Yardley Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yardley, Pennsylvania.
- Location
- 1480 Oxford Valley Road, Yardley, Pennsylvania 19067
- CMS Provider Number
- 395817
- Inspections on file
- 20
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Yardley Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents with hypertension did not receive care in accordance with physician-ordered parameters for antihypertensive medications. For one resident, staff administered amlodipine on multiple occasions even when the SBP was below the ordered hold parameter. For another resident, staff administered diltiazem three times daily over several months without consistently measuring and documenting heart rate as required by the physician’s order. The DON confirmed that these medication orders and parameters were not followed.
The facility did not follow its pain management policy or a resident’s care plan by failing to attempt or document non-pharmacological pain interventions before administering PRN tramadol. Policy required use of measures such as heat or ice, repositioning, massage, and opportunities to discuss chronic pain, and the resident’s care plan specified positioning, relaxation therapy, heat, cold application, bathing, and/or muscle stimulation. Despite these directives, MARs showed repeated administration of PRN tramadol over multiple months with no evidence that non-pharmacological interventions were tried first, a lapse confirmed by the ADON.
The facility failed to follow its Enhanced Barrier Precautions policy for a high-risk resident with Steele-Richardson-Olszewski syndrome, dementia, an enteral feeding tube, and multiple stage 4 pressure ulcers who was dependent on staff for toileting and hygiene. Policy required use of PPE, including gowns and gloves, during high-contact care such as incontinence care. A NA was observed providing incontinence care without a protective gown and acknowledged doing so, and the DON confirmed that staff did not use appropriate PPE during this resident’s care, resulting in noncompliance with infection control requirements.
A resident with bilateral below-the-knee amputations, who required assistance for transfers per the MDS, was being moved from a wheelchair to a weight chair by two NAs when the wheelchair rolled away and the resident was lowered to the floor. Facility documentation and a nurse’s observation identified that both wheelchair brakes were broken and did not fully engage before the transfer, allowing the chair to move. In an interview, the DON confirmed staff were expected to ensure the wheelchair brakes were engaged and working to prevent the wheelchair from rolling during transfers.
A resident with nausea and vomiting had a PIVC placed for ordered IV hydration, but the IV fluids were never administered and documentation showed the line was kept in place for several days without use. Facility policy required daily evaluation of vascular access, removal of PIVCs not used for more than 24 hours or no longer clinically indicated, and documentation of removal and site condition. The record lacked evidence of ongoing assessment of the IV site, justification for continued use, or documentation of removal, and leadership confirmed the PIVC remained in place beyond policy requirements.
The facility failed to store food under sanitary conditions, with raw chicken stored above cooked roast beef and raw poultry stored above raw beef in the walk-in refrigerator. This improper storage was confirmed by the Administrator.
A facility failed to ensure a call bell was accessible for a resident with a self-care deficit due to physical limitations. Despite the care plan's directive for staff to encourage the use of the call bell for assistance, it was observed on multiple occasions that the call bell was placed inside a drawer of the bedside stand, out of the resident's reach.
A facility failed to provide necessary services to improve ADLs for a resident with anxiety, osteoarthritis, and muscle weakness. The resident's care plan required a restorative nursing program for ambulation, but staff did not regularly offer assistance. The resident reported a lack of regular ambulation offers, and records showed no evidence of assistance on multiple dates, with no documented refusals. The Administrator confirmed the deficiency.
A resident with a left wrist contracture did not receive the prescribed soft resting hand splint as per the care plan. Observations on multiple days showed the splint was not applied, and the resident confirmed non-application without refusal. There was no documentation of the splint being used or any refusals.
A resident with dementia and dysphagia was not adequately supervised during meals, despite a care plan requiring supervision and upright positioning. Observations showed the resident eating unsupervised in bed, leading to a choking incident. The DON confirmed the need for supervision.
The facility failed to assess two residents for the cause of their bladder incontinence or the potential to restore normal bladder function. One resident, with heart failure and muscle wasting, was previously continent but became completely incontinent without assessment. Another resident, initially continent, became frequently incontinent and then completely incontinent after hospitalization, yet no assessment was conducted. Both cases show non-compliance with the facility's policy on incontinence management.
The facility was found to have improperly disposed of trash and refuse, with the trash compactor overflowing and trash bags spilling onto the ground. The compactor's lid and back cover could not be closed due to the overflow.
The facility did not post accurate and current nurse staffing information. Observations revealed that the staffing information in the lobby was outdated, displaying a date from three days prior. The DON confirmed the error during an interview.
Yardley Rehabilitation and Healthcare Center failed to provide required written notifications for resident transfers and discharges. A resident did not have their revised discharge notice communicated to their representative, and three residents transferred to the hospital did not receive written notifications. The facility's policy mandates such notices, but it was not followed, leading to a deficiency.
Failure to Follow Physician Parameters for Antihypertensive Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for blood pressure medications for two residents. One resident with hypertension and type 2 diabetes had a physician’s order, dated May 26, 2023, for daily amlodipine with instructions to hold the medication if the systolic blood pressure (SBP) was below 120 mm/Hg. Review of this resident’s MAR for October, November, and December 2025, and January and February 2026, showed that staff administered amlodipine despite SBP readings below 120 mm/Hg on multiple occasions: once in October, once in December, six times in January, and once in February. The second resident, with hypertension and multiple sclerosis, had a physician’s order dated May 15, 2025, for diltiazem three times daily, with instructions not to administer the medication if SBP was below 110 mm/Hg or if heart rate was less than 60 beats per minute. Clinical record review revealed that this resident’s heart rate was documented only twice in September 2025 and once each in January and February 2026. Despite this lack of heart rate measurements, review of the MAR for October, November, and December 2025 showed that staff administered diltiazem three times daily without measuring the resident’s heart rate as ordered. In an interview, the DON confirmed that the physician orders for both residents were not followed and that medications were administered outside the ordered parameters.
Failure to Use Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to follow its pain management policy and the resident’s care plan by not attempting or documenting non-pharmacological pain interventions before administering PRN pain medication to one resident. Facility policy, last reviewed January 25, 2026, required that physicians order both non-pharmacological and medication interventions for pain, and that staff provide a comfortable environment and complementary measures such as local heat or ice, repositioning, massage, and opportunities to talk about chronic pain. Resident 13, who had dementia, diabetes, and abnormalities of gait and mobility, had a physician’s order dated November 26, 2025, for tramadol every 12 hours as needed for pain, and a care plan that directed staff to use positioning, relaxation therapy, heat, cold application, bathing, and/or muscle stimulation for pain relief. Medication Administration Records showed that staff administered PRN tramadol without documented evidence that non-pharmacological interventions were attempted beforehand on 15 occasions in December 2025, 13 occasions in January 2026, and 18 occasions in February 2026. In an interview, the Assistant Director of Nursing confirmed there was no evidence that non-pharmacological pain interventions were provided prior to administering the PRN pain medication as required.
Failure to Use Enhanced Barrier Precautions and PPE During High-Contact Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not following its Enhanced Barrier Precautions (EBP) policy for a resident requiring high-contact care. The EBP policy, last reviewed January 25, 2026, required the use of PPE, including gowns and gloves, for high-risk residents with wounds or indwelling devices during high-contact care activities such as wound care, care of feeding tubes, hygiene, and changing briefs and linens. Clinical record review showed that Resident 1 had Steele-Richardson-Olszewski syndrome, dementia, an enteral feeding tube, and multiple stage four pressure ulcers on the sacrum, right hip, and buttocks, and was dependent on staff for toileting and personal hygiene. On February 25, 2026, at 12:00 p.m., a nurse aide was observed entering the resident’s room to change briefs without wearing a protective gown and stated she provided incontinence care without a gown. On February 27, 2026, at 1:00 p.m., the Director of Nursing confirmed that staff did not use appropriate PPE during this resident’s care, resulting in noncompliance with the facility’s EBP policy and state regulations at 28 Pa. Code 211.10(d) and 211.12(d)(1)(5).
Failure to Ensure Functional Wheelchair Brakes During Assisted Transfer
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent a fall for one resident when staff attempted a transfer using a wheelchair with defective brakes. Clinical record review showed that Resident 3 had bilateral below-the-knee amputations and, per the Minimum Data Set assessment, required assistance for transfers between surfaces such as wheelchair to chair. On October 5, 2025, at 3:38 p.m., a nurse documented that the resident was being transferred from a wheelchair to a weight chair by two nurse aides (NA1 and NA2) when the wheelchair rolled out from under the resident and the resident was lowered to the floor. The nurse’s observation and facility fall documentation for that date identified that both wheelchair brakes were broken and did not fully engage prior to the transfer, allowing the wheelchair to move during the assisted transfer. In a subsequent interview, the Director of Nursing confirmed that staff should have ensured the wheelchair brakes were engaged and functioning so the wheelchair would not roll during the transfer. This deficiency was cited under 42 CFR 483.25(d) Accidents and referenced a prior citation on March 12, 2025, as well as 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Assess, Use, and Timely Remove Unused Peripheral IV Catheter
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate treatment and care for a peripheral intravenous catheter (PIVC) in accordance with professional standards and its own policy for one resident. A resident with no cognitive impairment, who required supervision/touching assistance for most ADLs and transfers, experienced nausea and vomiting and had an order for placement of a PIVC for hydration. Provider orders directed staff to administer 0.9% sodium chloride at 100 mL/hr every shift for one day, totaling one liter of normal saline, starting late on the day the PIVC was placed and discontinuing the following morning. The Medication Administration Record showed that the ordered IV fluids were never administered. A nurse practitioner note documented that the PIVC was available in case of need but was not currently being used, and there were no further evaluations, assessments, or notes supporting the ongoing need for the PIVC after that. The facility’s policy required staff to evaluate the continued need for vascular access during provider visits and care planning, to remove a peripheral IV if it was not used for more than 24 hours or no longer clinically indicated, and to document the date and time of removal and resident tolerance. According to the resident’s interview and the Assistant DON’s investigation, the PIVC, which the resident reported was never used, remained in place for several days and was not removed until four days after insertion, despite the IV fluid order having been discontinued the day after it was written. Clinical record review revealed no documentation of removal of the PIVC and no documentation of assessment of the catheter or the skin surrounding the IV site. In an interview, the Assistant DON confirmed that the PIVC was not removed until several days after insertion and acknowledged that facility policy should have been followed.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food under sanitary conditions in the kitchen, as observed on March 9, 2025. In the walk-in refrigerator, a rolling storage rack was found containing raw meat, including a pan of raw chicken stored above a pan of cooked roast beef. Additionally, the same rack held pans of raw turkey, cubed beef, whole beef tenderloins, and ground meat, with raw poultry stored above raw beef, which requires a lower internal cooking temperature than raw poultry. This improper storage was confirmed by the Administrator during an interview on March 12, 2025.
Inaccessible Call Bell for Resident with Self-Care Deficit
Penalty
Summary
The facility failed to ensure that a call bell was accessible for a resident, leading to a deficiency. The resident, who had diagnoses including anxiety, dysphagia, and osteoarthritis, was identified as having a self-care deficit due to physical limitations. The care plan indicated that staff should encourage the resident to use the call bell for assistance. However, observations on two separate occasions revealed that the call bell was placed inside a drawer of the bedside stand, positioned away from the bed and out of the resident's reach. This inaccessibility of the call bell was noted on March 9, 2025, at 11:54 a.m. and 1:53 p.m., and again on March 11, 2025, at 11:02 a.m., indicating a failure to accommodate the resident's needs and preferences as required.
Failure to Provide Daily Ambulation Assistance
Penalty
Summary
The facility failed to provide necessary services to improve activities of daily living (ADLs) for Resident 14, who had diagnoses including anxiety, osteoarthritis, and muscle weakness. The resident's care plan required a restorative nursing program (RNP) for ambulation, with staff assistance for walking daily. However, the resident reported that staff did not regularly offer assistance for ambulation. A review of the nurse aide task record showed no evidence of staff offering ambulation assistance on multiple dates in February and March 2025, with no documented refusals from the resident. The Administrator confirmed the lack of evidence for daily ambulation assistance as required by the RNP.
Failure to Apply Prescribed Hand Splint for Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent a decline in range of motion for a resident with a left wrist contracture. The resident's care plan required staff assistance for activities of daily living and included a physician's order to apply a soft resting hand splint. However, during observations on three separate days, the splint was not in place. The resident confirmed that staff had not applied the splint recently and that he had not refused its use. There was no documentation to indicate that the splint had been applied or that the resident had refused it.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with dementia, anxiety, and dysphagia. The resident, who had moderate cognitive impairment, required supervision with eating and drinking as per her care plan. Despite this, observations revealed that the resident was left unsupervised during meals on multiple occasions. She was found lying in bed with the head of the bed at less than a 45-degree angle, which was not in accordance with the care plan that required her to be upright during meals. On March 5, 2025, the resident experienced a choking episode that required mechanical assistance from staff. Following this incident, a speech therapy evaluation recommended proper positioning and supervision during meals. However, subsequent observations on March 9, 11, and 12, 2025, showed that the resident continued to eat without supervision and was not positioned upright as required. The Director of Nursing confirmed that the resident should have been supervised while eating, indicating a failure to adhere to the care plan and provide necessary supervision.
Failure to Assess and Manage Bladder Incontinence
Penalty
Summary
The facility failed to assess two residents who were incontinent of bladder to determine the cause of their incontinence or if normal bladder function could be restored. Resident 9, who was admitted with diagnoses including heart failure and muscle wasting, was noted to have been previously continent of bladder. However, since admission, the resident was documented as completely incontinent, with no evidence of an assessment to determine the cause or potential for restoring bladder function. The Minimum Data Set (MDS) assessment indicated no cognitive impairment, and the resident was able to communicate needs, yet the facility did not conduct the necessary evaluations. Similarly, Resident 87, admitted with a urinary tract infection and muscle wasting, was initially continent of bladder. Over time, the resident's condition declined to frequent incontinence, and after a hospitalization, the resident became completely incontinent. Despite these changes, there was no documented evidence that the facility assessed the cause of the incontinence or evaluated the possibility of restoring normal bladder function. Both cases reflect a failure to adhere to the facility's policy on urinary continence and incontinence assessment and management.
Improper Disposal of Trash and Refuse
Penalty
Summary
The facility failed to properly dispose of trash and refuse, as observed during an environmental tour. The trash compactor was overflowing with trash bags, which were spilling from the top and out of the back of the machine onto the ground. The lid on top of the machine and the cover on the back could not be closed due to the excessive amount of trash.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information as required. On March 9, 2025, at 9:29 a.m., it was observed that the staffing information displayed in the lobby was outdated, showing the date of March 6, 2025. This discrepancy was confirmed during an interview with the Director of Nursing on March 12, 2025, at 12:36 p.m., who acknowledged that the incorrect staffing information was posted.
Deficiency in Transfer and Discharge Notifications
Penalty
Summary
Yardley Rehabilitation and Healthcare Center was found to have a deficiency related to the requirements for notice before transfer or discharge of residents. The facility failed to provide a 30-day advanced written notice of discharge to the resident's representative, as required by federal regulations. Specifically, Resident 1 received a revised discharge notice that was not communicated to the responsible party or legal representative in writing, as confirmed by the facility's Administrator. Additionally, the facility did not provide written notifications to residents or their representatives regarding hospital transfers. Residents 2, 3, and 4 were transferred to the hospital following changes in their conditions, but there was no documentation to support that these transfers were communicated in writing to the residents or their responsible parties. This lack of documentation was confirmed during an interview with the Administrator. The facility's policy, last reviewed on January 7, 2025, required that residents and their representatives receive a 30-day advanced written notice for planned transfers or discharges, as well as a transfer notice for hospitalizations. However, the facility failed to adhere to this policy, resulting in a deficiency related to the notice requirements before transfer or discharge.
Plan Of Correction
1. Resident 1, 2, 3 and 4 have had written notification provided to responsible party or legal representative regarding transfer to hospital and pending discharge. 2. A 7 day look back audit was completed to validate written notifications to responsible parties or legal representatives and resident are provided for hospital transfers to hospital and center initiated pending discharges. 3. Nurse supervisors and management are re-educated on written notifications being provided to responsible party or legal representative and resident regarding transfer to hospital and pending discharge due to center initiated discharge. 4. NHA/Designee will complete random weekly audits x4 weeks then monthly x2 to validate written notifications are provided. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.
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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