Wyndmoor Hills Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wyndmoor, Pennsylvania.
- Location
- 8601 Stenton Avenue, Wyndmoor, Pennsylvania 19038
- CMS Provider Number
- 396115
- Inspections on file
- 34
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Wyndmoor Hills Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with back pain had PRN orders for Morphine Sulfate for severe pain and Acetaminophen for mild pain, but no order for moderate pain. The facility’s pain scale defined scores of 1–3 as mild, 4–6 as moderate, and 7–10 as severe, yet nursing staff repeatedly administered Morphine when the resident’s documented pain scores were in the moderate range or even 0, and Acetaminophen was also given when pain was documented as 0. The DON and administrator confirmed that Morphine was given for pain levels below severe and that there was no specific pain management order for moderate pain, resulting in pain medications not being administered in accordance with physician orders or the facility’s pain management policy.
A resident with back pain had an order for PRN Morphine Sulfate 15 mg PO q6h for severe pain and a standing order for pain assessments using a 0–10 scale with nonpharmacological options. Facility policy required standardized pain assessment but did not define numeric ranges for pain levels; the DON later clarified that scores of 7–10 represent severe pain. On one evening shift, the resident’s pain was documented as 7, indicating severe pain, yet the ordered PRN Morphine was not administered and no other pain management interventions were documented. The DON confirmed that the Morphine was not given despite the documented severe pain.
Several residents admitted with incontinence and requiring substantial or total assistance for toileting and hygiene did not have goals or interventions for incontinence care documented in their care plans, despite facility policy requiring ongoing assessment and care plan updates.
Three residents did not have care plans addressing their specific clinical needs, including wound care for a resident with dementia and peripheral vascular disease, dementia care for another resident, and bipolar disorder management for a third. Clinical records and interviews confirmed the absence of required care plans despite documented diagnoses and physician orders.
On one nursing unit, 12 blister packs of medication were left unattended on a medication cart near residents, and the medication storage room was found propped open with an ointment bottle, allowing access to injectable medications and insulin. An LPN confirmed these areas should have been secured according to facility policy.
Annual performance evaluations for three nurse aides were not documented as required. Despite requests and additional time to locate the records, both HR and the DON were unable to provide the necessary yearly reviews, resulting in a deficiency related to staff evaluation documentation.
The facility did not maintain accurate medical records for three residents, including discrepancies in code status documentation, inaccurate recording of wound care treatments, and incorrect documentation of nutritional intake. For example, a resident's POLST form did not match the physician's order, wound care was documented as completed when it was not, and meal intake was overstated despite observed poor consumption.
A resident requiring two-person assistance for transfers was involved in an incident where a mechanical lift tipped over during a transfer because staff failed to widen the lift's legs as required by safety protocols. The resident was subsequently lowered to the floor, and staff interviews confirmed the improper use of the lift.
A resident's clinical records lacked documentation of a consistent turning and repositioning program as required by facility protocol. Review of records and staff interviews confirmed that there was no evidence the resident was repositioned or turned at least every two hours, and required details such as caregiver identity and resident response were not recorded.
Surveyors found a substantial amount of mouse droppings in two areas of the main kitchen, with the Dietary Director confirming the issue and acknowledging lapses in cleaning practices. The NHA was also aware of ongoing rodent problems, demonstrating a failure to maintain an effective pest control program.
A medication cup containing nine pills was found left on a resident's bedside table, contrary to facility policy requiring direct administration unless a physician's order for self-administration exists. The resident, who had multiple complex medical conditions and intact cognition, did not have such an order. The DON confirmed this was not in line with facility procedures.
A resident admitted after knee surgery was not assessed by physical therapy in a timely manner due to weekend staffing shortages and miscommunication between nursing and therapy staff. The resident was restricted to bed and not allowed to ambulate or use the lavatory independently until seen by PT, despite requests from the resident and family and the surgeon's recommendation for early ambulation. Nursing staff deferred assessment to PT, and the social worker was unable to facilitate a transfer or contact PT staff during the weekend.
Two residents were not reasonably accommodated when, after an emergency evacuation, multiple individuals remained in chairs overnight without beds, and another resident with significant mobility limitations did not receive a scheduled shower due to lack of equipment and water issues, contrary to facility policy.
A resident with multiple chronic pain conditions did not receive timely administration of prescribed Oxycodone for severe pain, as documented in the MAR and confirmed by staff interviews. Despite reporting a pain level of 10, the resident was only given Tylenol, and there was no documentation that Oxycodone was administered after the supply ran out and before a new supply was received. This resulted in a failure to follow physician orders and facility policy for pain management.
Two large transparent plastic garbage bags containing blister packs of medications were found unattended on the floor in a hallway outside an activity room used as a sleeping area. The DON confirmed that these medications were left unsecured, which was not in accordance with facility policy requiring drugs and biologicals to be stored in locked compartments or rooms.
Wyndmoor Hills Rehabilitation and Nursing failed to maintain air temperatures between 71 and 81 degrees Fahrenheit on two nursing units, with temperatures ranging from 59 to 70 degrees Fahrenheit. This posed a risk of hypothermia to 16 residents. Residents and staff reported discomfort due to the cold, and issues with the heating system were identified. The facility was aware of the malfunction but instructed the contractor to turn the air handler back on, leading to an Immediate Jeopardy situation.
The Nursing Home Administrator failed to maintain air temperatures between 71 and 81 degrees Fahrenheit in 16 resident rooms and common areas, resulting in an Immediate Jeopardy situation. Observations showed temperatures as low as 59 degrees, and residents reported discomfort due to the cold. The facility's heating system faced technical issues, and there was a lack of sufficient warm blankets available for residents.
The facility failed to maintain documentation for emergency lighting tests as required by NFPA 101, affecting the entire facility. During a review, it was found that the facility could not provide records of monthly and annual tests. This repeat deficiency was confirmed in an interview with the Administrator and Maintenance Director.
The facility failed to maintain documentation of monthly exit sign inspections as required by NFPA 101 standards, affecting the entire facility. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director and is a repeat issue from the previous year's survey.
The facility failed to maintain its fire alarm system, with discrepancies found during an annual inspection, including a failed operation of an indicating bell and a failed annunciation of a smoke detector. Additionally, the fire alarm panel was observed to be in trouble mode. These issues were confirmed by the Administrator and Maintenance Director.
The facility did not maintain the fire protection rating for linen chutes, affecting the entire facility. Observations revealed that the soiled utility room chute doors on multiple floors failed to self-close and positively latch, as confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not comply with smoking regulations in the designated smoking area, as observed by the accumulation of cigarette butts and the absence of a metal container with a self-closing cover for ashtray disposal. This was confirmed during an interview with the Administrator and Maintenance Director.
The facility failed to maintain documentation of annual fire door inspections as required by NFPA standards. During a review, it was found that the facility could not provide evidence of a fire door inspection within the past 12 months. This was confirmed in an interview with the Administrator and Maintenance Director, marking a repeat deficiency from the previous year.
The facility failed to maintain its generator and document essential tests and inspections, including weekly battery voltage testing and monthly under-load testing. These deficiencies were confirmed by the Administrator and Maintenance Director, with some being repeat issues from the previous year.
The facility failed to maintain an unobstructed means of egress, as the exit door from the emergency stairwell to the loading dock ramp and parking lot was encased in ice. This was due to overnight water damage that froze in sub-freezing temperatures, affecting one of the facility's four levels. The issue was confirmed by the Administrator and Maintenance Director.
The facility failed to maintain the initiation of the required fire alarm system on one level. A fire alarm pull station in the Activities Department was blocked by storage items, making it inaccessible. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain portable fire extinguishers as required by NFPA 10 standards. On the third floor, across from a resident's room, several transport wheelchairs were obstructing access to a fire extinguisher. This was confirmed during an exit interview with the Administrator and Director of Maintenance.
The facility failed to ensure corridor doors positively latched, affecting two levels. The door to a resident room was binding and unable to close, while another door was difficult to open due to a faulty handle. These issues were confirmed by the Administrator and Maintenance Director.
The facility failed to ensure smoke barrier doors on the second floor by room 203 closed smoke tight, as observed during a survey. This deficiency was confirmed in an interview with the Administrator and Maintenance Director.
The facility was found to have several electrical system deficiencies, including an unsecured junction box in the basement boiler room, improper use of electrical tape on the second floor, and an electric heater with exposed wiring in the Activities Department. These issues were confirmed during an exit interview with the Administrator and Maintenance Director.
Wyndmoor Hills Rehabilitation And Nursing Center was found deficient in their Emergency Preparedness plan, as it lacked policies and procedures for providing care at alternate sites during emergencies under an 1135 waiver. This deficiency was confirmed during a survey and an exit interview with the facility's Administrator and Maintenance Director.
A facility failed to maintain safe operating conditions for essential equipment, including an elevator and the main kitchen's heating system. A resident with multiple health conditions experienced a distressing elevator malfunction, which the facility was aware of but did not address promptly. Additionally, the kitchen's heating system had been non-functional since November, causing staff to work in cold conditions and leading to illnesses.
The facility failed to maintain a safe and functional environment, as observed in two residents' rooms and the laundry area. A resident's bathroom had a dirty toilet and a broken sanitizer dispenser, while another resident's room had a broken baseboard and missing drawer. Additionally, a baseboard was off the wall in another room, and a large hole near the industrial washing machine in the laundry room provided an access point for pests.
The facility failed to maintain an effective pest control program, leading to pest presence in nursing units, the kitchen, and laundry room. Residents reported mice sightings, and structural issues allowed pest entry. Staff lacked training on proper documentation, and pest control reports highlighted persistent issues like unsealed food and improper waste disposal.
The facility failed to conduct thorough investigations into allegations of abuse, neglect, and misappropriation of property for several residents. Incidents included a nurse attempting to force medication on a resident, missing money, physical abuse by a nurse aide, and neglect during an incontinence episode. The facility did not adhere to its policies, resulting in incomplete investigations and failure to notify the Department.
The facility failed to supervise residents who smoke, leading to multiple policy violations. A resident repeatedly smoked in non-designated areas and times, while another was found with an oxygen cylinder in the smoking area, violating safety protocols. Additionally, a resident was not informed of the smoking policy, resulting in unsupervised smoking. The facility did not enforce consequences for these violations, creating potential safety hazards.
The facility failed to protect residents' personal belongings, as residents were not provided with keys or a system to lock their cabinets, despite the presence of locks. Two alert and oriented residents reported missing valuables and confirmed the lack of a secure system. The Nursing Home Administrator acknowledged that several residents wanted a lock and key system, but it had not been implemented.
A resident with multiple medical conditions experienced neglect when staff delayed assistance during an episode of incontinence, leading to a fall. The resident reported disrespectful treatment by staff, including derogatory comments and refusal to help. The incident was not reported to authorities as required.
A facility failed to develop a comprehensive care plan for a resident with PTSD, as required by their Trauma-Informed Care policy. The resident, diagnosed with depression, anxiety, and PTSD, experienced a triggering event when stuck in an elevator, but no care plan was in place to address their trauma-related needs and triggers.
The facility failed to provide grooming services to residents unable to perform activities of daily living, despite having a policy and agreement with a cosmetology and barber service. The nursing home administrator confirmed no visits from these services since the agreement's initiation, leaving residents unaware and believing they had to groom themselves.
A facility failed to provide a resident with necessary vision services. The resident, diagnosed with glaucoma among other conditions, had not seen an eye doctor since admission. This was confirmed by both the resident and the DON, highlighting a lapse in ensuring proper treatment and assistive devices for maintaining vision.
A facility failed to provide a resident with an assistive device for bed mobility, despite a physician's order for side rails. The resident, who is alert and independent, needed the rails to assist with frequent nighttime bathroom visits. The facility's policy requires an assessment and consultation for side rail use, but the evaluation inaccurately marked the resident as not assessed, leading to the deficiency.
A facility failed to assess the necessity of an indwelling urinary catheter for a resident admitted post-hospitalization with sepsis and pressure injuries. Despite policy requirements, there was no documented rationale for the catheter's continued use, and the care plan lacked evidence supporting its necessity. The catheter was reportedly used to keep wounds dry, but documentation was insufficient.
A facility failed to adhere to professional standards for IV line care, as a resident's IV line was not capped between uses, contrary to standard practice guidelines. The resident, with multiple health conditions requiring IV antibiotics, noted the absence of sterile caps used in the hospital. The Unit Manager confirmed the necessity of capping the IV line, highlighting a deficiency in care.
Two residents did not receive oxygen therapy as prescribed by their physicians. One resident with chronic respiratory failure and congestive heart failure received less oxygen than ordered, while another with COPD did not have their oxygen tank turned on. These discrepancies were confirmed by facility staff.
A resident with PTSD was trapped in a malfunctioning elevator, triggering severe anxiety and PTSD symptoms. Despite the resident's request for psychological support, the facility failed to inform the physician or therapist and did not develop a care plan for the resident's mental health needs. The Nursing Home Administrator was aware of elevator issues but did not shut it down until after the incident.
A facility failed to provide timely dental services to a resident diagnosed with muscle weakness, lack of coordination, abnormal gait and mobility, high blood pressure, and glaucoma. The resident had not seen a dentist since admission, as confirmed by the DON, indicating a lapse in routine dental care.
The dietary services department was found to be operating under unsanitary conditions, with grease and food debris on ceiling tiles, inadequate chemical sanitizer concentration in the dish machine, and heavily soiled dishroom flooring. The dry food storage closet was improperly organized, and a public health inspection revealed rodent droppings and inadequate sanitation of food contact surfaces.
A facility failed to document multiple smoking incidents involving a resident, despite staff observations and discussions. The Administrator advised against recording these events to avoid creating a non-compliance record, complicating future placements. The lack of documentation violates clinical record maintenance standards.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with complex medical conditions, including coronary artery disease and renal failure. No dietary or nutritional assessments were completed, and no care plans were developed for therapy services, ADLs, or other medical needs. The resident discharged shortly after admission, and the care plan was initiated post-discharge.
Failure to Administer PRN Pain Medications According to Orders and Pain Scale
Penalty
Summary
The facility failed to ensure that pain medications were administered according to physician orders and the facility’s own pain management policy for one resident. The facility’s policy on administering pain medications described the use of standardized numeric pain assessment tools and defined pain levels as mild, moderate, and severe, but the written policy did not specify which numeric scores corresponded to each level. In an interview, the DON clarified that the facility’s pain scale categorized scores of 1–3 as mild pain, 4–6 as moderate pain, and 7–10 as severe pain. Review of the resident’s clinical record showed diagnoses including back pain and physician orders for PRN Morphine Sulfate 15 mg every 6 hours as needed for severe pain and Acetaminophen 325 mg, two tablets every 6 hours as needed for mild pain, with no physician order addressing moderate pain. Medication administration records for January 2026 showed multiple instances where the resident’s documented pain score did not match the ordered indication for the administered medication. On several dates, the resident had pain scores of 4 or 5, which the facility defined as moderate pain, yet was given Morphine Sulfate ordered only for severe pain. On other dates, Morphine Sulfate was administered when the resident’s pain score was documented as 0, indicating no pain. There was also an instance where Acetaminophen for mild pain was given when the pain scale for that shift was documented as 0. In interviews, the DON and the administrator confirmed that Morphine was administered for pain scores less than severe and acknowledged that there was no pain management order in place for moderate pain.
Failure to Administer Ordered PRN Analgesic for Severe Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident experiencing severe pain. Facility policy on administering pain medications states that pain management is based on a facility-wide commitment to resident comfort, defines pain management as alleviating pain to a level acceptable to the resident, and requires use of standardized pain assessment tools such as a 0–10 pain intensity scale. The policy, however, did not specify which numeric values corresponded to mild, moderate, or severe pain. In an interview, the DON (Employee E2) clarified that the facility’s pain scale categorized scores of 1–3 as mild pain, 4–6 as moderate pain, and 7–10 as severe pain. The resident, admitted with diagnoses including back pain, had a physician’s order for Morphine Sulfate 15 mg by mouth every 6 hours as needed for severe pain, and an order for pain assessment and monitoring every shift using a 0–10 pain scale with nonpharmacological interventions offered as indicated. Review of the medication administration record for January showed that during one 3–11 shift, the resident had a documented pain score of 7, which met the facility’s definition of severe pain. Despite this, the resident did not receive the ordered PRN Morphine Sulfate, and there was no documentation of any pain management interventions, pharmacological or nonpharmacological, being provided to alleviate the pain. In a subsequent interview, the DON confirmed that Morphine was not administered during that shift when the resident’s pain score was 7.
Failure to Include Incontinence Care in Resident Care Plans Upon Admission
Penalty
Summary
Multiple residents were admitted to the facility with documented needs for incontinence care, including total dependence for personal hygiene, toileting, and bathing, as well as episodes of bowel and bladder incontinence. Despite these documented needs, reviews of the residents' admission interim care plans and clinical records revealed that their care plans did not include any goals or interventions specifically addressing incontinence care. This omission was noted for several residents who required substantial or maximal assistance with toileting hygiene or were fully dependent on staff for these activities. The facility's policy on comprehensive person-centered care plans requires ongoing assessments and revisions as resident conditions change. However, the care plans for these residents did not reflect their incontinence care needs, as there was no evidence of appropriate interventions or goals documented. These findings were confirmed in an interview with the Nursing Home Administrator and Director of Nursing.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the specific needs of three residents. For one resident with dementia and peripheral vascular disease, clinical records showed podiatry recommendations for wound care, including daily application of betadine and gauze, monitoring for worsening gangrene, and daily measurements. Additional podiatry orders included continued antibiotics and specific dressing changes following toenail removal. Despite these documented needs and orders, there was no care plan in place for wound care or foot care as confirmed by the Director of Nursing. Two other residents were also found to lack appropriate care plans for their primary diagnoses. One resident with dementia and behavioral disturbances did not have a care plan addressing dementia, and another resident with bipolar disorder did not have a care plan for this mental health condition. These omissions were identified through clinical record reviews and care plan audits, indicating a failure to ensure that care plans were developed and implemented to meet the residents' assessed needs.
Unsecured Medications and Unlocked Storage Room
Penalty
Summary
The facility failed to maintain a resident environment free from potential accident hazards on one of two nursing units observed, specifically the third floor. During an observation, 12 blister packs of medication were found left unattended on a medication cart outside the nurse's station, with several residents sitting nearby. Additionally, the medication storage room on the same floor was found propped open with an ointment bottle, allowing access to injectable medications and vials of insulin. Facility policy requires all drugs and biologicals to be stored in locked compartments or rooms, and medication carts are not to be left unattended. An LPN confirmed that both the unattended medications and the unlocked medication storage room were not in compliance with facility policy and should have been secured to prevent resident access.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
Three nurse aides, identified as Employees E9, E10, and E11, did not have documented yearly performance evaluations as required. A review of staff training files was conducted, and it was found that these employees, who were hired on various dates in 2021 and 2023, should have had annual evaluations on file. The Human Resources Director was unable to locate the yearly reviews for these employees, and after additional time was given, the Director of Nursing confirmed that the annual reviews could not be found. This lack of documentation was observed during the survey and was in violation of facility policy and state regulations regarding management and nursing services. No information about residents or their medical conditions was included in the report, and the deficiency pertains solely to staff evaluation documentation.
Failure to Maintain Accurate Medical Records for Wound Care, Nutrition, and Code Status
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for three residents regarding wound care, nutritional intake, and code status documentation. For one resident with heart failure, muscle weakness, and dysphagia, there was a discrepancy between the physician's order in the electronic medical record, which indicated Full Code status, and the POLST form signed by the social worker, which indicated Do Not Resuscitate (DNR). The Director of Nursing confirmed that the POLST form did not accurately reflect the physician's order in the electronic system. Another resident with dementia had a physician's order for daily wound care to bilateral hallux ingrown toenails. Documentation showed the treatment was marked as completed daily, but an investigation revealed the dressing had not been changed as ordered, with the last actual change occurring several days prior. Additionally, a resident with chronic kidney disease and dementia experienced significant weight loss, and staff observations indicated poor nutritional intake. However, the resident's intake was inaccurately documented as 75-100% consumed, despite staff interviews and direct observation showing much lower intake.
Improper Use of Mechanical Lift During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a mechanical lift in accordance with safety protocols during a resident transfer. Facility documentation, including the Invacare User Manual, specified that the legs of the lift must be fully opened for maximum stability and safety. Clinical records showed that a resident with muscle weakness and difficulty walking, who required two-person assistance for transfers using a Hoyer lift, was involved in an incident where the lift tipped over during a transfer from chair to bed. Nursing notes and facility investigation confirmed that the resident was lowered to the floor after the lift tilted to the side over one of the nurse aides present. Interviews and observations with the nurse aide involved revealed that the Hoyer lift legs were not widened at the time of the transfer, which directly led to the device tipping. The aide demonstrated the transfer process and confirmed the improper use of the lift. Further interviews with facility leadership, including the Administrator and DON, verified that the lift legs are required to be widened during transfers, confirming that the established safety procedures were not followed in this instance.
Failure to Document Resident Repositioning per Facility Policy
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one of six residents reviewed. According to the facility's repositioning policy, documentation should include the resident's position, the name and title of the caregiver, any problems or complaints, refusals of care with reasons, and the signature and title of the person recording the data. For the resident in question, clinical records indicated a requirement for repositioning per facility protocol, but there was no documented evidence of a turning and repositioning program, nor consistent documentation of position changes and body realignment. Interviews with the Administrator and DON confirmed the absence of documentation showing that the resident was repositioned or turned at least every two hours as required by policy.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
Surveyors observed an unclean and unsanitary environment in the facility's main kitchen, specifically noting a substantial amount of mouse droppings in two separate areas on the kitchen floor. During an interview, the Dietary Director confirmed the presence of mouse droppings in multiple areas and acknowledged that the floor had not been cleaned, explaining that the cleaning schedule is based on focus areas such as ceiling tiles, and that staff are expected to know what needs to be done. The Nursing Home Administrator also confirmed awareness of rodent problems in the facility. These findings indicate that the facility failed to maintain an effective pest control program in the main kitchen, as required.
Medication Left Unattended at Bedside
Penalty
Summary
A deficiency occurred when a medication cup containing nine pills was observed left on a resident's bedside table. The facility's policy on medication administration requires that medications be administered in a safe and timely manner, with verification of the resident's identity, and prohibits leaving medications at the bedside unless the resident has been assessed and authorized to self-administer by the physician and care planning team. In this case, the resident did not have an order to self-administer medications, and the medication was left unattended, which was confirmed by the Director of Nursing as not being in accordance with facility policy. The resident involved had recently been admitted from the hospital with multiple diagnoses, including heart failure, hypertension, renal failure, diabetes, stroke, and seizure disorder, and required several medications such as antipsychotics, anticoagulants, anticonvulsants, and insulin. The resident's cognitive assessment indicated intact cognition. Despite this, the facility failed to ensure the safety of the resident's environment by not following established medication administration procedures, resulting in the medication being left at the bedside.
Failure to Provide Timely Rehabilitation Services Due to Staff Communication Breakdown
Penalty
Summary
A resident was admitted to the facility following knee surgery and arrived in the evening. Upon admission, the resident was placed in bed and instructed not to get out until assessed by physical therapy, despite the surgeon's recommendation for early ambulation to aid recovery. The resident requested assistance to use the lavatory but was told to use a bed pan or brief until a physical therapy assessment could be completed. The family inquired about when the resident would be seen by physical therapy and was informed that, due to it being the weekend, the assessment would not occur until Monday. Facility documentation and staff interviews revealed that the physical therapy department was short-staffed and had no therapist available on Saturday, resulting in a delay in assessment. The social worker was aware of the family's dissatisfaction and was unable to reach the physical therapy department or arrange a transfer to another facility due to weekend hours. The Director of Physical Therapy confirmed that the delay and the restriction on the resident's mobility were inappropriate, and clarified that nursing staff should have assessed the resident's ability to ambulate. A licensed nurse indicated a belief that only physical therapy could determine the appropriate level of care for ambulation, and the Nursing Home Administrator acknowledged a breakdown in communication regarding responsibilities between nursing and physical therapy staff.
Failure to Accommodate Resident Needs and Preferences During Emergency and Routine Care
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents during and after an emergency evacuation. Following the evacuation, approximately ten residents, including one of the affected individuals, remained in wheelchairs and regular chairs throughout the overnight shift, as confirmed by both staff and resident interviews. Beds for these residents were not provided until the following morning, resulting in residents spending the night without appropriate accommodations. Additionally, another resident with significant medical conditions, including hemiplegia, muscle weakness, lack of coordination, morbid obesity, and contractures, did not receive a preferred shower as scheduled. Instead, the resident received a bed-bath due to the unavailability of a Hoyer lift, which was located on another floor and charging at the time. The unit manager also cited water issues as a contributing factor. These actions were not in accordance with the facility's policies on resident rights and support for activities of daily living.
Failure to Provide Timely Pain Management for Resident with Severe Pain
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident with multiple complex medical conditions, including chronic pain syndrome, osteomyelitis, osteoarthritis, rheumatoid arthritis, and a history of joint replacement. The resident had physician orders for Oxycodone for severe pain and Tylenol for mild pain. On one occasion, the resident reported a pain level of 10, which is classified as severe, but was only administered Tylenol, the medication intended for mild pain, instead of the prescribed Oxycodone for severe pain. Review of the medication administration record (MAR) showed that after receiving Oxycodone for severe pain on one day, there was no further documented administration of Oxycodone until the resident's discharge, despite continued reports of severe pain. Interviews with nursing staff and review of medication supplies revealed that the resident ran out of Oxycodone, and a new supply was not received until the following day. Although staff reported pulling Oxycodone from a secure medication dispensing system (Pyxis) for the resident, there was no documentation that the medication was actually administered. Facility policy required timely assessment and intervention for acute or severe pain, including reassessment and modification of pain management strategies as needed. The lack of timely administration of the prescribed pain medication, failure to document administration, and reliance on a medication intended for mild pain despite reports of severe pain, all contributed to the deficiency in pain management for this resident.
Unsecured Storage of Medications in Hallway
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in a safe and secure environment in accordance with professional standards. During an observation conducted with the DON, two large transparent plastic garbage bags filled with blister packs of medications were found unattended on the floor in the hallway outside the activity room, which was being used as a resident sleeping area. This storage practice was not in compliance with the facility's own policy, which requires all drugs and biologicals to be stored in locked compartments or rooms and for medication storage areas to be maintained in a clean, safe, and sanitary manner. An interview with the DON at the time of observation confirmed that the bags of medications were left unattended in the hallway. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The cited regulations include 28 Pa. Code 201.14(a) and 28 Pa. Code 211.12(c)(d)(1), which pertain to the responsibility of the licensee and nursing services.
Failure to Maintain Safe Temperature Levels
Penalty
Summary
Wyndmoor Hills Rehabilitation and Nursing was found to be non-compliant with federal and state regulations regarding maintaining a safe and comfortable environment for residents. The facility failed to ensure that air temperatures were maintained within the required range of 71 to 81 degrees Fahrenheit on two nursing units, specifically the Second and Third Floors. Observations revealed that temperatures in various rooms and hallways ranged from 59 to 70 degrees Fahrenheit, which posed a risk of hypothermia to 16 residents. Interviews with residents and staff confirmed the discomfort and cold conditions within the facility. Residents were observed wearing additional clothing such as sweatshirts, coats, and hats to keep warm. Staff members, including nurse aides and the maintenance director, acknowledged the cold temperatures and reported issues with the heating system. The maintenance director noted that the facility had experienced problems with water pipes, which affected the heating system's functionality. Further investigation revealed that a commercial contractor had identified an issue with the air handler, which required shutting off the system to prevent further damage. Despite being aware of the malfunction, the facility instructed the contractor to turn the air handler back on. The lack of adequate warm blankets and the failure to maintain appropriate air temperatures led to an Immediate Jeopardy situation, as residents were at risk of developing hypothermia due to the cold environment.
Plan Of Correction
1. Residents that resided in affected rooms were immediately offered a room move. Superb Plumbing was on site on 2/7/2025 to address concerns related to the heating unit. Additional blankets were purchased and provided to residents. Warming liquid hydration stations were placed in resident common areas by culinary staff on 2/7/2025. All 16 residents identified were assessed by nursing staff to ensure that there have been no undesired outcomes related to hypothermia and that no signs and symptoms of hypothermia were present due to the central heating system being temporarily inoperable, including vital signs, skin assessments, and any other pertinent assessments. 2. All rooms in the facility have been temped and are back in compliance. Residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hypothermia are present. 3. Facility staff will be educated on ensuring residents remain warm and to ensure that residents are assessed frequently to ensure that no signs and symptoms of hypothermia are present. 4. An Ad Hoc QAPI Meeting was held on 2/7/2025 to discuss the events surrounding the facility's failure to ensure that the temperatures in the facility were maintained between 71 and 81 degrees Fahrenheit, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding ensuring that temperatures are appropriately maintained in the facility. The facility has a plan in place when temperatures are not maintained and to ensure that the central heating system has routine maintenance. The facility will continue to audit all rooms until there are no rooms being affected. The facility will do a temperature audit once a week for one month, twice a month for one month, and once a month for one month. 5. The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee monthly for six months.
Removal Plan
- The facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that facility air temperatures were maintained between 71- and 81-degrees Fahrenheit.
- Residents that resided in affected rooms were offered a room move and declined. They were informed that if they were uncomfortable and would like to move rooms at any time to inform facility staff.
- [Plumbing Company] on site to address concerns related to the heating unit. Additional blankets were purchased and provided to residents.
- Warming liquid hydration stations were placed in resident common areas by culinary staff.
- All 16 residents identified were assessed by nursing staff to ensure that there have been no undesired outcomes related to hypothermia and that no signs and symptoms of hypothermia were present to the central heating system being temporarily inoperable to include vital signs, skin assessment and any other pertinent assessments.
- All other rooms in the facility will have temperatures taken and residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hypothermia are present to include vital signs, skin assessments along with any other relevant assessment related to hypothermia.
- Facility staff will be educated on ensuring residents remain warm and to ensure that residents are assessed frequently to ensure that no signs of symptoms of hypothermia are present.
- Facility temperature will be checked every shift by the manager on duty and facility administration to ensure that they are within appropriate range along with resident interview to ensure that they are comfortable with the current temperatures.
- If the facility rooms affected does not meet and maintain the appropriate temperatures facility will initiate the emergency plan to include closure of the affected rooms and mandate movement of resident to functioning rooms.
- An Ad Hoc QAPI Meeting was held to discuss the events surrounding the facility's failure to ensure temperatures in the facility were maintained between 71- and 81- degrees Fahrenheit, to identify the root cause, and to initiate improvement to the facility's processes and procedures regarding ensuring temperature levels are appropriately maintained in the facility, the facility has a plan in place when temperatures are not maintained and to ensure that the central heating system has routine maintenance.
- The PA Healthcare Coalition was notified via phone with a voice message left.
- An interview was conducted with Heating and Air Contractor, Employee E11, reported that the heating issue had been resolved. Temperatures in the hallways and rooms were increasing.
- Observations revealed the Second-floor nursing unit-maintained temperatures between 71- and 81- degrees Fahrenheit. The third nursing unit continued to have rooms with 7 rooms were below 71 degrees Fahrenheit. Facility brought portable space heater (safe) to maintain air temperature levels between 71- and 81-degrees Fahrenheit.
- The facility provided education to all staff on assessing residents for signs and symptoms of hypothermia. Staff were instructed to ensure residents remained warm by providing blankets, conducting vital sign checks every shift, and offering warm beverages as needed.
- The vital signs auditing was reviewed and residents were not exhibiting signs and symptoms of hypothermia.
Failure to Maintain Safe Air Temperatures
Penalty
Summary
The deficiency identified in the report pertains to the failure of the Nursing Home Administrator to maintain air temperatures between 71 and 81 degrees Fahrenheit in 16 resident rooms, dining rooms, and nursing units on the second and third floors of the facility. This failure resulted in an Immediate Jeopardy situation, affecting the well-being of 16 residents. Observations conducted on February 7, 2025, revealed that air temperatures in various rooms and hallways were significantly below the required range, with some rooms as low as 59 degrees Fahrenheit. Interviews with residents and staff further highlighted the issue, with multiple residents expressing discomfort due to the cold temperatures. Residents were observed wearing additional clothing such as sweatshirts, coats, and hats to keep warm. Staff members, including nurse aides and licensed nurses, also reported feeling cold and noted that the facility had been providing blankets to residents to mitigate the discomfort. However, observations of the supply rooms revealed a lack of sufficient warm blankets available for residents. The report also details the technical issues contributing to the temperature deficiency. The Maintenance Director reported problems with the facility's heating system due to broken water pipes and debris affecting functionality. Additionally, a commercial contractor identified an issue with the air handler, which required shutting off the system to prevent further damage. Despite these known issues, the facility failed to maintain safe and comfortable temperatures, leading to the Immediate Jeopardy situation.
Plan Of Correction
1. Affected residents were immediately offered room changes. Blankets and warming hydration stations were immediately provided. Nursing assessed all 16 residents for hypothermia. Plumbers came that day to address the heating. 2. All other resident rooms' temperatures were checked and ensured they are in proper compliance. 3. The NHA/DON were educated on the components of this regulation with an emphasis on effectively managing the facility and ensuring that air temperatures are between 71 degrees Fahrenheit and 81 degrees. 4. The RDO/RDCO/Designee will conduct random audits of facility management and resident records to ensure that the DON/NHA/Facility staff are appropriately managing the facility related to ensuring that air temperatures are between 71 degrees Fahrenheit and 81 degrees. Audits will be completed 1x week for 1 month, 2x a month for 1 month, and 1x a month for 1 month. 5. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly for 6 months.
Failure to Maintain Emergency Lighting Documentation
Penalty
Summary
The facility failed to maintain emergency lighting as required by NFPA 101, affecting the entire facility. During a document review on January 27, 2025, it was found that the facility could not provide documentation that emergency lighting had been tested for 30 seconds on a monthly basis and for 90 minutes on an annual basis. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Notably, this is a repeat deficiency from the March 13, 2024, annual survey, indicating a continued failure to comply with the emergency lighting requirements.
Plan Of Correction
1. An audit of emergency lighting was conducted to ensure all units are in proper working order. 2. A log was created to document emergency lighting inspections and ensure compliance. 3. Education provided to ensure proper compliance with this regulation. 4. An audit of five emergency lights will be conducted to ensure they are in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Maintain Exit Signage Documentation
Penalty
Summary
The facility failed to maintain proper exit signage as required by NFPA 101 standards, specifically the 2012 Existing requirements for exit and directional signs. During a document review on January 27, 2025, it was found that the facility did not have documentation of monthly exit sign inspections, which is necessary to ensure compliance with safety regulations. This deficiency affects the entire facility and was confirmed during an exit interview with the Administrator and Maintenance Director. Notably, this is a repeat deficiency from the previous annual survey conducted on March 13, 2024, indicating a continued failure to address the issue.
Plan Of Correction
1. Exit sign inspections were conducted to ensure they are in proper working order. 2. A log was created to document exit sign inspections and ensure compliance. 3. Education provided to ensure proper compliance with this regulation. 4. An audit of five exit signs will be conducted to ensure they are in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system in proper operating condition, as evidenced by documentation, observation, and interviews. During a documentation review, it was found that the annual inspection of the fire alarm panel dated November 8, 2024, revealed discrepancies, including a failed operation of the indicating bell in the basement by the fire panel and a failed annunciation of the initiating smoke detector in room 234. Additionally, an observation on January 27, 2025, showed that the fire alarm panel was in trouble mode at the time of the survey. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged that the issues remained uncorrected.
Plan Of Correction
1. Discrepancies identified during the fire alarm panel's annual inspection were immediately scheduled for repair. 2. The fire alarm panel audited to ensure it is in proper working order. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of fire alarm panel inspections will be conducted to ensure all repairs are scheduled and completed. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Maintain Fire Protection Rating for Linen Chutes
Penalty
Summary
The facility failed to maintain the fire protection rating for linen chutes, which affected the entire facility. During observations conducted on January 27, 2025, between 12:00 p.m. and 2:30 p.m., it was noted that the soiled utility room chute doors on the first, second, and third floors did not self-close and positively latch as required. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 2:30 p.m. on the same day.
Plan Of Correction
1. The chute doors were immediately repaired to ensure they are in proper working order. 2. Chute doors were audited to ensure they remain in proper working order. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of chute doors will be conducted to ensure they remain in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Provide Proper Smoking Area Facilities
Penalty
Summary
The facility failed to adhere to smoking regulations in the designated smoking area. During an observation on January 27, 2025, at 8:00 a.m., it was noted that there was an accumulation of cigarette butts on the ground outside the entrance door to the lobby, which serves as the designated smoking area. Additionally, a metal container with a self-closing cover device, into which ashtrays can be emptied, was not available in this area. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 2:30 p.m.
Plan Of Correction
1. Cigarette butts outside the entrance door to the lobby were immediately cleaned up, and a metal cigarette container was ordered. 2. Smoking areas were audited to ensure they have a metal cigarette container. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of smoking areas will be conducted to ensure they have a metal cigarette container. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to maintain proper documentation of annual fire door inspections as required by NFPA 101 and NFPA 80 standards. During a document review conducted on January 27, 2025, it was discovered that the facility could not provide evidence of a fire door inspection having been conducted within the past 12 months. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the necessary documentation. Notably, this issue was identified as a repeat deficiency from the previous annual survey conducted on March 13, 2024.
Plan Of Correction
1. The annual fire door inspection was completed immediately. 2. A log was created to ensure proper documentation of the annual fire door inspection. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of annual fire door inspections will be conducted to ensure proper documentation and compliance. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Maintain Generator and Document Testing
Penalty
Summary
The facility failed to maintain its generator, which is essential for the entire facility's electrical system. During a document review on January 27, 2025, it was found that the facility did not provide documentation for several critical tests and inspections. These included weekly battery voltage or electrolyte levels testing, monthly specific gravity or conductance testing, monthly 30-minute under-load testing, monthly operation of transfer switches, and weekly visual inspections. Notably, the deficiencies in weekly battery voltage or electrolyte levels testing and monthly specific gravity or conductance testing were repeat deficiencies from the previous annual survey conducted on March 13, 2024. An interview with the Administrator and Maintenance Director on the same day confirmed that these tests had not been completed, and no documentation was logged for the past 12 months. This lack of documentation and testing indicates a failure to comply with the maintenance and testing requirements outlined in NFPA 101 and related standards, which are crucial for ensuring the reliability of the facility's essential electrical systems.
Plan Of Correction
1. All required tests and inspections were immediately scheduled. 2. A log was created to ensure proper documentation of all tests and inspections. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of tests and inspections will be conducted to ensure proper documentation and compliance. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Egress Obstruction Due to Ice Encapsulation
Penalty
Summary
The facility failed to maintain the means of egress free of obstructions, specifically affecting one of the four levels in the facility. On January 27, 2025, at 7:55 a.m., an observation revealed that the egress exit door leading from the emergency stairwell to the loading dock ramp, dumpsters, and parking lot was encapsulated in ice. This obstruction was caused by overnight interior building water damage that froze due to below 32-degree weather conditions. During an exit interview with the Administrator and Maintenance Director later that day, it was confirmed that the exterior egress walkway was encased in ice.
Plan Of Correction
1. The loading dock means of egress door was immediately salted again, and the ice melted. 2. Emergency exit doors audited to ensure egress remains free of all obstructions. 3. Education will be provided to ensure proper compliance with this regulation. 4. The loading dock means of egress door will be audited to ensure it remains free of all obstructions. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Fire Alarm Pull Station Obstructed by Storage Items
Penalty
Summary
The facility failed to maintain the initiation of the required fire alarm system, specifically affecting one of the four levels in the facility. During an observation on January 27, 2025, at 2:00 p.m., it was noted that the fire alarm pull station inside the Activities Department was not readily accessible. This inaccessibility was due to the pull station being blocked by miscellaneous storage items. During an exit interview with the Administrator and Maintenance Director on the same day at 2:30 p.m., it was acknowledged that the fire alarm pull station was obstructed by these items.
Plan Of Correction
1. Items blocking the pull station inside the Activities Department were immediately removed. 2. Pull stations throughout the facility audited to ensure they remain readily accessible. 3. Education provided to ensure proper compliance with this regulation. 4. An audit of the pull station in the Activities Department will be conducted to ensure it remains readily accessible. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Fire Extinguisher Blocked by Wheelchairs
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards, affecting one of four levels in the facility. During an observation on January 27, 2025, at 2:20 p.m., it was noted that on the third floor, across from resident Room 327, several transport wheelchairs were blocking access to a fire extinguisher. This observation was confirmed during an exit interview with the Administrator and Director of Maintenance at 2:30 p.m. on the same day.
Plan Of Correction
1. The area in front of the fire extinguisher across from resident Room 327 was immediately cleared. 2. Fire extinguishers were audited to ensure they remain free of obstructions. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of the area in front of the fire extinguisher across from resident Room 327 will be conducted to ensure it remains clear of obstructions. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Corridor Door Latching Deficiencies
Penalty
Summary
The facility failed to ensure that corridor doors positively latched in their frames, which affected two of the four levels in the facility. During an observation conducted on January 27, 2025, between 12:00 p.m. and 2:30 p.m., it was noted that the door to resident room 219 was binding in the frame and could not close properly. This issue with the door's functionality could potentially compromise the safety and security of the residents in that area. Additionally, the door to resident room 327 was found to be difficult to open due to the door handle not releasing the latch. This malfunction could hinder the ease of access to the room, potentially affecting the timely response to resident needs or emergencies. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1. The doors for rooms 219 and 327 were immediately repaired to ensure they are in proper working order. 2. Resident room doors audited to ensure they remain in proper working order. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of five resident room doors will be conducted to ensure they are in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Smoke Barrier Doors Failed to Close Smoke Tight
Penalty
Summary
The facility failed to maintain smoke barrier doors to resist the passage of smoke, as required by NFPA 101 standards. During an observation on January 27, 2025, at 1:20 p.m., it was noted that the smoke doors located on the second floor by room 203 did not close smoke tight when tested. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 2:30 p.m. on the same day, indicating a failure to meet the necessary fire safety requirements for smoke barriers.
Plan Of Correction
1. The smoke doors near room 203 were immediately scheduled for maintenance to ensure they close smoke-tight. 2. Smoke doors throughout the facility audited to ensure they close smoke-tight. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of three smoke doors will be conducted to ensure they are in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Electrical System Deficiencies in Facility
Penalty
Summary
The facility failed to maintain electrical equipment, as observed during a survey on January 27, 2025. The deficiencies were noted on two of the four levels of the facility. In the basement boiler room, an unsecured junction box was found resting on top of the middle boiler. On the second floor, above the smoke doors near the nurses' station, electrical tape was improperly used to secure a junction box cover instead of using appropriate screws. Additionally, in the Activities Department, an electric baseboard heater was improperly placed on top of an abandoned heating register, with exposed Romex wiring, and surrounded by combustible materials, including cardboard. These observations were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1. The open junction box in the basement boiler room was immediately secured. Appropriate screws were installed on the second floor, above the smoke doors to the left of the nurses' station, to secure a junction box. The heater inside the Activities Department was repaired to ensure compliance. 2. Electrical equipment throughout the facility audited to ensure compliance. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of the junction box in the boiler room and the heater in the Activities Department will be conducted to ensure compliance. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Deficiency in Emergency Preparedness Plan at Wyndmoor Hills
Penalty
Summary
Wyndmoor Hills Rehabilitation And Nursing Center was found to have a deficiency related to their Emergency Preparedness (EP) plan during a survey conducted on January 27, 2025. The facility failed to develop and implement policies and procedures that included their role in providing care and treatment at alternate care sites during emergencies, as required under an 1135 waiver declared by the Secretary. This deficiency was identified through a document review and confirmed during an exit interview with the Administrator and Maintenance Director. The survey revealed that the facility's EP plan did not address the facility's responsibilities in the event of an emergency that necessitates care at alternate sites, as identified by emergency management officials. This oversight affects the entire facility, as the EP plan is a critical component in ensuring preparedness and response during emergencies. The absence of these policies and procedures was confirmed during the exit interview, highlighting a gap in the facility's emergency preparedness strategy.
Plan Of Correction
1. Emergency preparedness plan was immediately updated with policy and procedures for 1135 waiver. 2. Emergency preparedness plan was audited to ensure proper compliance. 3. Education provided to ensure proper compliance with this regulation. 4. Emergency preparedness plan will be audited to ensure proper compliance 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Maintain Safe Operating Conditions for Essential Equipment
Penalty
Summary
The facility failed to ensure that essential mechanical equipment was in safe operating condition, specifically one of the two elevators and the heating system in the main kitchen. Resident R220, who has Type II Diabetes, high blood pressure, neuropathy, and a nonhealing diabetic foot ulcer, experienced a distressing incident on January 3, 2025, when the elevator malfunctioned. The elevator made loud thumping sounds and stopped misaligned with the floor, causing the doors not to open. This incident triggered the resident's PTSD, and it was revealed that the facility was aware of the elevator's issues since December 13, 2024, but did not address them until after the incident. Additionally, the main kitchen's heating system was non-functional, with temperatures ranging from 46 to 56 degrees Fahrenheit, making it difficult for dietary staff to perform their duties. The kitchen had been without heat since November 2024, and staff were observed wearing extra clothing to stay warm. The unfavorable working conditions were reported to have caused illnesses among the staff, with four members calling in sick. The Nursing Home Administrator confirmed that the heating system had been out of service since November 2024, requiring significant repairs to restore proper function.
Plan Of Correction
1. The elevator parts arrived and the elevator was fixed on 1/8/25. The kitchen heat has been restored and the doors were immediately fixed. 2. All kitchen doors will be audited to make sure they are working functionally. 3. Staff will be educated on the components of this regulation with an emphasis on maintaining essential equipment in a safe operating condition. 4. Elevators and the kitchen heat will be audited to sure they are working correctly 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Facility Fails to Maintain Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for its residents, as evidenced by several deficiencies observed during a survey. In Resident R49's bathroom, a dirty toilet with a brown substance and a soiled brief placed next to it were noted, along with a broken sanitizer dispenser near the resident's bedroom door. Resident R19's room had a broken baseboard near the table and a missing drawer on the left side of the desk, which was confirmed by Licensed Nurse, Employee E4. Additionally, Resident R10's room had a baseboard that was off the wall next to the restroom wall in the corner. The Maintenance Director, Employee E4, confirmed these observations and also noted a broken closet door in another room. Furthermore, during a laundry tour with the Housekeeping Director, Employee E11, a large hole in the floor near the industrial washing machine was observed, providing an open access point for pests.
Plan Of Correction
1. Resident R49 was immediately cleaned. The sanitizer dispenser near the resident's bedroom door was fixed. Multiple room repairs were made. 2. Hand sanitizers and rooms will be audited to ensure they are within compliance. 3. Staff will be educated on the components of this regulation with an emphasis on maintaining a safe and sanitary environment. 4. 5 Hand sanitizers and 5 rooms will be audited to ensure they are within compliance 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to QAPI monthly x6 months.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in multiple areas, including two nursing units, the food and nutrition services department, and the laundry room. Observations and interviews revealed that residents and staff had encountered mice and flies, with specific incidents such as a resident observing mice in her room and another resident finding candy with mice teeth marks. The maintenance log did not record these incidents, indicating a lack of proper documentation and response to pest sightings. Further investigation showed structural issues that facilitated pest entry, such as a large hole in the laundry room floor and gaps in the metal doors leading outside. The pest control policy outlined measures to prevent pest entry, but these were not effectively implemented. Staff interviews revealed a lack of training and awareness regarding the pest control logbook, with some employees using informal methods like sticky notes to document pest sightings, which were not transferred to the official logbook. The pest control operator's reports from previous months consistently highlighted the need for thorough cleaning and maintenance in the main kitchen, where pest droppings and food debris were found. Despite ongoing treatments for pests, the same issues persisted, such as unsealed food containers, improper waste disposal, and water left in sinks, providing sustenance for pests. These findings indicate systemic failures in the facility's pest control management, contributing to the ongoing pest problem.
Plan Of Correction
1. Gaps on the doors and holes in the dietary director's office were fixed. 2. Our pest control will do a house audit on our pest control to ensure compliance. 3. Staff will be educated on effective pest control measures. 4. Pest logs will be audited 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings will be reported to QAPI x6 months.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct complete and thorough investigations of allegations of physical abuse, neglect, and misappropriation of property for four residents. The facility's policies required the nursing home administrator to investigate and report any allegations of abuse within the required timeframes. However, the facility did not adhere to these policies, resulting in incomplete investigations and failure to notify the Department of the alleged perpetrators. For Resident R120, the facility did not conduct a thorough investigation into an allegation of physical abuse. The resident reported that a nurse attempted to administer an unfamiliar medication and placed her finger in the resident's mouth. Although an alleged perpetrator was identified, the facility failed to notify the Department. Similarly, for Resident R58, the facility did not complete a thorough investigation into the misappropriation of $200. The investigation was not concluded, and the resident's request for reimbursement was not addressed. Resident R22's case involved an allegation of physical abuse where a nurse aide allegedly yanked the resident by the collar. The facility did not document a complete investigation, including interviews with the resident, family members, or other residents. Additionally, Resident R1 reported neglect and disrespectful treatment by staff during an incident involving incontinence. The facility did not investigate this incident as required, further highlighting the failure to adhere to their abuse prevention policies.
Plan Of Correction
1. A PB-22 was completed for Resident R120. Resident R58 was given $200. The reportable incident regarding Resident R22 on August 13, 2024, will be properly investigated. 2. Grievances for the last 4 months will be audited to ensure proper investigations were done. 3. Staff will be educated on the components of this regulation with an emphasis on properly investigating, preventing, and correcting alleged violations. 4. Grievances will be audited to ensure proper investigations 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Inadequate Supervision and Policy Enforcement for Resident Smoking
Penalty
Summary
The facility failed to provide adequate supervision for residents who smoke, as evidenced by multiple incidents involving three residents. Resident R24 was repeatedly found smoking in non-designated areas and times, despite being re-educated on the facility's smoking policy. The facility's policy stated that smoking inside the building was prohibited, and violations could lead to revoked smoking privileges and potential discharge. However, despite numerous infractions, including smoking in his room and possessing smoking materials, the facility did not enforce these consequences, and documentation of these incidents was lacking. Additionally, Resident R5 was observed in the designated smoking area with an oxygen cylinder attached to his wheelchair, which violated the facility's policy prohibiting oxygen cylinders in the smoking area due to fire hazards. This incident occurred without staff supervision, as required by the facility's smoking policy. Resident R63 was also found smoking outside the designated times and without supervision, and it was revealed that he had not been informed of the smoking policy or signed a smoking agreement upon admission. The facility's failure to enforce its smoking policy and provide adequate supervision created potential safety hazards, particularly concerning the risk of fire. The lack of documentation and enforcement of consequences for non-compliance with the smoking policy contributed to the ongoing issues with resident smoking behavior. Interviews with staff and residents confirmed these deficiencies, highlighting the facility's inadequate management of smoking-related risks.
Plan Of Correction
1. An Ad Hoc QAPI meeting was immediately conducted to update the smoking policy and its enforcement. The new smoking policy allows for more smoking times for residents deemed safe to improve residents compliance and enforcement of the policy. Residents were educated that any violation of the smoking policy will result in immediate action with potential for 30 day discharge notice to be given. R24 was educated on the new smoking policy and was informed that he will not be able to keep cigarettes on his person. R5 was reassessed and it was determined that he should be on oxygen PRN. He was educated that he may not go outside to smoke with a oxygen tank on him. R63 was reeducation on the new smoking policy. 2. A Full house audit on all residents identified as smokers was done to ensure they are aware of the policy and that there no others identified smokers. 3. Staff will be educated on the components of this regulation with an emphasis on accident prevention, supervision, and appropriate use of devices. 4. 5 residents who smoke will be audited to ensure they understand the smoking policy and are being properly supervised 1x a week for 1 month, 2x a month for 1 month and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Safeguard Residents' Personal Belongings
Penalty
Summary
The facility failed to protect the personal belongings of residents, as evidenced by the lack of a system to secure valuables in resident rooms. The facility's policy and admission agreement both state that the facility is responsible for safeguarding residents' personal property. However, interviews and observations revealed that residents were not provided with keys or a system to lock their cabinets, despite the presence of locks. This deficiency was noted for two residents, both of whom were alert and oriented, with no impairments in their upper extremities. Resident R58 reported missing $200 since August 2024 and stated that he had not been offered a way to secure his cash. Observations confirmed that although there was a lock on the cabinet in his room, there was no key or system available for him to use. Similarly, Resident R63, who was also alert and oriented, had a cabinet with a lock but no means to secure it. The Nursing Home Administrator confirmed that several residents had expressed a desire for a lock and key system to safeguard their belongings, but this had not been implemented.
Plan Of Correction
1. Rooms 201, 204, 207, 213, 214, 220, 228, 301, and 334 were given a key to their locked drawer. Resident R63 was given a key to his drawer. Resident R58 received his $200.00. 2. Audit of all residents was done to see if anybody wants a key. Anybody who requests one will receive one. 3. Staff will be educated on the components of this regulation with an emphasis on maintaining a safe, clean, comfortable, and homelike environment. 4. Audits will be done on all new admissions to ensure they are being offered a key 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Report Suspected Abuse and Neglect
Penalty
Summary
The facility failed to report an allegation of suspected abuse and neglect to the Survey Agency for a resident. The resident, who was alert and oriented, had multiple medical conditions including chronic obstructive pulmonary disease, neuromuscular dysfunction of the bladder, multiple sclerosis, and colon cancer. The resident was frequently incontinent and required assistance with transfers. On a particular evening, the resident experienced uncontrollable bowel movements and called for nursing assistance, which was delayed. In attempting to use the bathroom independently, the resident fell and was left in a state of distress. When a nursing assistant eventually arrived, the resident reported being treated disrespectfully and was told by the staff that they did not have to help him. The resident was subjected to derogatory comments about his condition and was told to "shut up" by a nurse. The resident expressed frustration and apologized for his condition, explaining it was due to his cancer. Despite these events, the incident was not reported to the appropriate authorities as required, constituting a failure in the facility's duty to report suspected abuse and neglect.
Plan Of Correction
1. Grievance/concern dated November 6, 2024, regarding Resident R1 was reported. 2. Last 4 months of grievances will be audited to ensure any grievance that need to be reported, was reported. 3. Staff will be educated on the components of this regulation with an emphasis on timely and accurate reporting of alleged violations. 4. Audits will be done to ensure all grievances that need to be reported have been reported 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Implement Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The facility's policy on Trauma-Informed Care (TIC) aims to provide care that is safe, respectful, and responsive to trauma, preventing re-traumatization and promoting healing. However, upon reviewing the clinical records and facility policy, it was found that the facility did not create a care plan addressing the resident's PTSD, including their trauma-related needs, preferences, and triggers. The resident, who had a history of depression, anxiety, and PTSD, was on Seroquel for trauma-related issues. During an interview, the resident reported an incident where being stuck in an elevator triggered their PTSD, causing past traumatic memories to resurface. Despite this, there was no evidence in the clinical record of a care plan that addressed the resident's specific needs related to PTSD, as recommended by the psychiatric evaluation and therapy notes.
Plan Of Correction
1. Resident R220's care plan has been updated. 2. 5 residents' care plans will be audited to ensure proper comprehensive plan. 3. Staff will be educated on the components of this regulation with an emphasis on developing and implementing comprehensive care plans. 4. 5 care plans will be audited to ensure proper comprehensive care plan 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Provide Grooming Services to Residents
Penalty
Summary
The facility failed to provide grooming services to residents who were unable to perform activities of daily living, specifically grooming, as required by their policy. The facility's policy stated that professional beauty and barber services should be available and offered to residents regularly to enhance their quality of life. However, despite having an agreement with a cosmetology and barber service since September 2024, the facility did not accommodate the residents' grooming needs. Interviews with residents revealed that they were unaware of the availability of these services and believed they had to perform their own grooming. The nursing home administrator confirmed that no visits from the hairdresser or barber services had occurred since the initiation of the outside resources agreement. This lack of service affected multiple residents, as identified in the report, who were not informed about the availability of professional grooming services within the facility. The deficiency was identified through reviews of policies, procedures, and interviews with residents and staff, highlighting a failure to meet the residents' grooming needs as per the facility's policy and service agreement.
Plan Of Correction
1. The hairdresser came to the facility on 1-30-25. 2. Residents will be audited for grooming. 3. Staff will be educated on the components of this regulation with an emphasis on providing appropriate ADL care for dependent residents. 4. 5 residents will be audited to ensure proper grooming 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. Resident 55, who was admitted with diagnoses including muscle weakness, lack of coordination, abnormal gait and mobility, high blood pressure, and glaucoma, had not seen an eye doctor since their admission. This was confirmed during an interview with the resident on January 7, 2025, and further corroborated by the Director of Nursing on January 10, 2025, who acknowledged the absence of an eye exam for the resident since admission.
Plan Of Correction
1. Resident R55's eye exam was scheduled. 2. Residents will be audited to ensure they all had an eye exam within the proper time. 3. Staff will be educated on the components of this regulation with an emphasis on ensuring residents receive necessary treatment and devices to maintain hearing and vision. 4. 5 Residents will be audited to ensure they had an eye exam in the proper time 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Provide Assistive Device for Bed Mobility
Penalty
Summary
The facility failed to provide an assistive device for a resident, identified as Resident R23, to maintain independence with bed mobility. The facility's policy for bed safety requires an assessment for safety, medical conditions, comfort, and freedom of movement, with input from the resident and consultation with a physician. Despite a physician's order dated May 21, 2024, for 1/4 side rails as an enabler for bed mobility, the facility did not implement this order. The resident, who is alert, oriented, and independent with all activities of daily living, expressed the need for bed rails to assist with frequent nighttime bathroom visits. The deficiency was further highlighted by the inaccurate completion of the side rail evaluation, which marked the resident as not assessed for potential bed rail use. A regional registered nurse confirmed that the facility does not use side rails and that the assessment indicated the resident did not need them, contradicting the physician's order. This oversight resulted in the resident not receiving the necessary support to maintain independence in bed mobility, as initially planned upon admission to the facility.
Plan Of Correction
1. Resident R23 had a side rail installed. 2. Full house side rail assessment has been done. 3. Staff will be educated on the components of this regulation with an emphasis on increasing or preventing the decrease in residents' range of motion and mobility. 4. 5 residents will be audited to ensure they have a side rail if needed 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Assess Necessity of Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling urinary catheter was properly assessed for the necessity of the catheter's continued use. The resident, who was admitted following an acute hospitalization for an infection post-spinal surgery, had a diagnosis of sepsis and multiple pressure injuries, including an unstageable pressure ulcer on the sacrum. Despite the facility's policy stating that indwelling catheters should be used sparingly and only for appropriate indications, there was no documented rationale or clinical justification for the catheter's continued use in the resident's clinical record. The resident's care plan included goals to remain free from catheter-related trauma and to monitor for pain and discomfort. However, the Director of Nursing clarified that the catheter was used to keep the resident's wound dry due to incontinence, yet there was no documented evidence supporting this need. Additionally, a wound vac was ordered to promote wound healing, further questioning the necessity of the catheter. The lack of documentation and assessment for the catheter's necessity constitutes a deficiency in the facility's care for the resident.
Plan Of Correction
1. Resident R64 was assessed for the removal of the catheter. 2. Residents who have catheter will be assessed for removal of the catheter. 3. Staff will be educated on the components of this regulation with an emphasis on proper assessment and management of bowel/bladder incontinence, catheters, and UTIs. 4. Residents with a catheter will be audited for a removal of catheter 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Cap IV Line as per Standard Practice
Penalty
Summary
The facility failed to provide adequate treatment and care for an intravenous catheter (IV) line in accordance with professional standards of practice for one resident. The deficiency was identified through observations, clinical record reviews, and interviews with the resident and staff. The standard nursing practice guidelines, as outlined in a peer-reviewed journal, emphasize the importance of capping intravenous tubing and disinfecting intravenous ports to reduce the risk of infection. Specifically, the guidelines state that the exposed end of IV tubing used for intermittent infusions should be covered with a sterile cap between uses, and the port should be disinfected before connecting tubing or a syringe. Resident R220, who was diagnosed with Type II Diabetes, high blood pressure, neuropathy, and a nonhealing diabetic foot ulcer with osteomyelitis, required IV antibiotics. During an interview and observation, the resident noted that while in the hospital, orange caps were used on the end of the IV line, but the facility did not use them. The hospital records indicated that a PICC Single Lumen was placed, and the line was documented as capped. However, an interview with the Unit Manager confirmed that the IV line should be capped when not in use, indicating a failure to adhere to the standard practice at the facility.
Plan Of Correction
1. Resident R220 was assessed to ensure there were no adverse effects from this alleged behavior. Adequate treatment and care for the intravenous catheter (IV) line were provided in accordance with professional standards of practice. 2. Residents with a catheter will be assessed to ensure they had no adverse effects. 3. Staff will be educated on the components of this regulation with an emphasis on the proper administration and monitoring of parenteral/IV fluids. 4. Residents with a catheter will be audited to ensure they had no adverse effects 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide consistent respiratory care and supplemental oxygen as ordered by the physician for two residents. Resident R2, who was admitted with chronic respiratory failure with hypoxia and congestive heart failure, had a physician's order for oxygen at 3 liters/min via nasal cannula continuously. However, during an initial facility tour, it was observed that the oxygen level was set at 1.5 liters on the resident's oxygen concentrator. This discrepancy was confirmed by a licensed nurse, indicating that the incorrect amount of oxygen was being administered. Similarly, Resident R5, diagnosed with chronic obstructive pulmonary disease, had a physician's order for oxygen at 2 liters/min via nasal cannula continuously for shortness of breath. Observations revealed that the resident was not receiving oxygen as prescribed, as the valve connected to the oxygen tank was not turned on. This was confirmed by the Director of Nursing, highlighting a failure to adhere to the physician's orders for oxygen therapy.
Plan Of Correction
1. Residents R2 and R5 were provided with respiratory care and supplemental oxygen as ordered by the physician. 2. Residents on oxygen will be audited to ensure they are following MD orders. 3. Staff will be educated on the components of this regulation with an emphasis on providing appropriate respiratory and tracheostomy care. 4. 3 residents on oxygen will be audited to ensure they are following MD orders 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Address PTSD and Develop Care Plan After Elevator Incident
Penalty
Summary
The facility failed to develop a plan of care for a resident diagnosed with PTSD, anxiety, and depression, following a distressing incident where the resident was trapped in an elevator. The resident, who had a history of PTSD, hypertension, depression, and a nonhealing diabetic foot ulcer, experienced a traumatic event when the elevator malfunctioned, causing severe anxiety and triggering PTSD symptoms. Despite the resident's request for psychological support, there was no documented evidence that the facility informed the physician or therapist about the incident or the resident's request for therapy. Interviews with staff confirmed the resident's distress and the lack of immediate psychological intervention. The Nursing Home Administrator was aware of issues with the elevator prior to the incident but did not take action to shut it down until after the resident was trapped. The facility's failure to address the resident's mental health needs and the lack of a care plan for the resident's PTSD and related conditions contributed to the deficiency.
Plan Of Correction
1. Resident R220 was seen by psychological services. 2. Residents with PTSD will be seen by psychological services to ensure proper plan is in place. 3. Staff will be educated on the components of this regulation with an emphasis on managing behavioral difficulties appropriately. 4. Audits of 5 residents with PTSD will ensure they have been seen by psychiatric services 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that routine dental services were provided to residents in a timely manner, as evidenced by the case of Resident R55. The resident was admitted with diagnoses including muscle weakness, lack of coordination, abnormal gait and mobility, high blood pressure, and glaucoma. An interview with the resident on January 7, 2025, revealed that they had not seen a dentist since their admission. This was confirmed by the Director of Nursing on January 10, 2025, who acknowledged the absence of any record indicating that Resident R55 had received a dental exam since being admitted to the facility.
Plan Of Correction
1. Resident R55 has been scheduled to see the dentist. 2. Residents will be audited to ensure they have been seen by the dentist in the proper time. 3. Staff will be educated on the components of this regulation with an emphasis on providing access to routine and emergency dental services. 4. 5 residents will be audited to ensure they have been seen by the dentist in the proper time 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Unsanitary Conditions in Dietary Services
Penalty
Summary
The dietary services department was found to be operating under unsanitary conditions. Observations revealed that the ceiling tiles in the hot food preparation area were coated with grease and dried splattered food, and were brown stained and water damaged, indicating water leakage. The ceiling light fixtures contained dirt and dead bugs. The low temperature dish machine was not registering the proper concentration of chemical sanitizer, confirmed by the director of dietary, due to a leaking tube that dispenses the sanitizer. The dishroom flooring was heavily soiled with food debris, dirt, and mice droppings, and the metal shelving inside the walk-in refrigerator units was heavily soiled with dirt, food spillage, and sticky substances. Additionally, the dry food storage closet contained boxes of canned and dried foods stacked on top of each other and directly on the floor, making it difficult to clean and providing a place for pests. A review of the County Public Health Department's food service inspection report revealed that insects and rodents were out of compliance, with rodent droppings observed throughout the main kitchen. Food contact surfaces were not cleaned and sanitized, and the chlorine sanitizer concentration of the dish machine was below the required level. A non-protected opening to the loading dock was noted, and floor tiles were missing, with pooling of water cited in the hot food preparation and dish room areas.
Plan Of Correction
1. All kitchen areas, dishroom, ceiling tiles, metal shelving, walk-in refrigerator units, and light fixtures were immediately cleaned. The low-temperature dish machine was scheduled for maintenance. The tubing that dispenses the chemical sanitizer was fixed. Any items on the dry food storage closet floor were removed. 2. Other areas of the kitchen not mentioned in the 2567 were audited for cleanliness as well. 3. Staff will be educated on the components of this regulation with an emphasis on proper food procurement, storage, preparation, and serving in a sanitary manner. 4. The kitchen will be audited to ensure it is properly clean and storage is put away properly 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Document Resident Smoking Incidents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, identified as Resident R24, as required by professional standards. On multiple occasions, staff detected a smoking odor in Resident R24's room, and evidence of smoking, such as cigarette burn holes and a burnt-out cigarette, was observed. Despite these observations, the incidents were not documented in the resident's clinical records. The Social Worker, Employee E13, revealed that the Administrator advised against documenting these instances to avoid creating a record of non-compliance, which could complicate finding alternative placements for the resident. Additionally, a morning meeting was held on January 3, 2025, where the administrative team discussed concerns about Resident R24's smoking behavior. However, no documentation of this meeting or the discussion was recorded. The Director of Nursing confirmed the occurrence of this meeting and acknowledged that there were additional incidents involving Resident R24 that were not documented. This lack of documentation violates the requirements for maintaining clinical records and nursing services as per the relevant Pennsylvania Code.
Plan Of Correction
1. The administrator responsible no longer works for the facility as of September 2024. Staff were educated on the importance of proper documentation. 2. Audit of the current residents for the last 30 days will be done to ensure proper documentation; any concerns will be corrected immediately. 3. Staff will be educated on the components of this regulation with an emphasis on maintaining resident records with identifiable information securely and accurately. 4. Five residents' notes were audited for proper documentation once a week for one month, twice a month for one month, and then once a month for one month. 5. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly for six months.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, identified as Resident R1, which is a requirement according to the facility's policy. The baseline care plan should have included initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations. However, upon review, it was found that no such care plan was developed for Resident R1 during their stay at the facility. This oversight was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. Resident R1 was admitted with multiple complex medical conditions, including coronary artery disease, heart failure, renal failure, and several others. Despite these conditions, no dietary or nutritional assessment was completed, and no diet order was prescribed. Additionally, no care plans or focus areas were developed to address the resident's therapy services, assistance with activities of daily living, discharge planning, respiratory needs, diabetes, immune disorders, cardiac conditions, wound infection, pain, mental health disorders, or cancer therapy. The resident chose to discharge from the facility shortly after admission, and the care plan was only initiated after the resident had left.
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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