Wyncote Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wyncote, Pennsylvania.
- Location
- 208 Fernbrook Avenue, Wyncote, Pennsylvania 19095
- CMS Provider Number
- 396120
- Inspections on file
- 21
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Wyncote Care Center during CMS and state inspections, most recent first.
Two residents reported being physically and verbally abused by a CNA during care. One cognitively intact resident with dementia stated that a male and a female CNA turned the resident violently while providing incontinence care despite the resident’s refusal, that the male CNA hit the resident during the struggle, and that there was swearing by both parties; the resident later identified the female CNA as the caregiver involved that night. Another resident with a history of cerebral infarction and moderate cognitive impairment reported that the same female CNA slapped the resident’s wrist multiple times and grabbed the resident’s glasses. Facility investigations and reports to the State Survey Agency documented that the allegations against the female CNA were substantiated.
The facility failed to complete thorough investigations into abuse allegations involving two cognitively intact residents. In one case, a resident reported being turned violently and hit by two CNAs during nighttime care, but the investigation lacked interviews with other staff or residents on the unit. In another case, a resident with a history of verbal aggression alleged that an RN used unprofessional, racially charged language, which was partially corroborated by the ADON and social worker, yet no statement was obtained from the resident or other residents. The DON acknowledged that additional interviews were not conducted and that investigation documents were fragmented across multiple staff and locations, contrary to facility policy requiring comprehensive, factual documentation and witness statements.
A resident with hemiplegia, moderate cognitive impairment, and documented frequent urinary and bowel incontinence required supervision or touching assistance for toileting hygiene and had a care plan directing staff to provide needed ADL assistance. During an observation, the resident was found sitting on the bed in street clothes with a strong urine odor in the room, which the DON confirmed. The DON reported that the resident attempts to toilet independently but sometimes does not reach the bathroom in time, demonstrating that staff did not consistently provide the required toileting assistance.
A resident's confidential medical record, including sensitive information such as social security number and date of birth, was mistakenly provided to another resident's representative due to staff not following the facility's medical record request process. The staff member responsible could not be identified, and the incident was determined to be isolated.
A resident with dementia and muscle weakness, who was fully dependent on staff for bed mobility, developed a sacral pressure ulcer. Despite physician orders for pressure prevention devices and frequent repositioning, the resident was not enrolled in a turning and repositioning program, and no care plan was initiated for the facility-acquired pressure ulcer. Documentation gaps were confirmed by the DON and missing wound consult records.
A resident with diabetes, osteoarthritis, and dementia did not receive weekly skin and nail checks as ordered by the physician. Only one skin assessment was documented, and no further assessments or documentation of skin issues were found. The resident was later hospitalized with sepsis, acute renal failure, and a wound requiring surgery. Facility staff were unaware of any skin issues, and there was no evidence that the required weekly assessments were completed.
A resident at Wyncote Care Center fell from bed during a linen change due to improper technique by a nurse aide. The resident, who required substantial assistance for transfers, was turned away from the aide, leading to a fall when her hands slipped off the side rail. The incident resulted in severe right-side pain, and the resident was transported to the hospital for evaluation.
A facility failed to update a care plan for a resident who experienced a decline in self-feeding capabilities. The resident, who had dementia and varied meal completion, was observed being fed by a nurse aide without the adaptive devices specified in their care plan. The care plan had not been revised to reflect the resident's need for one-on-one feeding assistance.
A facility failed to follow proper infection control techniques during a dressing change for a resident with a wound. Despite the policy requiring gloves and gowns for high contact care, a nurse did not wear a gown while performing the procedure. The resident had conditions including hydrocephalus and edema, necessitating Enhanced Barrier Precautions.
The facility was found to be in violation of building construction requirements as it was classified as a two-story, Type V (000), unprotected wood frame construction with a basement, which is fully sprinklered. This classification exceeds the maximum allowable story height for this type of construction, which is limited to one story when sprinklered. The issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the required headroom clearance in the exit access corridor, affecting one smoke compartment. The basement level corridors near the maintenance office had a headroom of six feet at the ramp leading to the laundry, which is below the required six feet-eight inches. This was confirmed during an exit interview with the Administrator and Maintenance Director.
Failure to Protect Two Residents From Physical and Verbal Abuse by Nursing Assistant
Penalty
Summary
The facility failed to ensure residents were free from abuse when two residents reported being physically and verbally mistreated by a nursing assistant during care. One resident with dementia but a BIMS score indicating intact cognition reported that on a late evening, two staff members, described as a male and a heavy-set female nursing assistant, attempted to change the resident despite the resident’s refusal. The resident stated that the staff turned the resident violently, that the male staff member hit the resident after a possible altercation, and that both staff and resident were swearing during the incident. The resident identified the female nursing assistant as the person who had provided care that night and later identified the male nursing assistant through the nursing supervisor. The facility’s investigation documentation indicated that the allegation against the female nursing assistant was substantiated, while the male nursing assistant was determined by the facility not to be involved. A second resident with a history of cerebral infarction and a BIMS score indicating moderate cognitive impairment reported that the same female nursing assistant slapped the resident’s wrist three times and then grabbed the resident’s glasses. The resident’s statement and demonstration of the incident were documented in the facility’s investigation, which concluded there was sufficient concern regarding inappropriate physical interaction. The facility’s report to the State Survey Agency documented that the allegation against the female nursing assistant was substantiated and that the allegation was considered substantiated in the facility’s reported incident. The nursing home administrator confirmed these findings during interview.
Plan Of Correction
1. A thorough investigation of allegations of abuse was conducted for Resident R1 and R2. Interviews and witness statements as applicable with other staff and/or residents completed for alleged abuse for Resident R1 and R2. Employee E3, nurse aide, was terminated based on multiple allegations and refusal to provide statement. Employee E4, nurse aide was found to be not involved with Resident R1 based on facility investigation. 2. Facility will ensure that there will be strictly zero tolerance for any resident abuse and neglect. Any allegations of abuse or neglect will be thoroughly investigated. Appropriate corrective action plans will be taken such as disciplinary action/terminations. 3. All staff will be reeducated on abuse/neglect policy and procedures as part of the facility's mandatory abuse and neglect training. All new hires will also be educated on topics of abuse/neglect policy and procedures as part of facility's orientation. 4. The Administrator/Designee will monitor the frequency and pattern of all abuse allegations and follow up investigations. Any areas of non-compliance will be addressed in QAPI for two quarters or until substantial compliance is met.
Incomplete Abuse Investigations for Two Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to conduct complete and thorough investigations into allegations of abuse for two cognitively intact residents. Facility policy states there is zero tolerance for abuse, neglect, and exploitation and that documentation of abuse investigations must be objective and factual, including who, what, when, where, and witness statements. Despite this, the investigations did not include all relevant interviews or comprehensive documentation as required by the policy and federal regulation. For one resident with dementia but a BIMS score of 15, the resident reported that on a late evening two staff members, identified as a male and a heavy-set female nursing assistant, turned the resident violently while providing incontinence care, that the male staff member hit the resident, and that there was swearing by both the resident and the male staff member. The resident stated the male staff member had a very strong grip and that the female staff member was the aide who cared for the resident that night. The investigation documentation included a nursing supervisor’s note that the resident denied pain or injury and that no bruising was observed, and that the male aide was identified by another aide. However, there was no documented evidence that other staff or residents on the unit were interviewed regarding the alleged incident. For another resident admitted with a left fibula fracture and a BIMS score of 15, who had a care plan for verbal aggression and inappropriate verbal behavior, a grievance was filed alleging that a registered nurse spoke to the resident in an unprofessional manner and cursed at the resident. The investigation file contained statements from the ADON and social worker indicating they heard a commotion and heard the nurse refer to the resident as “boy,” followed by the resident’s upset response, and that there was no observed physical contact. Despite these accounts, there was no documented statement from the resident involved or from other residents on the unit. The DON confirmed that no interviews were conducted with the resident or other residents after the incident and described investigation materials as being scattered among different staff and offices rather than compiled.
Plan Of Correction
1. A thorough investigation of allegations of abuse was conducted for Resident R1 and Resident R3. Interviews and witness statements as applicable with other staff and/or residents completed for alleged abuse for Resident R1 and R3. 2. A review of facility investigation procedures was reevaluated. Facility administration will ensure thorough investigations including but not limiting to collecting witness statements and conducting staff/resident interviews for any alleged abuse cases are completed. 3. The Director of Nursing was educated and in-serviced by the Administrator on ensuring a complete and thorough investigation is complete for all allegations of resident abuse. Statements and interviews to be conducted where applicable and ensure timely reporting of incidents and documentation to the Administrator and the Department of Health. 4. The Administrator/Designee will monitor all reportable incidents pertaining to resident abuse/neglect and any identified non-compliance with reporting procedures will be reported to the QAPI committee.
Failure to Provide Needed Toileting Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide needed assistance with toileting and ADLs for a resident with hemiplegia/hemiparesis and moderate cognitive impairment. The resident’s MDS dated October 2, 2025 documented a BIMS score of 11, indicating moderately impaired cognition, and Section GG showed the resident required supervision or touching assistance for toileting hygiene. The same MDS indicated the resident was frequently incontinent of both bladder and bowel. The care plan, initiated July 18, 2024, identified incontinence of bowel and bladder related to impaired mobility and documented that the resident required assistance with ADLs, with an intervention to provide assistance as required for completion of ADL tasks. On December 29, 2025, at 11:44 AM, surveyors observed the resident in his room, sitting on his bed in street clothes, with a strong odor of urine coming from the room. The DON, who was present during the observation, confirmed the strong urine odor. The DON also stated that the resident tries to go to the bathroom independently but sometimes does not make it in time. These observations and statements showed that, despite the documented need for assistance with toileting and ADLs, the resident was not consistently receiving the necessary help, resulting in episodes of incontinence and a strong urine odor in the room.
Failure to Protect Medical Record Confidentiality
Penalty
Summary
The facility failed to protect the confidentiality of medical records for one resident when staff provided the wrong medical record to another resident's representative. Specifically, the record belonging to one resident was given to the representative of another resident, resulting in a breach of privacy. The facility's medical record request process was not followed, and the staff member responsible for the error could not be identified. The information disclosed included sensitive personal details such as social security number and date of birth, as reported by the recipient of the incorrect records. The incident was identified when the facility was notified that a family member had received the wrong medical records. Review of facility policy confirmed that medical records are to be released only in accordance with federal and state privacy laws, and only to authorized individuals. However, in this case, the required procedures were not adhered to, leading to the unauthorized disclosure of protected health information. The event was determined to be an isolated incident, with no evidence of additional residents affected.
Failure to Implement and Document Pressure Ulcer Prevention and Care
Penalty
Summary
A resident with dementia and muscle weakness was admitted to the facility and had physician orders for the use of pressure prevention devices, frequent turning and repositioning, and offloading of heels while in bed. Despite these orders, documentation revealed that the resident was not enrolled in a turning and repositioning program, and was totally dependent on staff for bed mobility. The care plan identified a risk for skin integrity issues related to incontinence, but there was no evidence of a care plan specifically addressing a facility-acquired pressure ulcer after one was identified. Clinical records showed that an open area was discovered on the resident's sacrum by a CNA and reported to the charge nurse, who assessed and measured the wound. A wound physician later documented significant deterioration of the wound, with necrosis and unmeasurable depth, and recommended offloading and repositioning per protocol. However, there was no documented evidence that a care plan was initiated for the pressure ulcer, and the Director of Nursing confirmed this omission. Additionally, some wound consult documentation was unavailable due to a system changeover.
Failure to Perform Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not performing weekly skin assessments as ordered by the physician for one resident. The facility's policy required comprehensive skin checks to be performed at a frequency consistent with physician orders and for findings to be documented immediately. The resident in question had a history of type 2 diabetes mellitus, bilateral osteoarthritis of the knees, and dementia. A physician's order specified weekly skin and nail checks every Tuesday during the day shift. Documentation showed that a skin check was performed on one occasion, noting abdominal fold irritation and redness, but there were no further skin assessments or documentation of skin issues after that date. Subsequently, the resident was transferred to the hospital due to a change in mental status and abnormal vital signs. Hospital records indicated the resident was diagnosed with sepsis and acute renal failure, and further examination revealed swelling and a wound on the right lower extremity, which required surgical intervention. Interviews with facility staff, including the DON and the nurse assigned to the resident on the day of transfer, revealed they were unaware of any skin issues or wounds, and the facility could not provide evidence that weekly skin assessments had been performed as ordered.
Resident Fall Due to Improper Linen Change Technique
Penalty
Summary
Wyncote Care Center was found to be non-compliant with the requirement to maintain a resident environment free of accident hazards, as evidenced by an incident involving a resident falling from bed during care. The facility's policy on fall management emphasizes the need to identify and mitigate hazards and risks, yet the incident occurred when a nurse aide was changing the resident's bed linens. The resident, who had diagnoses of lack of coordination, unsteadiness on feet, obesity, and muscle weakness, required substantial assistance for transfers and moderate assistance for bed mobility. During the linen change, the resident was turned away from the aide, and while the aide was changing the sheets, the resident rolled over the sheets and fell to the floor, resulting in severe right-side pain. The facility's investigation revealed that the bed was in a high position, and the resident was holding onto a side rail when her hands slipped, leading to the fall. The nurse aide involved stated that she was performing a complete bed change and had turned the resident towards the door with the side rails up. The Director of Nursing confirmed that the appropriate technique for changing linens with a resident in bed was not followed, which contributed to the accident. The resident was transported to the hospital for evaluation and returned with complaints of discomfort in the right shoulder.
Plan Of Correction
1. R1 was re-assessed by rehab and care planned updated for 2 person assist. Resident is currently on restorative care services. 2. ADON/DON to audit incident reports within the last 60 days. Residents affected will be re-assessed and care plans will be updated according to outcome. Interdisciplinary team will be consulted in order to develop comprehensive care plan updates. Completion Date: 5/30/2025 3. DON/ED provided all care staff with in-service & educated on policy's & procedures specific to bed mobility. Completion date: 4/25/2025 4. ADON/DON have ongoing audits of incident reports, and present any trends or decline to the ED/IDT during daily clinical meeting, weekly UR meeting, and weekly risk management meetings to ensure an ongoing review of potential risks & identifying/implementing interventions proactively. Completion Date: 5/30/2025
Failure to Update Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as R34, regarding feeding assistance. The resident had a comprehensive care plan indicating a potential for altered nutrition status due to dementia, varied meal completion, and a decline in self-feeding, necessitating the use of adaptive feeding devices. Despite interventions dated earlier in the year to provide a Kennedy cup and inner lip plate during meals, observations revealed that the resident was not provided with these adaptive devices during a lunch meal service. Instead, the resident was being fed by a nurse aide. An interview with the nurse aide confirmed that the resident had experienced a decline in self-feeding capabilities and now required one-on-one feeding assistance. However, the care plan had not been updated to reflect this change in the resident's condition and needs.
Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques during a dressing change for a resident. The facility's policy on Transmission Based Precautions, revised in May 2024, mandates the use of gloves and gowns during high contact resident care activities, such as wound care, for residents on Enhanced Barrier Precautions (EBP). However, during an observation on December 18, 2024, it was noted that two licensed nurses, Employee E3 and Employee E4, did not fully comply with these precautions. While both donned gloves, Employee E4 did not wear a gown while performing a dressing change on the resident's wound. The resident involved, identified as Resident R32, was admitted with diagnoses including hydrocephalus, edema, and lack of coordination. The resident had a physician's order for daily wound care on the left buttock, which included cleansing with normal saline, applying anasept gel and calcium alginate, and covering with border gauze. Despite the facility's policy and the resident's condition requiring EBP, the observation revealed a lapse in following the required infection control measures, as confirmed by an interview with Employee E4.
Building Construction Type Violation
Penalty
Summary
The facility was found to be in violation of building construction requirements as it was classified as a two-story, Type V (000), unprotected wood frame construction with a basement, which is fully sprinklered. This classification exceeds the maximum allowable story height for this type of construction, which is limited to one story when sprinklered. The deficiency was identified during an observation and document review conducted on December 17, 2024, at 8:15 a.m. The issue was confirmed during an exit interview with the Administrator and Maintenance Director later that morning.
Failure to Maintain Minimum Headroom Clearance in Exit Corridor
Penalty
Summary
The facility failed to maintain the minimum headroom clearance in the exit access corridor, which affected one out of five smoke compartments. During an observation and document review conducted on December 17, 2024, at 8:15 a.m., it was found that the headroom clearance within the corridors of the basement level, near the maintenance office and similar staff areas, measured at six feet at the ramp leading to the laundry. This measurement was less than the minimum height requirement of six feet-eight inches. An exit interview with the Administrator and Maintenance Director confirmed that the ceiling height was below the required minimum.
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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