Accela Rehab And Care Center At Somerton
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 650 Edison Avenue, Philadelphia, Pennsylvania 19116
- CMS Provider Number
- 395084
- Inspections on file
- 41
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Accela Rehab And Care Center At Somerton during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain and properly test multiple fire alarm system components, including smoke detectors near the medical supply area and house laundry that could not be located, elevator fire hat and primary recall functions that could not be reset due to lack of a key, and an untested elevator control shunt trip. On revisit, the missing smoke detectors had been replaced with battery-operated units that were not connected to the building’s fire alarm notification system, and the previously identified fire alarm issues remained uncorrected.
Surveyors found that floor-to-ceiling built-in millwork cabinetry with doors in the first floor dining room was installed and in use without interior sprinkler coverage or other required fire protection measures, and this cabinetry was not shown on the approved DOH renovation and sprinkler plans, preventing verification of proper sprinkler coverage; on revisit, the same lack of fire protection within the closed-door storage cabinetry remained uncorrected, as confirmed by the Administrator and Maintenance Director.
Surveyors identified that smoke barrier doors in two areas of the facility were not maintained to resist the passage of smoke. In one hallway outside a nurse's station, the smoke barrier doors did not close smoke-tight because the door frame was unsecured within the wall. In another area outside the lobby, the smoke barrier doors failed to swing and close smoke-tight due to a broken door closer, and this problem remained uncorrected at a later revisit survey, as confirmed by the Administrator and Maintenance Director.
A cognitively impaired resident with dementia, severe BIMS impairment, and a documented history of wandering, repeated attempts to leave, and removal of a wander guard was identified by the facility as an elopement risk, with care plan interventions including a wander guard, redirection, and supervision. Despite a policy requiring active front door monitoring and receptionist awareness of residents on the elopement alert list, the receptionist opened the front door while distracted with an x‑ray tech and did not notice the resident exiting. The resident, who had repeatedly verbalized a desire and intent to leave and lacked capacity to make informed discharge decisions, left the building unnoticed, traveled to a nearby train station, and boarded a train. Staff did not recognize the resident’s absence until later, and a search was initiated only after a delay, while another staff member reported seeing someone believed to be the resident at the train station but did not intervene, assuming a discharge. The resident was eventually located hours later at a hospital ED, and surveyors determined that the failure to supervise and monitor the exit placed the resident in Immediate Jeopardy.
A resident with COPD, acute and chronic respiratory failure, pneumonia, toxic encephalopathy, and dementia had new physician orders for continuous O2 at 3 L/min with SpO2 maintained at 88–92% and for nightly use of a Trilogy V60 (AVAPS) device with specific settings, including documentation of any refusals. Despite a cognitive status that allowed participation in care planning, the resident reported being unable to distinguish between CPAP, BiPAP, and AVAPS. Review of the care plan showed it was not timely revised to include goals and interventions related to recent hospitalization, change in mental status, assistance with AVAPS application, resident refusal of AVAPS, frequency of AVAPS use, or maintaining ordered O2 saturation parameters, in violation of facility policy and nursing service requirements.
A resident with COPD, chronic respiratory failure, and other comorbidities had physician orders for nightly AVAPS therapy with specific ventilator settings and continuous oxygen at 3 L/min, with SpO2 to be maintained between 88%–92% and all AVAPS refusals documented. Review of records showed SpO2 consistently documented at 94%–99%, missing or unclear documentation for more than half of the required evening/night AVAPS applications, missing entries for cleaning respiratory equipment, and unexplained “N/A” and “0” notations for AVAPS on multiple shifts. Nursing notes described a critical drop in SpO2 to 60% with confusion, conflicting documentation about whether AVAPS was applied during a prior shift when the resident reportedly refused, and subsequent transfer to the ED for shortness of breath with CO2 at the upper end of normal. The care plan noted AVAPS use and later refusal but lacked follow‑up interventions, AVAPS refusals were not documented as reported to the physician, and an NP reported being unaware of the specific AVAPS and oxygen orders, leading surveyors to cite the facility for failing to consistently administer and document ordered respiratory care.
Surveyors observed that the facility did not maintain a clean and sanitary environment on one nursing unit. The shower room tub had piles of dirty clothing, razors, and a soiled brief, with additional dirty items touching an exposed trashcan. In the soiled utility room, overflowing trashcans and a ripped bag of soiled clothing spilling onto the floor were also found. These conditions were confirmed by staff and the administrator.
A resident alleged that an LPN entered their room without permission, searched personal belongings, and attempted to take the resident's coat without explanation. Another resident and an LPN witnessed the incident, and the event was reported to the social worker. However, facility documentation lacked statements from those involved, resulting in a failure to determine potential misappropriation and ensure resident safety.
A resident with heart failure and hypertension was given antihypertensive medication despite physician orders to hold the dose for low systolic blood pressure. The medication was administered on several occasions when the resident's blood pressure was below the ordered threshold, and there was no documentation that the medication was held as required. The DON confirmed the error during interview.
A resident with intact cognition and serious medical conditions had a change in code status from full code to DNR, with the POLST form signed by a family member instead of the resident. Although staff reported the resident verbally agreed to the change and to the family member signing, there was no documentation in the clinical record confirming the resident's consent or agreement for the family member to sign on their behalf, resulting in incomplete and inaccurate medical records.
Accela Rehab and Care Center at Somerton failed to meet the required minimum of 3.2 hours of direct nursing care per resident per day on 14 out of 21 days reviewed. The facility's staffing levels were insufficient, with care hours per patient per day ranging from 2.97 to 3.15, below the mandated 3.2 PPD. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not ensure the privacy and confidentiality of personal medical information for several residents. A schedule of resident appointments, including sensitive details such as room numbers, medical services, and transportation arrangements, was left visible to the public at the nurse's station. A nurse aide confirmed this was a routine practice, and the Nursing Home Administrator acknowledged the breach of privacy expectations.
A resident's narcotic medication was misappropriated due to the facility's failure to adhere to narcotic counting procedures and documentation policies. The resident, with a prescription for Oxycodone Acetaminophen, was missing 28 tablets, and the facility could not account for them. Interviews revealed that required narcotic counts between shifts were not conducted, and discrepancies were found in medication administration records.
The facility failed to follow physician orders for vital signs and hypoglycemic protocols for three residents. A resident with chronic conditions did not have vital signs recorded as ordered. Two residents with diabetes experienced low blood sugar levels without appropriate interventions or physician notification, as confirmed by the DON.
Two residents in the facility received inadequate respiratory care related to oxygen therapy. One resident's oxygen tubing was not dated as required, and another resident was connected to an oxygen concentrator with insufficient capacity, contrary to the physician's order. These deficiencies were confirmed by nursing staff and the Director of Nursing.
The facility failed to maintain accurate drug records and reconcile controlled substances for two residents. For one resident, 28 tablets of Oxycodone were missing, and the original narcotic book was discarded. Staff interviews confirmed that required narcotic counts between shifts were not conducted. Additionally, an unopened vial of Lorazepam for another resident was found without proper documentation, and vials were not counted between shifts as required.
A facility failed to obtain physician orders for a resident to store medication at bedside and did not ensure the medication was stored securely. The facility's policy requires an assessment of the resident's abilities for safe self-administration and mandates secure storage of medications. An inhaler was found in an unsecured nightstand, and the resident stated they kept it there because staff often could not find it. The DON was unaware of the lack of assessment and unsecured storage.
The facility failed to maintain effective infection control, with improper disposal and storage of suctioning devices and urinary catheter equipment. A resident's suction catheter was improperly stored in a bedside drawer, and another resident's urinary catheter drainage bag was found touching the floor, both confirmed by staff.
The facility failed to maintain a sanitary environment for two residents, as mouse droppings were found in their rooms and remained unaddressed despite being reported. Observations confirmed the droppings, and interviews with staff revealed that deep cleaning was not performed, with daily cleaning not involving moving furniture. A shortage of housekeeping staff on the second floor was also noted.
A facility failed to maintain an effective pest control program on the 2nd floor, as evidenced by mouse droppings found in a resident's room. Despite the resident's reports of seeing mice, there was no documentation of the complaint, and pest control was not informed. This indicates a failure in the facility's pest control program and response to resident complaints.
The facility failed to provide timely Notices of Medicare Non-Coverage (NOMNC) for three residents and did not issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for two residents who remained in the facility after Medicare coverage ended. This deficiency was confirmed through documentation review and an interview with the Nursing Home Administrator.
The facility failed to notify the Office of the State Long-Term Care Ombudsman of emergency transfers for three residents. A resident was sent to the hospital twice in December, another was discharged to a hospital in November, and a third experienced involuntary jerking movements leading to an emergency transfer in January. These omissions were confirmed by the Nursing Home Administrator and violated regulatory requirements.
The facility failed to provide sufficient nursing staff, resulting in delayed medication administration. LPNs were observed administering morning medications hours after the prescribed times due to large resident assignments. The DON confirmed the staffing inadequacy, which led to the delays.
The facility failed to administer diabetic medications timely for five residents, as per physician orders. Medications were given hours after the prescribed times, contrary to the facility's policy. Licensed nurses confirmed the delays, and the DON acknowledged the failure to follow professional standards.
The facility failed to maintain accurate clinical records for two residents, as medications were administered late and recorded with incorrect times. Two LPNs confirmed the late administration but were unaware of how the incorrect times were entered. The facility could not explain the discrepancies in the records.
The facility did not update the daily nurse staffing information as required, with the posted data showing an outdated date of April 30, 2024. This was confirmed through an observation and an interview with the receptionist.
The facility failed to maintain a safe and functional environment for two residents. One resident's dresser was broken, exposing their clothes, while another resident's bed was not functioning properly, preventing the elevation of the foot of the bed. These issues were confirmed by the Nursing Home Administrator.
A facility failed to maintain complete and accurate clinical records for a resident with multiple diagnoses, including pulmonary embolism and respiratory failure. A Level of Care determination deemed the resident Nursing Facility Ineligible, but there was no documentation of this being communicated to the resident. The discharge notice lacked a specified reason, and the discharge summary was incomplete. An interview confirmed the absence of documentation regarding the resident's ineligibility discussion.
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards. Observations included a crystalized jug of honey, a dirty walk-in cooler, an AC unit blowing air through dusty vents, and cooking equipment with heavy buildup of grease and food spatters. The reach-in refrigerator also had dirty door gaskets and a buildup of dirt and food particles inside.
The facility failed to implement a complete drug regimen review process for three residents. The consultant pharmacist did not provide the required monthly medication regimen reviews, and there was a lack of documentation and follow-up on pharmacy recommendations.
The facility failed to maintain a clean, comfortable, and homelike environment in 2 of 5 nursing units. Observations revealed wet spills, a missing HVAC vent cover with sharp metal, broken headboards, scraped paint, and stained privacy curtains. The Maintenance Director was aware of some issues.
The facility failed to conduct a thorough investigation of missing narcotics involving three residents. The incident report and statements from licensed nurses were incomplete, and the investigation focused on only one possible perpetrator, despite indications of more potential perpetrators.
The facility failed to develop and implement a comprehensive care plan for a resident with a history of UTIs, despite the resident being hospitalized due to a UTI. The care plan did not include measures for UTI prevention, as confirmed by the DON.
The facility failed to maintain an environment free from hazards as cleaning supplies were left in a resident's room on two consecutive days. An interview with the DON confirmed that residents were not supposed to have cleaning supplies in their rooms.
The facility failed to ensure proper care of a urinary catheter bag and did not obtain a physician order for a resident to perform self-catheterization flushes. The resident was observed multiple times with the catheter bag lying on the floor, and it was confirmed that the resident was self-flushing the catheter without a physician order.
The facility failed to maintain accurate records for controlled drugs, with multiple instances of missing signatures and entries in the accountability logbook, as confirmed by a licensed nurse. This was a violation of the facility's policy and state regulations.
The facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with professional standards in the medication room on the first floor Unit A. An opened, unlabeled bottle of the probiotic Acidophilus was found in the top refrigerator without the date it was opened affixed to it. This was confirmed by a licensed nurse at the time of the observation.
The facility failed to properly dispose of trash and recyclables in the receiving and dumpster area. Observations revealed scattered trash, an overflowing recycling dumpster, and old mattresses leaning against a shed. These issues were confirmed by the Food Service Director.
The facility failed to follow proper infection control practices during wound care for a resident. A licensed nurse did not wear a gown as required by the facility's policy on enhanced barrier precautions, despite the resident having a physician's order for specific wound care procedures.
The facility failed to maintain an effective pest control program, with multiple observations and reports of mice and roaches in various areas. Residents and staff confirmed the presence of pests, and pest control logs revealed numerous instances of mice and roaches over several months. The facility's pest control policy was not effectively implemented, resulting in a deficiency in maintaining a safe and sanitary environment.
A facility failed to meet professional standards by allowing an LPN to pre-sign MARs before administering medications to residents. This included instances where medications were marked as given despite being unavailable, and a resident's blood sugar level was documented without observation. These actions violated the facility's policy and Pennsylvania Code Title 49.
Failure to Maintain and Properly Test Fire Alarm System Components
Penalty
Summary
The deficiency involves the facility’s failure to maintain fire alarm system components in operable condition and in accordance with NFPA 70 and NFPA 72 requirements. During document review, surveyors noted that a fire alarm inspection report dated October 21, 2025, listed several devices that were not tested and were not included in the Deficiency/Fail results section. There was no verification available at the time of survey to show that these devices had been tested or repaired. The unverified items included a smoke detector on the 1st floor by the medical supply area that could not be found, a smoke detector by the house laundry that could not be found, a fire hat function that could not be reset because Maintenance did not have the key to reset the elevator, a primary recall function that could not be tested for the same reason, and an elevator control shunt trip that was not tested. On a subsequent onsite revisit survey, surveyors observed that the missing smoke detectors identified near the medical supply area and the house laundry had been replaced with battery-operated smoke detectors that were not connected to the facility’s fire alarm notification system. The revisit findings confirmed that these items, along with the other previously identified fire alarm system issues, remained uncorrected. The Administrator and Maintenance Director confirmed during exit interviews that the fire alarm deficiencies identified in the original and revisit surveys had not been resolved.
Plan Of Correction
Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action 1. Smoke detectors by medical supply room and laundry room have been replaced and hard wired 5/18/26. Facility retrieved and in possession of fire hat and elevator recall key. Shunt trip, Elevator control, tested 4/13/26.Plan Review Department will be contacted for installation of new fire alarm component. 2. Maintenance director or designee to re-educate maintenance staff on the importance of maintaining smoke detectors and ensuring elevator testing is maintained. 3.Maintenance director or designee to audit laundry rooms and medical supply rooms for smoke detectors weekly X4 monthly X2 4.Maintenance director or designee to audit elevator inspections weekly X4 monthly X2 5.Results will be reviewed at the quarterly QAPI meeting. Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action 1. Smoke detectors by medical supply room and laundry room have been replaced and hard wired 5/18/26. Facility retrieved and in possession of fire hat and elevator recall key. Shunt trip, Elevator control, tested 4/13/26.Plan Review Department will be contacted for installation of new fire alarm component. 2. Maintenance director or designee to re-educate maintenance staff on the importance of maintaining smoke detectors and ensuring elevator testing is maintained. 3.Maintenance director or designee to audit laundry rooms and medical supply rooms for smoke detectors weekly X4 monthly X2 4.Maintenance director or designee to audit elevator inspections weekly X4 monthly X2 5.Results will be reviewed at the quarterly QAPI meeting.
Incomplete Sprinkler Coverage for Built-In Dining Room Cabinetry
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 101 sprinkler system installation requirements. During observation on the first floor, surveyors noted that floor-to-ceiling built-in millwork cabinetry with doors had been installed and was in use inside the dining room without any interior sprinkler coverage. Review of the approved Department of Health (DOH) renovation plan H-22-0980 and Sprinkler Plan H-24-1079 showed that this built-in millwork was not depicted on the submitted plans, preventing DOH Plan Review from accurately verifying sprinkler coverage conditions in this fully sprinklered facility. The cabinetry was in use during the survey without DOH life safety occupancy approval, and no alternative fire protection measures (such as heat detection tied to the fire alarm, automatic sprinklers within the cabinetry, non-combustible/limited-combustible construction, or fire-retardant-treated wood) were provided as required. During an onsite revisit survey, the same condition was again observed, and Item 1 (the lack of fire protection within the floor-to-ceiling built-in, closed-door storage cabinetry in the first floor dining room) was found not to have been corrected. In both the initial and revisit surveys, the Administrator and Maintenance Director confirmed the absence of required fire protection within the cabinetry.
Plan Of Correction
Completion Date: 05/18/2026 Status: APPROVED Date: 05/21/2026 Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action 1. Plan Review contacted 5/8/26 to acquire appropriate approval for built-in millwork, and for the appropriate means of protection. Cabinet doors removed to ensure compliance. Heat detectors installed 5/18/26 2. Maintenance director or designee to re-educate maintenance staff on the importance of ensuring sprinkler heads or protection by heat detection which activates the fire alarm system are in accordance with NFPA13 standards 3. Maintenance director or designee to audit built in millwork to ensure Protection by heat detection which activates the fire alarm system Weekly X4 monthlyX2 4.Results will be reviewed at the quarterly QAPI meeting.
Failure to Maintain Smoke Barrier Doors to Resist Passage of Smoke
Penalty
Summary
Surveyors found that smoke barrier doors on one of two facility levels were not maintained to resist the passage of smoke as required by NFPA 101. During observation, the smoke barrier doors in the A09 hallway outside the nurse's station did not close smoke-tight when tested because the door frame was unsecured within the wall. In addition, the smoke barrier doors in the A-Wing outside the lobby failed to swing and close smoke-tight due to a broken door closer. These deficiencies were confirmed during interviews with the Administrator and Maintenance Director. On a subsequent onsite revisit survey, surveyors observed that the previously cited issue with the smoke barrier doors in the A-Wing outside the lobby, which failed to swing and close smoke-tight due to a broken door closer, had not been corrected. This uncorrected deficiency was again confirmed with the Administrator and Maintenance Director during the revisit exit interview.
Plan Of Correction
Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action 1. Smoke barrier door closures repaired and adjusted to ensure appropriate closure 4/30/26. 2. Maintenance director or designee to re-educate maintenance staff on the importance of maintaining facility smoke barrier doors 3. Maintenance director or designee to audit facility smoke barrier doors to ensure appropriate closure. Weekly X4 monthly X2 4. Maintenance director or designee to audit laundry rooms and medical supply rooms for smoke detectors weekly X4 monthly X2 5. Results will be reviewed at the quarterly QAPI meeting.
Failure to Supervise Cognitively Impaired Elopement‑Risk Resident at Front Entrance
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise a cognitively impaired resident who had been clearly identified as an elopement risk, resulting in the resident leaving the building and boarding a train without staff knowledge or authorization. Facility policy on wandering and elopements stated that residents at risk for unsafe wandering would be identified and that the front entrance must be actively monitored at all times, with reception staff responsible for knowing which residents were on the elopement alert list. Despite this, the receptionist opened the front door while focused on giving room numbers to an x‑ray technician and did not observe that the resident exited the building. The receptionist later stated she was unaware she had let the resident out and could not recall if the resident was listed as an elopement risk in the elopement binder at the time of the incident. The resident involved had been admitted with diagnoses including dementia, cerebrovascular accident, and cognitive communication deficit, and had a BIMS score of four, indicating severe cognitive impairment. Clinical documentation showed a history of confusion, wandering, refusals of care, and repeated expressions of wanting to go home. The resident’s elopement risk evaluation identified multiple risk factors: prior attempts to leave without informing staff, verbalizing a desire to go home, packing belongings, staying near doors, and goal‑directed wandering behavior likely to affect safety. The care plan documented that the resident was at risk for elopement, had impaired safety awareness, and had removed a wander guard several times, with interventions including use of a wander guard and distraction from wandering, as well as cueing, reorientation, and supervision as needed. Progress notes in the days and weeks before the incident documented ongoing behaviors consistent with elopement risk. Nursing and therapy notes described the resident as severely cognitively impaired, disoriented to time and place, agitated, and unable to recognize their current location. The resident repeatedly expressed a desire to leave, packed belongings, walked to the front door, and tried to reason with staff about being allowed to leave. A social services note on the day of the incident recorded that the resident stated an intent to leave on their own if discharge did not occur, and that the resident lacked capacity to make informed discharge decisions and could not verbalize understanding of the risks of leaving independently. Despite this known risk profile and documented behaviors, the resident was able to exit through the front door at 1:42 p.m. without staff awareness, and the facility did not initiate a search until 2:00 p.m. The Maintenance Director later reported that he believed he saw the resident at a nearby train station but did not intervene because he thought the resident was being discharged; by the time he returned to the station, a train had departed and the resident was not located. The resident was ultimately found hours later after walking into a hospital emergency department, where they were noted to be disoriented to time and place. Based on these findings, surveyors determined that the facility failed to ensure the environment was free from accident hazards and failed to provide adequate supervision to prevent accidents for a resident identified as an elopement risk. The resident’s ability to leave the facility unnoticed, travel to a train station, and board a train, combined with the delay in recognizing the resident’s absence and initiating a search, was determined to have placed the resident in an Immediate Jeopardy situation.
Failure to Revise Respiratory Care Plan After New Oxygen and AVAPS Orders
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and implement a comprehensive care plan related to respiratory care for one resident following changes in condition and new treatment orders. Facility policy on “Comprehensive Person-Centered Care Plans,” revised March 2022, states that assessments are ongoing and care plans are to be revised as information about the resident and the resident’s condition changes. The resident had a medical history that included toxic encephalopathy, COPD with exacerbation, acute and chronic respiratory failure with hypoxia and hypercapnia, pneumonia, and dementia. A Minimum Data Set assessment completed on February 20, 2026, documented a BIMS score of 14, indicating the resident was cognitively able to participate in care discussions. Physician orders dated February 17, 2026, directed continuous oxygen at 3 L/min via nasal cannula with SpO2 to be maintained between 88–92% every shift, and an additional order at 11:00 p.m. the same day for assistance with applying a Trilogy V60 (AVAPS) device at bedtime with specified ventilator settings, including documentation of any refusal of AVAPS every evening and night shift and PRN for COPD. During an interview on March 3, 2026, the resident stated an inability to differentiate between CPAP, BiPAP, and AVAPS machines. Review of the resident’s care plan showed no timely update or revision of goals and specific interventions addressing the recent hospitalization, change in mental status, assistance with applying AVAPS, the resident’s refusal of AVAPS, the frequency of AVAPS application, or maintaining oxygen saturation between 88–92%, contrary to facility policy and regulatory requirements.
Failure to Provide and Document Ordered AVAPS Therapy and Oxygen Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care to a resident according to professional standards of practice, specifically related to AVAPS therapy and oxygen administration. The resident had a significant medical history including toxic encephalopathy, COPD with exacerbation, acute and chronic respiratory failure with hypoxia and hypercapnia, pneumonia, and dementia, and had a BIMS score indicating intact cognition. Physician orders directed that the resident receive AVAPS via a Trilogy V60 ventilator at bedtime with specific settings, that refusals of AVAPS be documented each evening and night shift, and that oxygen be administered at 3 L/min via nasal cannula with SpO2 maintained between 88%–92% each shift. The facility’s own respiratory therapy policy required staff to collaborate with the interdisciplinary team and document assessments, treatments, resident response, and education in the medical record. Review of the electronic treatment administration record (e‑TAR) for February showed that the resident’s SpO2 levels were documented between 94%–99%, which was inconsistent with the physician’s ordered target range of 88%–92% for a COPD resident on AVAPS. Between February 17 and February 25, of 15 required evening/night AVAPS applications, 8 shifts (53%) had missing or unclear documentation of treatment or refusal, and there were also missing entries for cleaning the resident’s respiratory appliances on specified day shifts. The e‑TAR contained entries of “N/A” and “0” for AVAPS application on several evening and night shifts, and the DON could not clarify what these notations meant. The care plan documented AVAPS use and respiratory monitoring interventions, and later noted that the resident refused AVAPS at times, but there were no follow‑up interventions related to refusals, and the clinical record lacked evidence that AVAPS refusals were communicated to the physician. Nursing notes documented that on one evening the resident’s pulse oximetry dropped to 60% and the resident was noted to be confused, at which time AVAPS was applied. Progress notes indicated that the resident had refused AVAPS during the prior night shift, while the e‑TAR for that same period showed AVAPS as applied, demonstrating conflicting documentation. The resident was subsequently transferred to the emergency room for shortness of breath, with CO2 measured at the upper end of normal (45 mmHg), and was later readmitted and placed on AVAPS with 3 L oxygen. An NP interviewed during the survey stated she was unaware of the physician orders regarding AVAPS frequency and oxygen parameters. Based on these findings, surveyors concluded that the facility failed to consistently administer and appropriately document life‑sustaining AVAPS therapy and physician‑ordered oxygen parameters, resulting in actual physical harm and significant clinical decline for the resident, including acute respiratory distress, mental confusion, and elevated CO2 levels that necessitated emergency transfer.
Failure to Maintain Clean and Sanitary Resident and Service Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment in resident-use and service areas on one of its nursing units. During observations on the second floor, surveyors found that the shower room tub contained piles of dirty clothing, three razors, and a soiled brief. Additional dirty clothing, including socks and gowns, was observed along the left side of the tub, in contact with an exposed trashcan containing soiled briefs. In the soiled utility room, two exposed trashcans were overflowing with trash, and a ripped bag of soiled clothing was lying on the floor with its contents spilling out and touching the floor. These findings were confirmed by staff and the facility administrator during the survey.
Failure to Investigate Alleged Violation of Resident Privacy and Property
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation that a Licensed Practical Nurse (LPN) entered a resident's room without permission and searched through the resident's personal belongings while the resident was not present. The resident reported that the LPN attempted to take their coat and did not provide an explanation, resulting in the resident feeling that their privacy and property rights were violated. Another resident, who was the roommate, confirmed witnessing the LPN take the coat, and a second LPN also witnessed the event and reported it to the social worker. Despite being made aware of the incident, facility documentation did not include statements from the involved residents or staff, which resulted in a failure to determine potential misappropriation and ensure resident safety as required by regulation.
Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
A deficiency was identified when a resident with diagnoses of heart failure and primary hypertension was administered antihypertensive medication outside of the parameters ordered by the physician. The physician's order specified that Carvedilol should be held if the resident's heart rate was less than 60 or if the systolic blood pressure was less than 110. Clinical record review showed that on multiple occasions, the medication was administered even when the resident's systolic blood pressure was below the specified threshold, including readings of 92 and 85. There was no documentation indicating that the medication was held as per the physician's order on these dates. The DON confirmed during an interview that the medication was given when the resident's blood pressure was significantly low and acknowledged that it should have been held according to the order. This failure to follow physician orders resulted in a significant medication error for the resident.
Failure to Accurately Document Resident Consent for Code Status Change
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident. Upon admission, the facility's policy required that residents be provided with information about their right to formulate advance directives, and that any changes in decision-making capacity or code status be communicated and documented appropriately. A resident with diagnoses including malignant neoplasm of the brain, COPD, and chronic kidney disease was admitted and later had a code status change from full code to DNR. The resident was cognitively intact, as indicated by a BIMS score of 14, and was their own responsible party without a legal representative. On the date of the code status change, the POLST form was updated to DNR and signed by the resident's family member, despite the resident being their own responsible party. Progress notes indicated that the family member was involved in discussions and signed documentation, but there was no documentation in the clinical record confirming the resident's agreement to the code status change or to having the family member sign on their behalf. Staff interviews confirmed that the resident verbally agreed and nodded assent, but this was not documented in the clinical record as required by facility policy and professional standards.
Non-Compliance with Nursing Care Hour Requirements
Penalty
Summary
Accela Rehab and Care Center at Somerton was found to be non-compliant with the Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day on 14 out of 21 days reviewed. The deficiency was identified through a review of nursing staffing hours and confirmed by an interview with the Nursing Home Administrator. The facility's staffing levels fell short of the mandated care hours on multiple days in February and March 2025, with care hours per patient per day (PPD) ranging from 2.97 to 3.15, all below the required 3.2 PPD. The report details specific dates and the corresponding care hours and resident census, highlighting the shortfall in nursing care hours. For instance, on February 9, 2025, the facility provided 630.5 care hours for 206 residents, resulting in only 3.06 PPD. Similar deficiencies were noted on other days, such as March 8, 2025, where 635.5 care hours were provided for 214 residents, totaling 2.97 PPD. These findings were corroborated by the Nursing Home Administrator, who acknowledged that the staffing levels did not meet the required minimums.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action: 1. Staffing coordinator or designee will be re-educated on number of staff and ratios per state guidelines. 2. Nursing supervisor or designee to audit 4 random resident charts of the identified day, to identify any unmet resident needs due to staffing shortages. 3. Staffing coordinator or designee to audit a random day per week for staffing ratios weekly X4 Monthly X3. 4. Results will be reviewed at the quarterly QAPI meeting.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of personal medical information for six residents. During an observation on March 12, 2025, it was noted that a schedule of resident appointments was left on the desk of the nurse's station, visible to the public. This schedule included sensitive information such as the residents' room numbers, types of medical appointments, pick-up times, appointment times, staff escorts, addresses of appointment locations, and transportation arrangements. The residents affected were scheduled for various medical services, including gastroenterology, dialysis, eye measurements, neurology, and methadone treatment. A nurse aide confirmed that it was routine practice to keep such schedules in a plastic frame on top of the nurse's station, accessible to visitors and other residents. The Nursing Home Administrator acknowledged that this practice did not comply with the privacy and confidentiality expectations for residents' protected health information.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically involving the diversion of narcotic medication. Resident R416, who was admitted with diagnoses including sepsis and cellulitis, had a prescription for Oxycodone Acetaminophen for pain management. An investigation revealed that 28 tablets of this medication were missing, and the facility could not account for them. The narcotic accountability records were incomplete, with missing dates and illegible signatures, and the original records were reportedly discarded, making it impossible to verify the proper handling of the medication. Interviews with the Director of Nursing and staff indicated that the required procedure of counting narcotics between shifts was not followed. On June 9, 2024, the narcotics were not counted between the 7-3, 3-11, and 11-7 shifts, leading to the discovery of the missing tablets on June 10, 2024. Additionally, there were discrepancies in the medication administration records, with instances where tablets were documented as pulled but not administered to the resident. This lack of adherence to policy and documentation failures contributed to the misappropriation of the resident's medication.
Failure to Implement Vital Signs and Hypoglycemic Protocols
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards by not ensuring vital signs were obtained and hypoglycemic protocols were implemented as per physician orders for three residents. Resident R28, who was admitted with chronic kidney disease, hypertension, and peripheral vascular disease, had physician orders for vital signs to be taken every evening shift on specific days. However, there was no documentation of vital signs being recorded from March 1 to March 10, 2025, as confirmed by the Unit Manager. Resident R65, diagnosed with diabetes, had physician orders for hypoglycemia management, including administering glucose gel and notifying the physician if blood sugar levels were below 70. Despite having low blood sugar readings on multiple occasions, there was no evidence of appropriate interventions or physician notification. Similarly, Resident R123, also with diabetes, experienced severe hypoglycemic events with blood sugar levels as low as 46, yet there was no documentation of nursing interventions or physician notification. These deficiencies were confirmed by the Director of Nursing.
Inadequate Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care related to oxygen therapy for two residents. Resident R85, who was admitted with diagnoses including heart failure and chronic respiratory failure, was observed receiving oxygen therapy via nasal cannula. However, the oxygen tubing was not dated as required by the physician's order and facility policy. This was confirmed by a registered nurse, indicating a lapse in following the prescribed protocol for oxygen administration. Resident R99, admitted with traumatic brain injury and acute respiratory failure, had a physician's order for oxygen to be administered at 6 liters per minute via a tracheostomy tube. However, observations revealed that the oxygen concentrator in use had a maximum output of 5 liters per minute, which was confirmed by both a registered nurse and the Director of Nursing. This discrepancy indicated that the incorrect oxygen concentrator was being used for Resident R99, failing to meet the prescribed oxygen therapy requirements.
Deficiency in Controlled Substance Accountability
Penalty
Summary
The facility failed to maintain accurate drug records and reconcile controlled substances for two residents, leading to a deficiency in pharmaceutical services. For Resident R416, there was a discrepancy in the narcotic accountability record for Oxycodone Acetaminophen Oral Tablet 5-325 MG. The facility's investigation revealed that 28 tablets were missing, and the original narcotic book containing the records was discarded, making it unavailable for review. Interviews with staff confirmed that the required narcotic counts between shifts were not conducted, and the facility's policy on narcotic accountability was not followed. Additionally, for Resident R141, an unopened vial of Lorazepam concentrates 2mg/ml was found in the medication room refrigerator without a corresponding Controlled Drug Receipt/Proof of Use/Disposition Form in the narcotic accountability binder. Further investigation revealed that there was no record of this Lorazepam in the narcotic book, and the staff confirmed that the vials were not counted between shifts as required. Instead, the vials were only counted once every 24 hours during the day shift, and the accounting was recorded in the pyxis system. The deficiency highlights the facility's failure to comply with its own policies and regulatory requirements for handling and documenting controlled substances. The lack of proper documentation and reconciliation of narcotics poses a significant risk to the safety and well-being of the residents, as evidenced by the missing medications and unaccounted vials.
Failure to Securely Store Resident Medication
Penalty
Summary
The facility failed to obtain physician orders for a resident to store medication at bedside and did not ensure the medication was stored securely. The facility's policy on self-administration of medications requires an assessment of the resident's cognitive and physical abilities to determine if self-administration is safe and appropriate. Additionally, the policy mandates that self-administered medications be stored in a secure location inaccessible to other residents. During an observation, a surveyor found an inhaler belonging to a resident in an unsecured nightstand. The resident mentioned keeping the inhaler in their room because staff often could not locate it. The Director of Nursing was unaware that there was no assessment conducted and that the medication was kept in an unlocked drawer.
Infection Control Deficiencies in Suctioning and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper disposal and storage of used and potentially contaminated suctioning devices and improper handling of urinary catheter equipment. Specifically, for one resident with a tracheostomy, the facility's policy required that suction catheters be wrapped in a glove and discarded in a designated receptacle. However, observations revealed that the resident's open suctioning catheter was stored in the bedside table drawer, along with other open medical items, which was confirmed by interviews with nursing staff. Additionally, another resident with a urinary catheter had their drainage bag touching the floor, contrary to the facility's policy that required catheter tubing and drainage bags to be kept off the floor. This was observed and confirmed by a registered nurse. These deficiencies were identified during a review of the facility's policies, clinical records, and through staff interviews, indicating a lapse in adherence to infection control protocols.
Failure to Maintain Sanitary Environment Due to Mouse Droppings
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for two residents, as evidenced by the presence of mouse droppings in their rooms. Resident R160, who was admitted with a surgical amputation and has an intact cognitive response, reported ongoing concerns about room cleanliness, specifically noting that the room had not been cleaned properly since admission. Observations confirmed the presence of mouse droppings along the baseboards of R160's room, which remained unaddressed despite staff being informed. Similarly, Resident R130, admitted with diagnoses including opioid abuse and pneumonia, also had mouse droppings observed in their room beside the dresser, which were not cleaned up after being reported. Interviews with staff, including a registered nurse and the nursing home administrator, confirmed the presence of mouse droppings in both residents' rooms. The facility's Quality Assurance Performance Improvement System Compliance Plan had identified a concern regarding the deep cleaning of rooms, yet interviews with housekeeping staff revealed that deep cleaning was not being performed, and daily cleaning did not involve moving furniture. The housekeeping supervisor acknowledged a shortage of staff on the second floor, which may have contributed to the deficiency.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on the 2nd floor, as evidenced by the presence of mouse droppings in a resident's room. The facility's pest control policy, revised in May 2008, mandates an ongoing program to keep the building free of insects and rodents. However, during an observation on March 11, 2025, mouse droppings were found by the baseboards between the head of the resident's bed and the nightstand. A registered nurse confirmed the presence of these droppings. The resident, who has an intact cognitive response with a BIMS score of 15, reported seeing mice frequently in his room and the hallway, especially at night, and stated that he had informed the staff about this issue. Despite the resident's reports, there was no documentation of the complaint in the Customer Complaint Record Log, which is supposed to be maintained at the nursing station. The facility administrator confirmed that no report was made, and there was no documented evidence that pest control was informed of the resident's complaint or the presence of mouse droppings. This lack of documentation and communication indicates a failure in the facility's pest control program and its response to resident complaints, leading to the deficiency noted in the survey.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide timely notices of Medicare non-coverage for three residents, as required by federal regulations. Specifically, the Notices of Medicare Non-Coverage (NOMNC) were not delivered at least two calendar days before the end of Medicare-covered services for Residents R76, R161, and R117. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the NOMNC forms were not provided in a timely manner. Additionally, the facility did not provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to Residents R76 and R161, who remained in the facility after their Medicare coverage ended. This notice is essential to inform residents of their potential financial liability for services no longer covered by Medicare. The absence of these notices was confirmed through a review of facility documentation and further corroborated by the Nursing Home Administrator during the interview.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers for three residents. Resident R123 was sent to the hospital on two occasions in December 2024, but the facility did not inform the Ombudsman. This oversight was confirmed by the Nursing Home Administrator on March 13, 2025. Similarly, Resident R136 was discharged to a Short-Term General Hospital in November 2024, and the facility again failed to notify the Ombudsman, as confirmed by the Nursing Home Administrator. Additionally, Resident R171 experienced gross involuntary jerking movements and altered vital signs, leading to an emergency transfer to a local hospital in January 2025. The facility did not include this resident on the list sent to the Ombudsman, which was confirmed by the Nursing Home Administrator. These failures to notify the Ombudsman were in violation of the regulatory requirements outlined in 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(2).
Insufficient Staffing Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide timely medication administration, as evidenced by observations and interviews with staff. On multiple units, Licensed Practical Nurses (LPNs) were observed administering morning medications significantly later than the prescribed times. For instance, on the second floor, LPNs were still administering 9:00 a.m. medications well past 11:00 a.m., with some medications documented as administered after 12:00 p.m. This delay in medication administration was confirmed by the LPNs themselves, who cited large resident assignments as a contributing factor. The report highlights specific instances where residents did not receive their medications at the prescribed times. For example, Resident R1's medications, including Divalproex, Quetiapine fumarate, and others, were documented as administered at 12:04 p.m., despite being scheduled for 9:00 a.m. Similar delays were noted for other residents across different units, with medications being administered hours after the prescribed times. These delays were consistently confirmed by the LPNs responsible for the medication passes. Interviews with the Director of Nursing (DON) further confirmed the facility's failure to provide sufficient staffing for timely medication administration. The DON acknowledged that the staffing levels were inadequate to meet the needs of the residents, resulting in the observed delays. The facility's policy on medication administration, which requires medications to be administered within one hour of the prescribed time, was not adhered to, leading to the deficiency noted in the report.
Failure to Administer Diabetic Medications Timely
Penalty
Summary
The facility failed to administer diabetic medications in accordance with professional standards for five residents. The facility's policy requires medications to be administered within one hour of their prescribed time unless otherwise specified. However, the review of clinical records and medication administration records revealed that medications for Residents R1, R6, R9, R13, and R17 were administered late, not adhering to the prescribed times. For instance, Resident R1's Glipizide and Metformin were administered hours after the prescribed time, and similar delays were noted for the other residents. Licensed nurses confirmed the late administration of medications, and the Director of Nursing acknowledged that the facility did not follow professional standards of practice and physician orders during medication administration. The report highlights that the facility's failure to administer medications timely affected all five residents reviewed, indicating a systemic issue in medication management and adherence to physician orders.
Inaccurate Medication Administration Records
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, as observed during a survey. Licensed Nurse, Employee E3, was administering medications late for several residents, including Resident R1, whose medications were scheduled for 9:00 a.m. but were documented as administered at 12:04 p.m. Despite this, the administration time was inaccurately recorded as 8:03 a.m. Employee E3 confirmed the medications were administered late and was unaware of how the incorrect time was entered. Similarly, Licensed Nurse, Employee E4, was also administering medications late for Resident R5, with medications scheduled for 9:00 a.m. but documented as administered at 12:38 p.m., while the administration time was inaccurately recorded as 8:45 a.m. Employee E4 also confirmed the late administration and was unaware of how the incorrect time was entered. The facility's Medication Administration Policy requires medications to be administered at the ordered times and signed out immediately when given. However, both employees E3 and E4 were observed administering medications significantly later than scheduled, and the administration times recorded in the clinical records did not reflect the actual times of administration. The facility was unable to provide an explanation for the discrepancies in the clinical records when requested by the surveyors, indicating a failure to adhere to professional standards for maintaining accurate clinical records.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information as required by regulations. On November 5, 2024, at 10:00 a.m., an observation revealed that the staffing data displayed at the front desk of the lobby was outdated, showing the date April 30, 2024. An interview with the receptionist at the same time confirmed that the posted staffing information was indeed from April 30, 2024, indicating a failure to update the information daily as mandated.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for two residents. During an observation, it was noted that a resident's dresser had a broken top handle and a second drawer shelf that was broken and lacked a cover, leaving the resident's clothes exposed. The shelf cover was found leaning against the wall near the window. Additionally, another resident reported that their bed was not functioning properly, specifically that the foot of the bed could not be elevated. This issue was reported to a nurse aide. The Nursing Home Administrator confirmed both the broken dresser and the malfunctioning bed.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, identified as Resident R1. The resident was admitted with multiple diagnoses, including pulmonary embolism, seizures, and respiratory failure, among others. A Level of Care determination was made on April 18, 2024, indicating that the resident was Nursing Facility Ineligible, but there was no documentation that this determination was communicated to the resident. Additionally, the discharge notice given to the resident on May 8, 2024, lacked a specified reason for the discharge, and the discharge summary was incomplete. The discharge instruction sheet also noted that the facility refused to provide housing arrangements for the resident. An interview with the social services director confirmed the absence of documentation regarding the discussion of the resident's ineligibility. These deficiencies were identified through observations, review of resident records, and staff interviews, indicating a failure to adhere to accepted professional standards in maintaining clinical records.
Food Service Safety Deficiencies
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the Food Service Department, several concerns were observed. In the dry storage area, a jug of honey was found to be very dark and crystalized with a receiving date of 2/2022. The walk-in cooler had a dusty and dirty floor littered with debris, and the shelving and dunnage racks were also dusty and dirty, with dark spots on the walls and ceiling. In the kitchen, an AC unit was blowing air through vents covered with dark blackish dust and grime. Cooking equipment, including a tilt skillet and two stack convection ovens, had a heavy buildup of dark substances, burned-on grease, and food spatters. The reach-in refrigerator had dusty and dirty door gaskets with food particles in the cracks, and the inside had a buildup of dirt and food particles on the bottom and sides. These findings were confirmed by the Food Service Director during the tour.
Failure to Implement Complete Drug Regimen Review Process
Penalty
Summary
The facility failed to implement a complete drug regimen review process for three residents. The consultant pharmacist did not provide the required monthly medication regimen reviews for Resident R54, Resident R26, and Resident R61. Specifically, Resident R54's clinical record showed no pharmacy notes since the last review on December 11, 2023. Resident R26's clinical record lacked pharmacy notes for multiple months, including December 2023, January 2024, February 2024, April 2024, and May 2024. Resident R61's clinical record was missing pharmacy medication regimen reviews for March 2024 and April 2024, and there was no physician response to a pharmacy recommendation made in February 2024 regarding the continued need for oxycodone. The Director of Nursing confirmed the absence of documentation for the December monthly medication regimen review. The facility was unable to provide the requested pharmacy medication regimen reviews for Resident R61 for the specified months. These deficiencies indicate a failure to adhere to the facility's policy requiring monthly documented reviews of each resident's medication regimen and appropriate communication of potential or actual medication-related problems to prescribers and facility leadership.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in 2 of 5 nursing units. Observations on April 30, 2024, revealed several wet spills in the hallway entering the second floor off the elevator. In one room, the HVAC unit was missing a vent cover, exposing sharp metal and significant dust accumulation, which a resident confirmed had been in this condition for some time. Another room had a broken headboard and scraped paint on the wall behind the bed. Additionally, two rooms had brown/red stained privacy curtains. Further observations noted two wet spills at the end of the hallway on A-wing. The Maintenance Director confirmed awareness of the missing vent cover in one of the rooms.
Incomplete Investigation of Missing Narcotics
Penalty
Summary
The facility failed to conduct a complete and thorough investigation related to missing narcotics for three residents. The facility's policy on 'Accidents and Incidents - Investigating and Reporting' requires specific data to be included in the report, such as the date and time of the incident, the circumstances, and the names of witnesses. However, the incident report dated January 13, 2024, involving three residents, was incomplete. The statement by Licensed Nurse Employee E23 did not include the name of the outgoing licensed nurse with whom the narcotics count was conducted. Additionally, statements from other licensed nurses (Employees E18, E14, and E15) also lacked the names of the nurses they counted narcotics with, rendering the statements incomplete. Further review of the investigation report provided to the State Agency revealed that it was only completed for one possible perpetrator, Employee E11. Interviews with the Nursing Home Administrator and Director of Nursing indicated that there could be more possible perpetrators, but there was no documented evidence that notification and investigation of other possible perpetrators were submitted to the State Agency. This lack of thorough investigation and incomplete documentation led to the deficiency.
Failure to Develop Comprehensive Care Plan for UTI Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of urinary tract infections (UTIs). The resident, who has a past medical history of UTIs and benign prostatic hyperplasia with lower urinary tract symptoms, was hospitalized due to a UTI. Despite this, the resident's current care plan did not include any measures for the prevention of UTIs. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Remove Cleaning Supplies from Resident's Room
Penalty
Summary
The facility failed to maintain an environment free from hazards related to cleaning supplies left in a resident's room. On April 30, 2024, at 10:01 a.m., observations were made of the A wing, room A1, where Resident R5 had cleaning supplies (Comet) left on the floor, visible to anyone passing by the room. The issue persisted as, on May 1, 2024, at 1:10 p.m., the cleaning supplies were still present in the resident's room. An interview with the Director of Nursing on May 1, 2024, at 1:15 p.m. revealed that residents were not supposed to have cleaning supplies in their rooms.
Failure to Ensure Proper Catheter Care and Obtain Physician Orders
Penalty
Summary
The facility failed to ensure proper care of a urinary catheter bag and did not obtain a physician order for a resident to perform self-catheterization flushes. Resident R9, who was admitted with diagnoses including spinal stenosis, lumbosacral, neurogenic bladder dysfunction, and urinary tract infection, was observed on multiple occasions with the urinary catheter bag lying directly on the floor. This was noted on April 30, 2024, May 1, 2024, and May 2, 2024. Licensed nurse Employee E19 confirmed these observations during an interview on May 1, 2024. Additionally, it was revealed during an interview with Resident R9 on May 1, 2024, that the resident was self-flushing her urinary catheter. A review of the resident's physician orders for April and May 2024 showed no order for the resident to self-flush the catheter. Licensed nurse Employee E19 confirmed that there was no physician order for this procedure. These findings indicate a failure to adhere to the facility's catheter care policy and to obtain necessary physician orders for catheter management.
Failure to Implement Controlled Drug Accountability System
Penalty
Summary
The facility failed to implement a system of records for the receipt and disposition of all controlled drugs between shifts, leading to a lack of accurate reconciliation and accountability for one of four medication carts observed on the Second Floor A unit. The facility's policy on controlled substances requires that only authorized licensed nursing and pharmacy personnel have access to controlled drugs, and that these substances are reconciled upon receipt, administration, disposition, and at the end of each shift. However, during an observation on April 30 at 11:25 a.m., it was found that multiple dates and shifts lacked the required signatures from both incoming and outgoing nurses, indicating a failure to follow the policy. Specific dates with missing signatures included December 28, 2023, through April 30, 2024, with numerous instances of missing entries and signatures on the accountability logbook. An interview with a licensed nurse, Employee E11, confirmed that staff had not been signing the shift accountability logbook as required. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The lack of proper documentation and reconciliation of controlled substances was a clear violation of the facility's policy and state regulations, specifically 28 Pa. Code 201.18(b)(2) Management, 28 Pa. Code 211.9(a)(1)(k) Pharmacy services, and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with professional standards in the medication room on the first floor Unit A. During an observation conducted with the Unit Manager, it was found that an opened, unlabeled bottle of the probiotic Acidophilus was present in the top refrigerator. Additionally, the opened bottle did not have the date it was opened affixed to it. This was confirmed by a licensed nurse at the time of the observation. The facility policy states that all medications must be properly labeled in accordance with state and federal guidelines, which was not adhered to in this instance.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility did not ensure that trash and recyclables were properly disposed of in the receiving and dumpster area. During a tour of the Food Service Department, it was observed that cardboard, bread racks, milk crates, paper, and other trash were scattered around the generator and staff smoking area. Additionally, the recycling dumpster was overflowing with the lid open, and a mound of cardboard boxes was piled in front of the dumpster. Four old mattresses were also found leaning against a metal shed. These findings were confirmed by the Food Service Director during an interview.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed according to professional standards during wound care for one resident. Specifically, the facility's policy on enhanced barrier precautions was not adhered to during the wound care procedure for Resident R103. The policy requires the use of gowns and gloves during high-contact resident care activities, including wound care, to prevent the transfer of multidrug-resistant organisms (MDROs). However, during an observation, a licensed nurse did not wear a gown while performing wound care on Resident R103's left heel wound, which is against the facility's policy. Resident R103 had a physician's order to cleanse the left heel wound with normal saline solution, pat dry, apply betadine-soaked gauze, cover with an abdominal pad, and secure with Keflex daily and as needed. Despite these specific instructions, the licensed nurse failed to follow the enhanced barrier precautions by not wearing a gown during the wound care procedure. This lapse in protocol was observed and documented, highlighting a deficiency in the facility's infection control practices.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by multiple observations and reports of mice and roaches in various areas of the building. A mouse was observed in Room A24, and residents on the second floor reported seeing mice in their rooms and common areas. The pest control logs revealed numerous instances of mice and roaches in different wings of the facility, including D-wing and A-wing, over several months. Specific incidents included mice in rooms and hallways, roaches in food containers, and roaches on residents and walls in multiple rooms and common areas. Interviews with residents and staff confirmed the presence of pests, with one resident reporting seeing a mouse in the hallway and another resident seeing mice in their room and common areas. The facility's pest control policy, dated May 2008, was not effectively implemented, as evidenced by the ongoing pest issues. The policy stated that the facility should be kept free of insects and rodents, with pest control services provided regularly, but the logs and observations indicated a persistent problem. The facility's failure to adhere to its pest control policy resulted in a deficiency in maintaining a safe and sanitary environment for residents.
Improper Medication Documentation Practices
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality, as evidenced by improper documentation practices during medication administration. Observations revealed that a licensed nurse, Employee E11, pre-signed the Medication Administration Records (MAR) for several residents before actually administering the medications. This practice was observed for six residents, where the MAR entries were marked as completed before the medications were given. This included medications such as Plavix, Hydrochlorothiazide, Lisinopril, and others for different residents. Further observations highlighted specific instances where medications were not available, yet the MAR indicated they had been administered. For example, Gabapentin was not available for one resident, but the MAR was marked as if it had been given. Additionally, a resident was not wearing a prescribed stump shrinker, yet the MAR was marked to indicate it was in use. Interviews with the nurse confirmed that the MAR entries were signed in advance, based on the assumption that the medications would be administered and accepted by the residents. Another instance involved the documentation of a resident's blood sugar level without the actual measurement being observed. The nurse claimed to have taken the blood sugar earlier, but this was not witnessed during the medication pass. These practices are in violation of the facility's policy, which requires that medications be documented as administered only after they are given, and highlight a significant lapse in adhering to professional standards as outlined in the Pennsylvania Code Title 49.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
