) indicated that MS Contin and acetaminophen were not administered as they were on hold, and the resident experienced a pain level of 10. The medications were not delivered on time despite being faxed and refaxed by the nursing staff, and attempts to obtain them from the medication dispensing system were unsuccessful. Consequently, the resident was in severe pain and was transferred back to the hospital. Additionally, the facility failed to ensure the availability of physician-ordered medications for Resident 3, who was admitted with diagnoses including Nontraumatic Subarachnoid Hemorrhage and fractures of the lumbosacral spine and pelvis. Resident 3's orders included Donepezil, Tamsulosin, and Levetiracetam, which were not administered on a specific date due to awaiting pharmacy delivery, resulting in missed doses. The Assistant Director of Nursing confirmed that these medications were not available for administration, highlighting a lapse in the facility's pharmacy services.
Failure to Provide CPR in Accordance with Policy
Penalty
Summary
The facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of the residents reviewed. The resident, who was admitted as a short-term respite admission on hospice service, had a physician's order for full life-sustaining interventions, including CPR. However, when the resident was found unresponsive and not breathing, the RN Supervisor did not initiate CPR, citing the resident's hospice status and a conversation with the resident's daughter, who stated that the family did not wish to have CPR performed. This decision was made despite the resident's documented full code status and the facility's policy requiring CPR to be initiated unless a DNR order was in place or there were obvious signs of irreversible death. The RN Supervisor's actions were contrary to the facility's policy and the resident's physician's order, leading to the resident being pronounced dead without CPR being attempted. The facility's policy clearly stated that CPR should be initiated if the resident's DNR status is unclear, which was not followed in this case. The failure to perform CPR as required placed the resident in Immediate Jeopardy. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that they were aware of the staff's failure to provide CPR in accordance with the resident's code status and the facility's policy.
Removal Plan
- A facility wide review of all residents' life sustaining code status to ensure each resident's advanced directive and physician-ordered code status was in place.
- The facility developed an education plan for all licensed nurses regarding the facility's CPR policy including general guidelines, preparation and emergency procedure for all residents; to ensure that CPR will be provided in accordance with each resident's advanced directive and physician orders and further education on where to find the code status of residents.
- The plan also included to actively hold Code Blue drills (simulated event whereby staff respond to a resident experiencing cardiac arrest) with staff, and to complete ongoing audits.
- An audit of the eleven hospice residents including nine with Do Not Resuscitate (DNR) and Full life sustaining measures were reviewed.
- The Immediate Jeopardy was lifted when it was confirmed that the facility provided licensed nursing staff of 11 LPN's (Licensed Practical Nurses) and 4 RN's (Registered Nurses) with education regarding providing CPR in accordance with residents' advanced directives, physician's orders and the facility's policy and completed a Code Blue drill to ensure that licensed nurses were prepared to respond to situations that required CPR.
- Staff were able to identify resident's code status is located on the Medication Administration Record (MAR) which is accessible to all licensed staff.
- Any remaining staff were scheduled to receive the education prior to the start of their next shift.
Failure to Follow Physician's Orders for Dialysis Care
Penalty
Summary
The facility failed to follow physician's orders regarding pre-dialysis and post-dialysis weight monitoring and to maintain ongoing communication with the dialysis center for four residents receiving dialysis. Resident 18, diagnosed with End Stage Renal Disease (ESRD) and dependent on Hemodialysis, had no recorded pre and post-dialysis weights on multiple dates in April 2024. Similarly, Resident 98, also diagnosed with ESRD and dependent on Hemodialysis, had missing pre and post-dialysis weights on several dates in April 2024. Resident 161, with the same diagnosis, had multiple instances of missing pre and post-dialysis weights in April 2024. The Nursing Home Administrator confirmed the lack of documentation for these residents during an interview on April 29, 2024. Resident 369, admitted to the facility with a diagnosis of ESRD and dependence on renal dialysis, also had issues with documentation. The physician's order required a Dialysis Communication Tool to be completed and sent to dialysis three times a week, along with recording pre and post-dialysis weights. However, the Nursing Home Administrator reported that the facility did not have a communication book for Resident 369, indicating a failure to comply with the physician's orders. This lack of documentation and communication was confirmed during an interview on April 29, 2024.
Failure to Administer CPR According to Policy
Penalty
Summary
The facility failed to ensure that Cardio Pulmonary Resuscitation (CPR) was provided in accordance with the facility policy and procedures for a resident who was a FULL CODE. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure compliance with federal and state guidelines and regulations. The job descriptions for both the NHA and DON indicated their responsibilities included ensuring proper healthcare services and providing leadership and direction for nursing services. However, they did not fulfill these essential duties, resulting in the failure to administer CPR as required by the facility's policy and procedures.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician of significant weight changes in two residents diagnosed with End Stage Renal Disease (ESRD) and dependent on Hemodialysis. Resident 18 experienced a 13.8% weight gain over five days, but the clinical record did not show that the physician was notified of this significant change. Similarly, Resident 161 had a 29.78% weight gain over four days, and the physician was not notified until six weeks later. This delay in communication was confirmed by the Director of Nursing during an interview. The clinical records review and staff interviews revealed that the facility did not adhere to the requirement of promptly informing the physician about significant weight changes. This deficiency was identified through the review of the residents' weights and vitals, which showed substantial weight gains that were not communicated to the physicians in a timely manner. The Director of Nursing confirmed these findings, indicating a lapse in the facility's management and nursing services.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to comprehensively investigate an injury of unknown origin for a resident diagnosed with Dementia, Cancer of the Larynx, Acute Respiratory Failure, and generalized muscle weakness. The resident, who had severe cognitive impairment and required extensive assistance with bed mobility and transfers, experienced worsening bilateral hip pain. An X-ray revealed bilateral subcapital fractures of undetermined age, leading to the resident's transfer to the hospital. Despite the resident denying any trauma or falls, the facility did not conduct interviews or obtain statements from staff who had cared for the resident in the last 48 hours. An interview with a licensed employee confirmed that staff interviews should have been completed for injuries of unknown origin. The Nursing Home Administrator also confirmed the lack of staff interviews or statements regarding the resident's bilateral hip fracture. This failure to ensure a comprehensive investigation of the injury constitutes a deficiency in the facility's management and nursing services.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of a resident's transfer or discharge. Specifically, a nursing progress note indicated that a resident was sent to the hospital due to being unresponsive. However, there was no documented evidence that the State Ombudsman's office was notified of this transfer. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Develop Comprehensive Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 95, who has a diagnosis of Dementia, Bipolar Disorder, and Anxiety Disorder. The resident's Quarterly Minimum Data Set (MDS) indicated severe cognitive impairment. Psychiatry notes revealed a history of at least four prior psychiatric hospitalizations and previous attempts to hurt self, with the resident currently on medication management. Despite this, the care plan for Resident 95 did not include any plan of care for the resident's behavior related to previous attempts to hurt self. This deficiency was confirmed during an interview with the Nursing Home Director.
Failure to Consistently Complete Wound Treatment and Follow Wound Consultant Recommendations
Penalty
Summary
The facility failed to ensure that wound treatment for Resident 18 was consistently completed and that the wound recommendation from a wound consultant was followed. Resident 18 was readmitted to the facility with a surgical wound post incision and drainage of a hematoma to the left lateral leg. A wound treatment order was given to cleanse the wound with cleanser, apply Collagen to the base of the wound, and cover with dressing daily and as needed. However, the Treatment Administration Record for April 2024 revealed that the wound treatment was not performed on April 7, 14, 16, 20, and 21, 2024. Additionally, on April 18, 2024, the wound NP evaluated Resident 18's surgical wound and recommended a new treatment involving the application of Medihoney. This recommendation was not placed as an order and therefore was not implemented. The Director of Nursing reported that the wound NP's recommendation should have been relayed to the physician for approval, but there was no documented evidence that this was done. The DON was unable to provide an explanation for the missed treatments or the failure to implement the new wound treatment recommendation.
Failure to Reduce Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free of unnecessary psychotropic medication. Resident 42 had a physician's order for trazodone 50 mg at bedtime, which was questioned by the consultant pharmacist. The psychiatrist recommended tapering off the trazodone due to its ineffectiveness and the resident being on three antidepressants. Despite this recommendation, the resident continued to receive the full dose of trazodone until March 28, 2024, leading to increased daytime sleepiness and low energy levels, as documented in the resident's progress notes and medication administration records. The Director of Nursing confirmed that the facility did not follow the psychiatrist's recommendations to reduce the trazodone dose in a timely manner. This oversight resulted in the resident experiencing excessive sleepiness and reduced food intake, as noted in a nurse's progress note. The facility's failure to act on the psychiatrist's recommendations and the pharmacist's query led to the resident continuing on an unnecessary psychotropic medication for an extended period.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to obtain and monitor weights for two residents, leading to significant unaddressed weight changes. According to the facility's Weight Policy, residents should be weighed monthly, and any significant weight change (greater than or equal to 5% gain/loss in one month) should be reported to the Registered Dietitian and reweighed. Resident 3 experienced a weight loss of 34.7 pounds (15.3%) in one month and 38.9 pounds (17.1%) over three months without a reweigh. Similarly, Resident 4 lost 16.9 pounds (10.1%) in one month without a reweigh. There was no evidence that the Registered Dietitian reviewed the records of these residents despite the significant weight losses. An interview with the Registered Dietitian confirmed that monthly weights should be obtained by the 9th of the month and reweighs should be requested for significant changes. The Registered Dietitian acknowledged that reweighs should have been obtained for both residents. This failure to follow the facility's Weight Policy and ensure proper monitoring and intervention for significant weight changes resulted in a deficiency under 483.25 F692 Nutrition/Hydration Status Maintenance.
Failure to Accurately Assess and Monitor Sacral Wound
Penalty
Summary
The facility failed to accurately assess and monitor a sacral wound for a resident, leading to the wound progressing to an unstageable stage with undermining. Initially, the resident was admitted with intact skin and was identified as high risk for developing pressure sores. Despite this, the facility's staff did not consistently and accurately document the wound's condition. The wound was initially identified as MASD and later assessed as a Stage 2 pressure ulcer, but subsequent assessments revealed it was actually a Stage 3 wound with significant slough and eschar, and eventually became unstageable with undermining. The wound care nurse and other licensed nurses provided conflicting assessments, with some documenting the wound as MASD even after it had been identified as a Stage 3 pressure ulcer. The wound care nurse confirmed that the wound was a Stage 3 on December 1, 2023, but the physician was incorrectly informed that it was a Stage 2. This miscommunication led to inappropriate treatment being continued. The wound continued to worsen, and by December 15, 2023, it was documented as unstageable with significant slough and eschar, and undermining. Interviews with the Director of Nursing and the wound care nurse revealed that the facility's protocol for wound assessment and treatment was not followed accurately. The failure to properly assess and document the wound's condition, and to communicate the correct stage to the physician, resulted in inadequate treatment and the progression of the wound to a more severe stage. This deficiency was confirmed through clinical record reviews, staff interviews, and the facility's own policy review.
Failure to Ensure Timely Availability of Medication
Penalty
Summary
The facility failed to ensure medications were available for Resident CL1, who had a physician's order for Gabapentin 300mg to be administered orally at bedtime for neuropathy. The order was dated January 26, 2024, but the medication was not administered until January 31, 2024, resulting in the resident missing four doses. The delay was due to the pharmacy not delivering the medication until January 31, 2024. This was confirmed through clinical record review, pharmacy record review, and an interview with the Director of Nursing on February 28, 2024.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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