Wyomissing Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reading, Pennsylvania.
- Location
- 1000 East Wyomissing Blvd, Reading, Pennsylvania 19611
- CMS Provider Number
- 395237
- Inspections on file
- 32
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Wyomissing Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents did not receive care according to physician orders and documented plans. One resident with Parkinson’s disease, aphasia, prior CVA, and a feeding tube had missing MAR documentation for multiple scheduled medications and no TAR evidence of ordered tube feeding or required water flushes during a day shift. Another resident with dementia and depression had no TAR documentation of ordered daily wound care to two fingers, and observations showed the fingers covered with band aids instead of the prescribed saline cleansing, oil emulsion gauze, and gauze dressing; the DON confirmed the orders were not implemented as written.
Surveyors found that the facility failed to follow physician-ordered pressure ulcer treatments and wound care protocols for two residents with significant skin breakdown. One resident with multiple pressure sores and deep tissue injuries had detailed orders for cleansing, packing, and dressing multiple wound sites each evening, but the TAR showed no evidence these treatments were completed on several dates. Another resident with multiple sclerosis and a sacral ulcer had orders for continuous negative pressure wound therapy at 125 mmHg with dressing changes and shift checks, as well as repositioning in bed, yet documentation did not show the therapy was functioning on multiple shifts. Observations confirmed the NPWT pump was turned off and disconnected while the resident lay flat in bed without repositioning, and the DON acknowledged the lack of documentation that ordered treatments and repositioning had been provided.
Surveyors found that the facility did not ensure ordered medications were available and administered for two residents. One resident with cancer-related pain had an order for PRN oxycodone, but when the resident complained of pain, the nurse documented that the oxycodone was unavailable and could not be given. Another resident with diabetes and polyneuropathy had new orders for insulin glargine, metoprolol, metformin, and gabapentin, but nursing notes indicated these medications were not available from the pharmacy and were not administered. The DON confirmed that the medications were not given because they were unavailable and that staff should have used the emergency supply.
The facility failed to follow its abuse reporting policy and state requirements by not timely reporting two separate resident-to-resident altercations involving physical aggression and injury. In one case, a resident with multiple medical conditions and no memory impairment was heard yelling that another resident had struck him and was seen being shoved onto his bed, but the allegation was not reported to authorities within the required timeframe. In another case, a resident with dementia and agitation was shoved onto his bed by his roommate, sustaining lip and eye injuries, and this allegation also was not reported within the required reporting window. The Administrator confirmed that these incidents of alleged abuse were not reported to state and local agencies as required.
Two residents with complex medical conditions were admitted or readmitted, and their initial assessments, including skin assessments, were completed solely by an LPN without RN review or co-signature. The DON confirmed that these assessments lacked RN oversight, which does not meet professional standards of quality.
Two newly hired nurse aides began working before their state registry status was verified, contrary to facility policy requiring pre-employment screening. The DON confirmed that documentation of registry verification was not completed prior to their start dates.
Physician orders for a blood test and daily weights were not carried out for three residents with serious medical conditions. The DON confirmed that a blood test was not performed as ordered for a resident with vascular disease, and daily weights were not documented for two residents with chronic illnesses, indicating a failure to follow medical orders.
A resident was admitted without a documented inventory of personal belongings, as required by facility policy. Review of the clinical record and confirmation from the DON showed that the inventory was not completed or maintained in the record.
The facility did not provide written transfer notifications or Ombudsman information to residents and their representatives when several residents were transferred to the hospital after a change in condition. The DON confirmed that neither the residents, their responsible parties, nor the Ombudsman received the required written notices.
Surveyors found that the nurse staffing information posted in the lobby was outdated, displaying data from the previous day. The DON confirmed that the posted information was not accurate or current.
A facility failed to follow physician's orders for a resident with hypertension, heart disease, and dementia. Staff did not check the resident's blood pressure before administering amlodipine 13 times and did not check blood pressure or heart rate before administering metoprolol 12 times over two months. The DON confirmed the lack of documentation for these vital signs prior to medication administration.
A resident with cognitive impairment and malnutrition was not provided with necessary foot care, despite a physician's order for podiatry consultation. The resident was observed with long and jagged toenails, and the facility's records indicated a need for podiatry services since July, yet no evidence of care was found. The DON confirmed the oversight.
Failure to Follow Physician Orders for Medications, Tube Feeding, and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for two residents. For one resident with Parkinson’s disease, aphasia, a history of stroke, and an abdominal feeding tube for nutrition and medications, clinical record review showed multiple ordered medications were not documented as given on a specific date. The MAR for that date lacked documentation of administration of amlodipine besylate ordered daily for hypertension at 2:00 p.m., carbidopa-levodopa ordered three times daily for Parkinson’s disease at 12:00 p.m., and baclofen ordered three times daily for muscle spasms at 12:00 p.m. In addition, physician orders directing continuous tube feeding with Jevity 1.5 at 65 mL/hr from 1:00 p.m. to 7:00 a.m., and specific water flushes (60 mL before and after each medication and feeding, 5 mL between medications, and every shift) were not documented as completed on the day shift for that date. The TAR showed no evidence that the tube feeding formula was administered as ordered or that the required tube flushes were performed on that shift. For another resident with dementia and depression, a physician’s order directed daily day-shift wound care to the right hand’s second and third fingers, including cleansing with saline, application of oil emulsion gauze, and wrapping with a gauze dressing. Review of the TAR for a specific date showed no documented evidence that this wound treatment was provided. Observations on a later date revealed that the resident’s affected fingers were covered with band aids instead of the ordered gauze dressing. In an interview, the DON confirmed there was no evidence that staff implemented the physician’s orders as written and that the resident’s hand wounds were covered with band aids rather than the prescribed gauze dressing.
Failure to Provide Ordered Pressure Ulcer Treatments and Maintain Negative Pressure Wound Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered pressure ulcer treatments and services to promote healing and prevent new pressure sores for two residents with significant skin breakdown. For one resident with a seizure disorder and metabolic encephalopathy, admission assessments and an MDS indicated a sacral pressure sore and multiple deep tissue injuries present on admission. The care plan identified actual skin breakdown with an intervention for staff to provide treatments as ordered. Physician orders directed specific wound care to multiple sites (sacrum, right and left hips, left and right lower back, lower spine, and right plantar foot), including cleansing with normal saline, application of Santyl, Medihoney, skin prep, betadine-moistened gauze, packing with saline-moistened gauze, and covering with bordered foam or gauze dressings on the evening shift. Review of the Treatment Administration Records for this resident showed no evidence that any of the ordered wound treatments were completed on multiple specific dates in December, January, and March. These missed treatments involved all ordered wound sites, indicating that the facility did not follow the physician’s wound care regimen as required by its own wound management policy, which states that the physician or wound consultant determines appropriate treatment and staff are to follow the physician’s orders and product instructions. There was no documentation to show that the ordered cleansing, packing, and dressing applications were carried out on the identified dates. For another resident with multiple sclerosis and a sacral pressure ulcer, a wound care note and MDS documented a sacral pressure sore, cognitive intactness, and total dependence on staff for care. The care plan included interventions for staff to provide treatments as ordered and to reposition the resident in bed. Physician orders required application of black foam and a negative pressure wound therapy (NPWT) dressing connected to a vacuum pump set at 125 mmHg continuously, with dressing changes three times weekly and checks of placement and function every shift. The TAR contained no documented evidence that the NPWT treatment was functioning during several shifts. Observations showed the resident lying flat on her back with the bed flat, the wound pump turned off and disconnected, and the resident reporting that the pump had not worked since the previous afternoon and that staff did not reposition her. Further observation confirmed she remained flat in bed without repositioning, and the DON acknowledged there was no documentation that the treatments for one resident or repositioning and NPWT for the other had been completed as ordered.
Failure to Obtain and Administer Ordered Medications From Pharmacy
Penalty
Summary
Surveyors identified that the facility failed to ensure physician-ordered medications were available and administered as prescribed for two residents. One resident was admitted with neoplasm-related pain and pancreatic cancer and had a care plan intervention for staff to administer medications as ordered. On February 7, 2026, a physician ordered oxycodone every three hours as needed for severe pain. On February 9, 2026, nursing documentation showed the resident complained of pain, but the nurse was unable to administer the ordered oxycodone because it was not available. Another resident was admitted with diagnoses including polyneuropathy and diabetes. On February 5, 2026, a physician ordered insulin glargine at bedtime, metoprolol tartrate twice daily, metformin twice daily, and gabapentin twice daily. Nursing documentation on that same date indicated these medications were unavailable from the pharmacy and therefore were not administered. In an interview, the DON confirmed that the medications for both residents had not been administered as ordered because they were not available from the pharmacy and acknowledged that staff should have utilized the emergency supply.
Failure to Timely Report Allegations of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report allegations of abuse to the required state and local agencies for two residents. Facility policy titled "Abuse Policy - Prevention and Management," last reviewed in August 2025, required that incidents, investigations, and the facility's response to suspected abuse or neglect be reported immediately upon receiving information, and that incidents without serious bodily injury be reported no later than 24 hours after identifying a suspicion of abuse. For one resident with diagnoses including intellectual disability, liver transplant failure, heart failure, and type II diabetes, and with no memory impairment per the MDS, facility documentation showed that on December 29, 2025, the resident was heard yelling that another resident had struck him and was observed being shoved onto his bed before the residents were separated. There was no evidence that this alleged abuse was reported to the required state and local agencies until January 19, 2026, which was 21 days after the incident. For another resident with diagnoses including dementia with agitation and type II diabetes, and significant memory impairment per the MDS, facility documentation dated January 14, 2026, showed that the resident was involved in an altercation in which his roommate shoved him onto his bed, resulting in injuries to his lip and eye. There was no evidence that this alleged abuse incident was reported to the required state and local agencies until January 19, 2026, five days after the incident. In an interview on January 19, 2026, the Administrator confirmed that the facility did not report these incidents of alleged abuse to the required state and local agencies in a timely manner, contrary to facility policy and state regulatory requirements.
Failure to Ensure RN Oversight in Admission Assessments
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not having a Registered Nurse (RN) conduct or review admission and readmission assessments for two residents. According to Pennsylvania Code Title 49, RNs are responsible for assessing, planning, implementing, and evaluating nursing care, while Licensed Practical Nurses (LPNs) may participate in these activities using focused assessments. In both cases, the initial admission/readmission assessments, including initial skin assessments, were completed solely by an LPN without evidence of RN oversight or co-signature. Resident 1 was readmitted with multiple diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, generalized anxiety disorder, suicidal ideation, and a history of venous thrombosis and embolism. Resident 2 was admitted with diagnoses such as cirrhosis of the liver, hepatic encephalopathy, acute posthemorrhagic anemia, acute respiratory failure with hypoxia, and acute kidney failure. The Director of Nursing confirmed that the assessments for both residents were conducted by an LPN without RN involvement, which does not meet the required professional standards.
Failure to Verify Nurse Aide Registry Status Prior to Employment
Penalty
Summary
The facility failed to verify the professional license or registration status of two newly hired nurse aides prior to the start of their employment, as required by its own Abuse Policy-Prevention and Management. According to the policy, screening for all potential hires must include an inquiry to the state nurse aide registry, with results recorded before employment begins. However, documentation showed that both employees began working as nurse aides before the registry inquiries were completed, with verification for both occurring several months after their start dates. The Director of Nursing confirmed that there was no documented evidence of registry verification prior to employment for these individuals, which was not in accordance with facility policy.
Failure to Implement Physician Orders for Lab Work and Daily Weights
Penalty
Summary
The facility failed to implement physician's orders for three residents, as evidenced by clinical record reviews and staff interviews. For one resident with peripheral vascular disease, a physician ordered a Complete Blood Count to be obtained on a specific date, but there was no documented evidence that the blood test was performed. The Director of Nursing confirmed that the blood work was not completed and that nursing staff did not communicate the order to the laboratory. Additionally, two other residents with chronic conditions, including chronic kidney disease, failure to thrive, congestive heart failure, liver cell cancer, and edema, had physician orders to be weighed daily. Review of their records showed multiple dates where there was no documentation that daily weights were obtained as ordered. The Director of Nursing confirmed the lack of documentation for these daily weights, indicating that the physician's orders were not followed for these residents.
Failure to Document Inventory of Personal Belongings on Admission
Penalty
Summary
The facility failed to document an inventory of personal belongings upon admission for one of the 19 sampled residents. According to the facility's policy, the nursing department is required to complete and maintain a documented inventory of all residents' personal belongings in the clinical record at the time of admission. Review of the clinical record for the identified resident showed no evidence that such an inventory was completed or included. This was confirmed by the Director of Nursing during an interview, who acknowledged the absence of the required documentation in the resident's clinical record.
Failure to Provide Required Written Transfer Notifications and Ombudsman Information
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers and information about the Ombudsman, as required. Clinical record reviews for five residents who were transferred to the hospital after a change in condition revealed no documented evidence that written transfer notices were given to the residents or their responsible parties. Additionally, there was no documentation that copies of these notices were sent to a representative of the Office of the State Long-Term Care Ombudsman. During an interview, the Director of Nursing confirmed that the required notifications and written copies of transfer notices were not sent to the residents, their representatives, or the Ombudsman for these transfers. The deficiency was identified for all five residents reviewed who experienced a transfer out of the facility due to a change in condition.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
During a facility tour, surveyors observed that the nurse staffing information posted in the lobby was not current, as it displayed data from the previous day. This observation was confirmed in an interview with the Director of Nursing, who acknowledged that the posted staffing data was incorrect and not up to date. No information about specific residents or their medical conditions was included in the report.
Failure to Implement Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with hypertension, heart disease, and dementia. The orders required staff to administer amlodipine and metoprolol daily, with specific instructions to hold the medications if the resident's systolic blood pressure was below 100 mmHg or if the heart rate was below 60 beats per minute for metoprolol. A review of the medication administration records for August and September 2024 showed that staff did not obtain the resident's blood pressure before administering amlodipine 12 times in August and once in September. Additionally, there was no evidence that staff checked the resident's blood pressure or heart rate before administering metoprolol 11 times in August and once in September. The Director of Nursing confirmed the lack of documentation for these vital signs prior to medication administration, as required by the physician's order.
Failure to Provide Necessary Foot Care
Penalty
Summary
The facility failed to provide necessary nail care to promote foot health for a resident, identified as Resident 12, who was part of a sample of 20 residents. The clinical record review showed that Resident 12 had diagnoses including protein calorie malnutrition and cognitive communication deficit, with cognitive impairment noted in a Minimum Data Set assessment. A physician's order from September 13, 2024, instructed staff to consult podiatry services as needed. However, on October 23, 2024, the resident was observed with long and jagged toenails, indicating a lack of foot care. A facility resident list from July 15, 2024, had already identified the resident as needing podiatry services, yet there was no evidence of the resident being seen by a podiatrist or receiving foot care. The Director of Nursing confirmed in an interview that the resident had not been seen by a podiatrist despite being identified as needing such services since July 2024.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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