Bryn Mawr Extended Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bryn Mawr, Pennsylvania.
- Location
- 956 Railroad Avenue, Bryn Mawr, Pennsylvania 19010
- CMS Provider Number
- 395311
- Inspections on file
- 35
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Bryn Mawr Extended Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, CVA, ESRD, and a wheelchair mobility status was transported to dialysis in a contracted van without being secured with a wheelchair seatbelt. When the van made an abrupt stop, the resident fell out of the wheelchair, sustained facial bleeding and pain, and hospital records showed a tibia fracture requiring surgery.
A resident with multiple wounds requiring daily NSS cleansing and calcium alginate dressings received wound care from an RN who failed to follow infection control standards. The RN did not perform hand hygiene between glove changes, cleansed three separate wound areas without changing gloves or performing hand hygiene between sites, used the same saline-soaked gauze to wipe drainage from one wound and then cleanse another area, and applied clean dressings with the same contaminated gloves. The RN also opened all wound areas at once, treated an excoriated thigh area with alginate and a dressing instead of a moisture barrier cream, and placed bundled soiled dressings on the bedside table and a soiled draw sheet on the resident’s chair, as later confirmed by the DON.
A resident with muscle weakness, cognitive communication deficit, and moderately impaired cognition was abruptly moved to a new room without reasonable notice or a choice in the change. The resident was visibly upset in the hallway with personal belongings after being told only about 30 minutes before the transfer, and an LPN said the move was directed by the Admissions Director to make room for a new male admission. The DON was unaware of the transfer, and the Social Services Director confirmed the resident should not have been moved because staff could not reach the resident's representative.
A resident’s MDS record showed an admission MDS was transmitted, followed later by a quarterly assessment, but no initial comprehensive assessment was transmitted in between. The NHA confirmed that no MDS assessment was transmitted during that period.
Failure to Revise Care Plans to Match Resident Needs: The facility did not update a resident’s care plan after the wound practitioner recommended stopping a scoop mattress, and the resident was observed without that mattress in place. The resident had severe cognitive impairment and aphasia, while the DON confirmed the care plan still listed the outdated intervention. A second resident’s record also showed multiple chronic diagnoses, intact cognition, wheelchair use, and care plans addressing impaired ADLs and fall risk.
Wound treatment orders were not followed for a resident with stroke-related diagnoses, including hemiplegia and aphasia. The RN cleansed the ordered wounds on the ischium and sacrum, but also treated an un-ordered excoriated area on the inner thigh with alginate and a bordered gauze dressing instead of the moisture barrier cream confirmed by the DON.
Incomplete dialysis communication records were identified for two residents with ESRD who received outpatient HD. Their dialysis communication tools repeatedly lacked the dialysis facility nurse’s signature in the section to be completed by dialysis staff, and the DON confirmed the missing documentation.
Thermometer Unavailable for Resident Meal From Home A resident at increased nutrition/hydration risk due to severe protein-calorie malnutrition and decreased intake had a favorite homemade meal brought in by family to encourage eating. Staff did not reheat the food because a thermometer was unavailable and the kitchen could not heat it up, despite facility policy requiring reheated food to reach 165°F and the RD having encouraged the family to bring food from home.
A resident who was cognitively intact and needed moderate assistance with transfers and toileting had repeated falls and unsafe self-transfers after being reminded to use the call bell for help. The resident reported staff did not answer the call bell in a timely manner, and survey observation confirmed the call system was not fully functioning because it did not alert the nurse's station when activated.
A resident did not receive multiple scheduled medications at the correct times, with some doses significantly delayed and others not documented as given, in violation of facility policy and professional standards for medication administration.
The facility failed to install an automatic sprinkler system in the Main electrical (switchgear) Room in the basement, affecting one of three levels. This deficiency was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations, indicating incomplete sprinkler protection as per NFPA standards.
The facility failed to maintain its automatic sprinkler system, affecting the entire facility. An inspection revealed that the wet system's tamper did not report to the panel due to water accumulation in the pit, which requires monitoring and pumping. Additionally, the dry system's last FDC hydrotest date was unknown and needs immediate testing. These issues were confirmed during an exit interview with facility leadership.
The facility failed to maintain HVAC equipment inspection, affecting the entire facility. A review revealed that 73 fire dampers were deficient due to inaccessibility or damage, with no evidence of repairs. This was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
The facility failed to maintain and inspect the emergency generator, affecting the entire facility. Documentation for critical tests and inspections, such as monthly battery testing and annual fuel sampling, was unavailable. Additionally, the emergency generator set location lacked battery back-up emergency lighting, as confirmed during an exit interview with facility leadership.
The facility failed to maintain self-closing doors in hazardous areas, affecting one of three levels. Observations revealed that the Food Services office door was binding, the Dry Storage door closure was broken, and the 2nd floor D wing's storage closet hardware was broken, preventing proper latching. These issues were confirmed during an exit interview with facility leadership.
The facility failed to maintain smoke barrier doors to resist smoke passage. A door on the first floor was blocked by a wheelchair, and another in the Chateau Dining area was dragging on the floor, preventing them from closing smoke tight. These issues were confirmed during an exit interview with the facility's administration.
The facility was cited for improper storage of medical gases after a free-standing oxygen cylinder was observed in the Med room on the first floor. This was confirmed during an exit interview with the facility's administration.
The facility failed to meet operational standards by installing heat detectors and Halotron fire extinguishers in the Main Electrical Room without Department-approved plans. This was confirmed during an exit interview with the facility's leadership.
The facility did not provide a resident-centered activities program as required, with observations and interviews revealing that scheduled activities were often not conducted, lacked variety, and did not reflect resident interests or preferences. Multiple residents reported not being included in activity planning, not being offered activities of interest, and that the activities listed on the calendar were not actually provided. Staff interviews and observations confirmed inconsistencies and a lack of meaningful engagement, resulting in unmet physical, mental, and psychosocial needs.
A nursing assistant was overheard by a family member making a profane and derogatory statement to a resident with multiple medical and cognitive conditions, constituting verbal abuse as defined by facility policy.
A resident with multiple complex diagnoses, including diabetes, recent significant weight loss, and impaired mobility, was admitted without a baseline care plan to address their risk for pressure ulcers. Although assessments identified the risk and some treatments were in place, there was no documented care plan or interventions such as a turning/repositioning program or foot dressings, contrary to facility policy.
A licensed nurse delayed the administration of scheduled morning medications to a resident by two hours while watching a training video on the computer, resulting in the resident not receiving medications such as Allopurinol, Amlodipine, Cholecalciferol, Dorzolamide, and Metoprolol at the prescribed time, contrary to facility policy and physician orders.
A resident who was always incontinent and required substantial assistance with toileting hygiene experienced significant delays in receiving incontinence care on multiple occasions. Despite making her needs known and informing staff, care was not provided promptly, with staff either occupied with other residents or delaying their response after turning off the call bell.
A resident with diabetes, limited mobility, and cognitive impairment developed a right heel wound after staff failed to consistently implement physician-ordered interventions, such as the use of multi-podus boots, and did not update the care plan to address the risk of diabetic ulcers. The wound progressed, requiring debridement and antibiotics, after the resident was observed pressing their feet against the bed's footboard without proper offloading.
The facility did not ensure staff supervision in the designated smoking area, as required by policy and resident care plans. Multiple residents were observed smoking outside without staff present, and both staff and resident interviews confirmed that supervision was not consistently provided. This failure to supervise residents during smoking activities resulted in a deficiency related to accident hazard prevention.
A resident with an indwelling urinary catheter and a history of urinary retention did not have a recommended follow-up appointment with a urologist scheduled after a consult indicated the need for further discussion of treatment options. This failure was confirmed by the unit manager and was not in accordance with facility policy for continence management and resident care.
A resident's pharmacy review recommendations regarding Eszopiclone and Cyclobenzaprine were not properly addressed or documented by the physician, with no clear evidence of review or rationale for declining the pharmacist's suggestions, as confirmed by the DON.
A resident with diabetes and anemia did not receive breakfast as ordered, with staff failing to document meal monitoring and providing an unsuitable late meal, resulting in the resident refusing the food. The deficiency was confirmed by both the resident and a nursing supervisor.
A resident with polymyalgia rheumatica did not receive a recommended rheumatology consultation after both the physiatrist and physician agreed it was needed, and no appointment was scheduled as confirmed by the Unit Manager.
A resident with multiple chronic conditions was placed on hospice care, but the facility failed to maintain complete hospice documentation, including an updated plan of care and required correspondence from hospice staff. The administrator was unable to provide the missing records when requested.
Staff failed to consistently use required PPE, including gowns and gloves, during high-contact care activities for two residents on enhanced barrier precautions, including one with a history of C. difficile, MRSA, and ESBL, and another with an indwelling catheter. Observations and interviews revealed confusion and lack of awareness among staff regarding proper PPE use, despite clear signage and care plan documentation.
A resident with chronic pain and a wound was not properly assessed or medicated for pain, leading to uncontrolled pain and harm. The facility failed to provide timely Oxycodone, and the resident's severe pain and suicidal ideation were not communicated to the physician. Staff delays and policy failures contributed to the deficiency.
The facility breached residents' privacy by displaying transmission-based precaution signage that revealed personal medical information, such as peg tubes and tracheostomies, for five residents. This action violated the facility's policies on resident rights and confidentiality.
The facility did not adhere to resident meal preferences, leading to complaints about incorrect meals being served. A resident received chicken and cranberry juice instead of her requested meal, while another consistently received incorrect meals. A grievance log and resident council meeting further highlighted ongoing issues with meal service not matching resident requests.
A resident experienced a fall during a leave of absence, resulting in hospitalization. The facility failed to promptly notify the resident's physician, as required by their policy. Upon return, the resident exhibited pain and an abrasion, but there was no documented evidence of physician notification. This deficiency was confirmed by the Regional Nurse.
A facility failed to accurately complete a resident's discharge assessment. A nursing note indicated the resident was discharged to home, but the MDS assessment incorrectly coded the discharge status as a short-term general hospital. This error was confirmed by the RN Assessment Coordinator.
A resident experienced a delay in receiving timely laboratory services after complaining of headache, dizziness, and lightheadedness. Lab work was ordered, but the urine sample was not sent promptly, and a subsequent sample leaked and was discarded. The lab's attempt to contact the facility was unsuccessful, and no follow-up was conducted.
A resident who experienced headache, dizziness, and lightheadedness had lab work ordered, including CBC and CMP. Although the lab work was completed, the results were not printed or communicated to the physician. The results showed some values out of range, including a low blood sodium level.
A resident's room lacked a functional call bell system, with the wired bell removed and a tap bell placed out of reach. The resident's calls for assistance went unanswered due to the bell's inaudibility at the nurse's station, where music was playing. Staff were unaware of the issue, leading to delayed responses to the resident's needs.
The facility did not ensure that nurse aides received the required 12 hours of continuing education annually. A review of personnel files revealed that three out of five nurse aides, including Employees E6, lacked documentation of these educational hours. The Nursing Home Administrator confirmed the absence of records during the survey, violating Pennsylvania Code requirements for personnel policies and staff development.
A resident with acute respiratory failure and hypoxia did not receive continuous oxygen therapy as ordered. Family members observed the resident without an oxygen mask multiple times, and a nursing assistant admitted to forgetting to replace the mask after providing care.
A resident reported that the hallway temperature in the B wing was uncomfortably cold, requiring her to keep her room door closed. An observation confirmed the temperature was 69 degrees, attributed to closed fire doors due to a malfunctioning magnetic door lock system, which trapped cold air from the air conditioning.
A resident was found unresponsive, and due to a misidentification of the resident's code status by a licensed nurse, CPR was not initiated immediately. The delay was further compounded by the actions of the Nursing Supervisor and the Acting DON, leading to a 14-minute delay before CPR was started. The resident was eventually transported to the hospital with a pulse after paramedics took over CPR.
The Nursing Home Administrator and DON failed to ensure timely CPR for a resident due to a misidentification of the resident's code status, resulting in a significant delay. The resident was found unresponsive, and the licensed nurse mistakenly identified the resident as DNR, leading to a 14-minute delay before CPR was initiated.
Resident Fell From Unsecured Wheelchair During Transport
Penalty
Summary
The facility failed to ensure that Resident R3 was adequately secured during transport in the contracted transportation van. Resident R3 had diagnoses including hemiplegia, hemiparesis, CVA, psychotic disorder, seizure disorder, end stage renal disease, and depression, and used a wheelchair for mobility. The resident’s care plan identified impaired mobility and fall risk related to right hemiparesis/hemiplegia and a history of right hip fracture. On February 21, 2026, Resident R3 boarded the van for a scheduled dialysis appointment. During transport, the van driver made an abrupt stop when vehicles in front stopped unexpectedly, and Resident R3 fell out of the wheelchair and onto the floor of the van. The driver told facility staff that the resident had not been secured with a wheelchair seatbelt. Nursing staff instructed the driver to take the resident to the emergency room for evaluation, but the driver initially attempted to return the resident to the facility. Facility staff later assessed Resident R3 and observed redness on the face and fresh blood above the eyebrow. The resident reported falling forward out of the wheelchair and having significant pain. Hospital records documented that the resident arrived after a motor vehicle accident while seated in a transport wheelchair, struck the right side of the body, and had pain in the right shoulder, elbow, knee, and ankle, along with headache and neck pain. X-ray findings showed a fracture of the tibia, and the hospital record indicated the resident was transferred for surgery of the right tibia.
Inadequate Infection Control Practices During Wound Care
Penalty
Summary
The deficiency involves a failure to maintain appropriate infection prevention and control practices during wound care for one resident. The resident had been readmitted with diagnoses including cerebral infarction, right-sided hemiplegia, and aphasia following stroke, and had physician orders for daily cleansing and dressing of wounds on the right ischium and sacrum with NSS, calcium alginate, and a clean dry dressing. During observed wound care, the RN performed initial hand hygiene and donned gloves before preparing a clean field and rolling the resident onto her left side. After placing an absorbent pad, the RN removed soiled bandages from the ischial and sacral wounds and uncovered an additional area on the left inner thigh. The RN then removed soiled gloves and donned clean gloves without performing hand hygiene, and proceeded to cleanse all three wounds with NSS without changing gloves or performing hand hygiene between wounds. When a drip from the sacral wound was noticed, the RN used a saline-soaked gauze to wipe the drip and then used the same gauze to cleanse the thigh wound. Alginate was applied to all three wounds and covered with adhesive bordered gauze using the same gloves that had been used for cleansing. After dressing the wounds, the RN gathered soiled dressings and trash into the absorbent pad and placed this bundle on the resident’s bedside table, and placed the soiled draw sheet on the resident’s chair before later disposing of them. The DON confirmed that multiple hand hygiene indications were missed, that all three wounds should not have been open at the same time, that the thigh area was excoriation that should have been treated differently, and that soiled materials should not have been placed on the bedside table or chair.
Resident moved to new room without notice or choice
Penalty
Summary
The facility failed to ensure a resident was provided self-determination regarding a room change and was not given written notice before the move. Facility policy stated that room changes may be necessary for resident welfare and that the resident and resident representative should be given reasonable notice and an explanation before a change. In this case, Resident 157 had diagnoses including muscle weakness, cognitive communication deficit, and need for assistance with personal care, and had a BIMS score of 12, indicating moderately impaired cognition. On March 11, 2026, the resident was observed in the hallway, visibly upset and holding personal belongings after being abruptly informed of a room transfer. The resident stated the move was unwanted, that no choice had been provided, and that the notice came only about 30 minutes before the transfer, after belongings had already been moved by nursing staff. An LPN stated the resident was moved on instruction from the Admissions Director so a room could be made available for a new male admission. The DON stated he/she was unaware of the transfer, and the Social Services Director confirmed the resident should not have been moved because staff were unable to contact the resident's representative.
Failure to Transmit Required Initial Comprehensive MDS Assessment
Penalty
Summary
The facility failed to transmit the required initial comprehensive MDS assessment for one resident, R153, after admission. Review of the MDS transmission data showed that an admission MDS was transmitted on October 28, 2025, and a quarterly assessment was transmitted on February 28, 2026, but no initial comprehensive assessment was found to have been transmitted between those assessments. During interview, Employee E1, the Nursing Home Administrator, confirmed that no MDS assessment was transmitted between October 28, 2025, and February 28, 2026.
Failure to Revise Care Plans to Match Resident Needs
Penalty
Summary
The facility failed to review and revise resident care plans in accordance with resident needs for one of 33 residents reviewed. Resident R134’s quarterly MDS dated February 13, 2026, showed severe cognitive impairment and a diagnosis of aphasia. The resident’s comprehensive care plan dated August 27, 2025, identified a fall risk related to limited mobility and impaired balance, and an intervention dated August 10, 2025, specified that a scoop mattress was in place. During observation on March 12, 2026, at 11:00 a.m., RN E12 stated that Resident R134 did not have a scoop mattress, and the resident instead had a regular pressure reduction mattress in place. During interview on March 12, 2026, at 11:22 a.m., the DON stated that Resident R134 had been seen by the wound practitioner in October 2025 after a skin tear to the thigh. The wound care communication log dated October 29, 2025, documented that the wound practitioner recommended discontinuing the scoop mattress because it would inhibit turning and repositioning. The DON confirmed that the facility failed to revise Resident R134’s care plan to remove the scoop mattress intervention. The record also showed Resident R3 had multiple diagnoses including hemiplegia, hemiparesis, CVA, psychotic disorder, seizure disorder, ESRD, and depression, with a BIMS score of 15 indicating cognitive intactness and wheelchair use for mobility; the care plan included impaired ADLs related to mobility and a fall-risk care plan related to impaired mobility.
Wound Treatment Orders Not Followed
Penalty
Summary
The facility did not ensure physician wound treatment orders were followed for one resident with a history of cerebral infarction, right-sided hemiplegia, and aphasia following stroke. The resident had physician orders for the right ischium and sacrum to be cleansed with normal saline, packed with calcium alginate, and covered with a clean dry dressing once daily. During observed wound care, the registered nurse removed soiled bandages from the ischium and sacrum wounds and also uncovered an area on the left inner thigh. The nurse cleansed all three areas with normal saline, applied alginate to all three wounds, and covered them with adhesive bordered gauze. The DON confirmed that the left inner thigh area was excoriation that should have been treated with moisture barrier cream and that there was no order for alginate and dressing for that thigh wound.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete dialysis records related to dialysis communication for two residents receiving outpatient hemodialysis. Resident R3 had end-stage renal disease and a physician order dated August 14, 2024, directing dialysis treatment at an outpatient dialysis facility on Tuesdays, Thursdays, and Saturdays, with a special instruction for the dialysis communication tool to be completed. Resident R16 also had end-stage renal disease and a physician order dated May 02, 2024, directing dialysis treatment at an outpatient dialysis facility on Mondays, Wednesdays, and Fridays, with a special instruction for the dialysis communication tool to be completed. Review of the Hemodialysis Communication Record, titled Dialysis Communication Tool, showed that for both residents, on uncountable days in December 2025, January 2026, and February 2026, the section to be completed by dialysis staff was missing the signature of the dialysis facility nurse. The Director of Nursing confirmed the incomplete dialysis communication logs for Residents R3 and R16 during interview on March 12, 2026, at 11:14 a.m.
Thermometer Unavailable for Reheating Food Brought From Home
Penalty
Summary
The facility failed to have a thermometer available to reheat food brought from home for Resident R162. The facility policy on food brought in from outside the facility stated that staff outside the dietary department will store and handle food in accordance with food safety standards, and that if food needs to be reheated it should be microwaved so all parts reach at least 165 degrees Fahrenheit, with the temperature then confirmed after reheating. Resident R162’s comprehensive care plan identified the resident as being at increased nutrition/hydration risk related to severe protein-calorie malnutrition and decreased food intake, with interventions to respect dietary choices and provide assistance with meals as needed to encourage intake. The resident’s family member brought in homemade spaghetti and meatballs to encourage intake, and the resident expressed a desire for that meal. Staff, including an LPN and the nurse identified in the report, did not heat the food because a thermometer was unavailable and the kitchen was unable to heat it up. The RD confirmed the family had been encouraged to bring in food from home and stated the nurse should have obtained or requested a thermometer to assist the resident in consuming the meal.
Nonfunctioning Call Bell System for a Resident Needing Transfer and Toileting Assistance
Penalty
Summary
A resident who was cognitively intact and required moderate assistance with toilet transfers, sit-to-stand positioning, chair-to-bed and bed-to-chair transfers, and walking ten feet was repeatedly documented as needing staff help for standing, transferring, and toileting. The resident was also frequently incontinent of bowel and bladder. Nursing notes documented multiple falls and unsafe self-transfers, including being found on the floor near the bed, standing from the wheelchair to transfer without assistance, falling while trying to self-transfer from bed to wheelchair and sustaining a skin tear of the shin, and falling while attempting to transfer self to the wheelchair. The resident was repeatedly reminded to use the call bell system to request assistance. During interview, the resident stated that staff do not answer the call bell system in a timely manner for care needs and confirmed needing assistance with standing, transferring, and toileting. Observation later showed that the resident's call bell system was not fully functioning: the call bell activated in the room, but the light above the door and the panel light at the nurse's station did not sound or light to alert staff. A registered nurse confirmed that the call bell system was not operating according to manufacturer's specifications. The DON later stated that a temporary three-way call system had been purchased for the resident.
Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
Facility staff did not ensure that a resident received medications in accordance with professional standards of practice and facility policy. The facility's policy requires staff to verify and administer medications at the correct time, dose, route, and for the correct resident. However, review of the electronic medication administration record (e-MAR) revealed multiple instances where medications, including artificial tears, Biotene oral rinse, escitalopram, levothyroxine, pregabalin, Restasis eye drops, and ziprasidone, were administered significantly later than their scheduled times or not administered at all. For example, artificial tears scheduled for 8:00 a.m. were given at 12:34 p.m., and levothyroxine scheduled for 6:00 a.m. was not documented as administered on two consecutive days. These delays and omissions in medication administration were identified through a review of the clinical record and facility policy. The findings indicate that the resident did not consistently receive medications as ordered, which is not in accordance with the facility's established procedures and professional standards of practice.
Incomplete Sprinkler System Installation in Electrical Room
Penalty
Summary
The facility failed to install required sprinkler system components, specifically in the Main electrical (switchgear) Room located in the basement. This deficiency was identified during an observation on April 15, 2025, at 11:25 a.m. The absence of an automatic sprinkler system in this area was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations on the same day at 2:45 p.m. This oversight affects one of the three levels of the facility, indicating incomplete automatic sprinkler protection as per the requirements outlined in NFPA 101 and NFPA 13 standards.
Plan Of Correction
1) The facility contractor is submitting plans to the Plan Review Department for approval of modifications to the fire suppression system for approval. 2) The Maintenance Director and/or designee will inspect the Main Electrical Room once a suitable fire suppression system is installed. 3) To prevent the potential for reoccurrence, the Administrator will educate the Maintenance Director and/or designee on the importance of a suitable fire suppression system is installed. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will check the fire suppression system is in place as required monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, impacting the entire facility. During a document review on April 15, 2025, it was found that the sprinkler inspection report from April 2, 2025, identified several deficiencies. The wet system's tamper in the pit did not report to the panel during the inspection, and it was noted that the pit consistently fills with water, requiring the facility to monitor and pump out the water for proper inspection and maintenance. Additionally, the dry system's last Fire Department Connection (FDC) hydrotest date was unknown, necessitating an immediate test. These deficiencies were confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) A. Wet System - The tampers in the report to the alarm panel. B. Dry System - The Maintenance Director or Designee will ensure to FDC hydrotest date is confirmed and completed. 2) The Maintenance Director and/or designee inspected the tampers, confirmed reporting to the alarm system, and the pit does not have accumulating water. 3) To prevent the potential for reoccurrence, the Administrator educated the Maintenance Director and/or designee on the importance of ensuring the tampers report to the alarm system and the pit does not have accumulating water. 4) To monitor and maintain ongoing compliance, the Maintenance Director and/or designee will inspect the pit weekly for one month, and monthly for the next two months. If an issue is identified, the vendor will be contacted to restore the tamper connection to the alarm and assure there is no accumulation of water in the pit. Findings will be reported to facility QAPI for continued review and recommendations.
Failure to Maintain HVAC Equipment Inspection
Penalty
Summary
The facility failed to maintain the inspection of its Heating, Ventilating, and Air Conditioning (HVAC) equipment at the required intervals, affecting the entire facility. During a document review on April 15, 2025, it was discovered that a fire damper inspection report dated May 9, 2022, identified 73 dampers as deficient due to inaccessibility or damage. At the time of the survey, there was no evidence available to confirm that these deficiencies had been repaired. This finding was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) The facility vendor is in the process of identifying, repairing, and determining if the dampers are all necessary and if necessary to make modifications, will contact the Plan Review Department for approval of modifications to the fire suppression system. 2) The Maintenance Director and/or designee reviewed and confirmed the fire dampers are operable. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of ensuring fire dampers are inspected and operable. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee ensure fire dampers remain operable monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.
Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which affected the entire facility. During a document review, it was found that the facility could not provide documentation for several critical tests and inspections. These included the monthly testing of battery electrolyte specific gravity or conductance testing, an annual 90-minute load bank test or a report indicating the unit meets 30% of the nameplate, and an annual fuel sample report. This lack of documentation was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations. Additionally, an observation revealed that the emergency generator set location in the basement, specifically the transformer room, lacked battery back-up emergency lighting. This deficiency was also confirmed during the exit interview with the facility's leadership team. The absence of these critical components and documentation indicates a failure to comply with the necessary maintenance and testing requirements for the emergency power systems as outlined by NFPA standards.
Plan Of Correction
1.) A. Upon observation on April 15, 2025, the Maintenance Director and/or Designee performed the monthly testing of battery electrolyte specific or conductance testing. B. Annual 90-minute load bank or report indicating unit meets 30% of name plate - was not due for annual testing; however, it was completed. C. Annual fuel sample report although not due was completed. D. In the basement, the emergency generator set location (transformer room) a battery back-up emergency light was installed. 2.) The Maintenance Director and/or designee although not due had the Annual 90-minute load bank and Annual fuel sample reports completed. 3.) To prevent the potential for reoccurrence the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of ensuring all reports are completed timely and available for review. 4.) To monitor and maintain ongoing compliance the Administrator and/or designee audit both the monthly and annual testing reports and ensure the back-up battery operated emergency lighting is in place and operable monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.
Failure to Maintain Self-Closing Doors in Hazardous Areas
Penalty
Summary
The facility failed to maintain self-closing doors at hazardous locations, affecting one of three levels in the facility. During an observation on April 15, 2025, several deficiencies were noted: at 12:40 p.m., the door at the Food Services office was binding in the frame, preventing it from latching; at 12:45 p.m., the door closure at the Dry Storage was broken, preventing the door from closing; and at 2:10 p.m., the hardware on the 2nd floor D wing's storage closet was broken, preventing the door from latching. These deficiencies were confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) A. Food Service Office Door and frame was replaced and latches as required. B. Dry Storage door closure was repaired and closes properly. C. 2nd Fl. D Wing storage closet, hardware was replaced and the door latches as required. 2) The Maintenance Director and/or designee inspected all self-closing doors in hazardous locations to ensure that the doors latch and close as required. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of self-closing doors in hazardous locations close and latch as required. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will audit all self-closing doors in hazardous locations monthly for 3 months to ensure compliance. If an issue is identified, the door/s will be fixed immediately and the Maintenance Director and/or designee will be reeducated. Findings will be reported to facility QAPI for continued review and recommendations.
Smoke Barrier Door Deficiencies
Penalty
Summary
The facility failed to maintain smoke barrier doors to resist the passage of smoke, affecting one of three levels. During an observation on April 15, 2025, it was noted that a smoke barrier door on the first floor next to room 112 was blocked by a wheelchair, preventing it from closing smoke tight. Additionally, the smoke barrier door in the Chateau Dining area was dragging on the floor, which also prevented it from closing smoke tight. These deficiencies were confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) A. Immediately upon observation on April 15, 2025, the wheelchair next to room 112 was removed so as not to prevent the door from closing smoke tight. B. Chateau Dining the smoke barrier door was repaired so that it does not drag the floor, preventing the door from closing smoke tight. 2) The Maintenance Director and/or designee audited all smoke doors for obstructions and door dragging the floor preventing the door from closing smoke tight. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee and staff on the importance of all smoke doors closing smoke tight without obstructions. 4) To monitor and maintain ongoing compliance, the Maintenance Director and/or designee will audit 3 smoke doors for closing smoke tight without obstruction for the next 3 months. If an issue is identified, the Maintenance Director or designee will immediately notify the administrator and correct the problem. Findings will be reported to facility QAPI for continued review and recommendations.
Improper Storage of Oxygen Cylinder
Penalty
Summary
The facility was found to be non-compliant with the proper storage of medical gases, specifically oxygen cylinders. During an observation on April 15, 2025, at 12:20 p.m., it was noted that on the first floor, in the Med room across from the conference room, there was a free-standing oxygen cylinder. This indicates that the facility did not adhere to the required storage protocols for medical gases as outlined in NFPA 101 and NFPA 99 standards. The deficiency was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations on the same day at 2:45 p.m. The improper storage of the oxygen cylinder suggests a lapse in following the guidelines that require cylinders to be stored securely and in a manner that prevents potential hazards. The report does not mention any specific residents or staff being directly affected by this deficiency at the time of the observation.
Plan Of Correction
1.) Immediately upon observation on April 15, 2025 the one free standing oxygen cylinder on the first floor in the Med Room across from the conference room was immediately removed. 2.) The Maintenance Director and/or designee audited the number and location of oxygen tanks and confirmed they were being stored properly. 3.) To prevent the potential for reoccurrence the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of ensuring all oxygen cylinders held in a holder and not free standing. 4.) To monitor and maintain ongoing compliance the Administrator and/or designee audit all oxygen tanks monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.
Failure to Obtain Approval for Fire Safety Alterations
Penalty
Summary
The facility was found to be deficient in meeting the minimum standards for operation as required by the Department and other state and local agencies. During a document review, it was observed that in the basement's Main Electrical (switchgear) Room, two heat detectors were programmed into the fire panel, and four Halotron fire extinguishers were installed after the removal of existing ADX Halon units. These alterations and renovations were conducted without obtaining Department-approved plans, as confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) Our vendor will submit plans to the Plan Review Department for approval of modifications to the fire suppression system. 2) No other areas affected. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of making sure all plans are approved prior to initiating alterations and renovations. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will review all plans to make alterations and/or renovations and will seek approval from DOH as required prior to following through with said plans. Findings will be reported at the facility QAPI for continued review and recommendations as changes occur.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide an ongoing, resident-centered activities program that met the interests and physical, mental, and psychosocial well-being of residents on both nursing units. Despite having a policy and job description outlining the need for comprehensive, individualized, and diverse activities, observations and interviews revealed that scheduled activities were either not conducted as planned or were limited in variety and engagement. The activities calendar showed repetitive offerings such as daily greetings, room visits, and bingo, with little evidence of adaptation to resident preferences or abilities. Observations of scheduled activities, such as Taco Tuesday and fitness sessions, showed minimal resident engagement, with some activities not occurring as scheduled or being limited to passive participation like watching staff prepare food or sitting at tables without active involvement. Multiple residents reported that they were not included in activity planning, were not offered activities of interest, and that the activities listed on the calendar were not actually provided. Several residents stated that no one from the activities department had visited their rooms to discuss or offer activities, and that the only activity regularly offered was bingo, which was not of interest to all. Some residents expressed a desire for more meaningful engagement and noted that they had never been taken outside the facility for activities or allowed outside, contrary to what was indicated in the facility's policy. Staff interviews confirmed inconsistencies in the delivery of activities, with some staff unable to describe or recall the activities scheduled or conducted. Observations further revealed that activities such as room visits were sometimes limited to offering snacks for purchase rather than providing meaningful engagement. The Life Enrichment Director and assistants demonstrated a lack of awareness regarding resident preferences and the actual implementation of the activities program, resulting in unmet needs for resident engagement and well-being.
Verbal Abuse of Resident by Nursing Assistant
Penalty
Summary
A facility failed to ensure that a resident was free from verbal abuse, as required by its own policy and state regulations. The incident involved a nursing assistant who was overheard by a resident's family member using a profane and derogatory statement directed at a resident with multiple medical conditions, including high blood pressure, chronic kidney disease, type II diabetes, dementia with behavioral disturbance, cognitive communication deficit, history of TIA, delusional disorder, and unspecified psychosis. The facility's documentation confirmed that the staff member made the inappropriate comment to the resident, constituting verbal abuse as defined by the facility's policy.
Failure to Develop Baseline Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop a baseline care plan with appropriate interventions to prevent pressure injury or trauma for a resident diagnosed with diabetes and other significant health conditions. Upon admission, the resident was assessed as cognitively impaired, with fluctuating inattention and disorganized thinking, bilateral lower extremity impairment, wheelchair dependence, incontinence, and substantial assistance required for hygiene and bed mobility. The resident's diagnoses included a progressive neurological condition, hypertension, diabetes mellitus, cerebrovascular accident, dementia, malnutrition, Parkinson's disease, and a psychotic disorder. The resident had experienced significant recent weight loss and was identified as being at risk for developing pressure ulcers, as indicated by the Braden assessment and clinical evaluation. Despite these findings, the clinical record did not contain a care plan addressing the resident's risk for pressure ulcers or interventions to prevent skin breakdown, particularly in light of the resident's uncontrolled diabetes, decreased bed mobility, and substantial weight loss. Although the MDS assessment indicated that skin and ulcer treatments were in place, such as pressure-reducing devices for the chair and bed, there was no evidence of a turning/repositioning program or application of dressings to the feet at the time of admission. The absence of a baseline care plan within the first 48 hours of admission was not in accordance with the facility's policy and regulatory requirements.
Delayed Medication Administration Due to Nurse Inattention
Penalty
Summary
A licensed nurse failed to administer scheduled morning medications to a resident in accordance with facility policy and physician orders. The nurse was observed on the nursing unit two hours after the scheduled medication administration time, engaged in watching a training video on the facility computer instead of performing the medication pass. Upon inquiry, the nurse confirmed she was preparing to administer the resident's morning medications, which were due two hours earlier, and acknowledged that she still had additional residents to medicate. Facility policies require that medications be administered safely, timely, and in accordance with physician orders, specifying that medications must be given at the correct time. The nurse's actions resulted in a delay of medical treatment for the resident, as the medications, including Allopurinol, Amlodipine, Cholecalciferol, Dorzolamide, and Metoprolol, were not administered at the prescribed time.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and able to communicate her needs, did not receive timely assistance with incontinence care. The resident's clinical record indicated she was always incontinent of bowel and bladder and required substantial to maximal assistance with toileting hygiene. On two separate occasions, the resident reported having a bowel movement and requested assistance multiple times. Despite informing staff, there were significant delays before care was provided. On one occasion, the assigned nurse was aware of the resident's need and relayed the information to the nurse aide, who was occupied with another resident. The nurse ultimately provided the care after a delay. On another occasion, the resident's call light was engaged, and a nurse aide entered the room, turned off the call bell, and told the resident she would return after assisting another resident. The resident continued to wait for incontinence care for an extended period, with care not provided until nearly 35 minutes after the initial request.
Failure to Implement Interventions to Prevent Diabetic Wound
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of a diabetic wound for a resident with multiple risk factors, including diabetes, limited mobility, malnutrition, and dementia. The resident was assessed as cognitively impaired, required substantial assistance with hygiene and bed mobility, and had a history of pressing their feet against the bed's footboard, which was observed by staff and confirmed by the resident. Despite a physician's order to apply multi-podus boots to both feet while in bed to relieve pressure, the resident was observed not wearing the boots, and the care plan did not address the risk of developing diabetic ulcers to the lower extremities. Clinical documentation revealed that discoloration on the resident's right heel was first noted, and subsequent wound assessments identified the wound as being related to the resident's diabetes and pressure from the footboard. The wound progressed, requiring debridement and antibiotic therapy after becoming infected. Staff interviews confirmed awareness of the resident's behavior of sliding down in bed and pressing their feet against the footboard, which contributed to the wound's development. The wound physician emphasized the importance of proper footwear and positioning to prevent further injury, noting that the wound may not heal due to the resident's chronic conditions and ongoing risk factors. Observations and interviews indicated that the resident was not consistently using the prescribed multi-podus boots, and staff acknowledged the connection between the lack of proper offloading and the development of the wound. The facility's failure to update the care plan to address the resident's risk for diabetic ulcers and to ensure consistent implementation of physician-ordered interventions directly contributed to the resident developing a significant wound that required advanced medical intervention.
Failure to Provide Supervision in Smoking Area
Penalty
Summary
The facility failed to provide an environment free from accident hazards by not ensuring adequate supervision in the designated smoking area. Facility policy requires that residents who smoke must sign a safe smoking agreement, smoke only in designated locations, and, if requiring supervision, only smoke at designated times with staff present. Review of care plans for several residents indicated interventions such as education on smoking risks, storage of smoking items at the nurse's station, provision of supervision during smoking, and use of a smoking apron. Despite these policies and care plan interventions, observations on two separate occasions revealed multiple residents smoking outside in the designated area without any staff present to supervise the activity. Interviews with staff and residents confirmed the lack of supervision, with one staff member stating that some employees preferred to watch from the window rather than be physically present outside, and a resident indicating that staff are never outside during smoking times. The facility's documented smoking list and care plans specifically required supervision for certain residents, but this was not provided as observed. This lack of supervision in the smoking area constitutes a failure to follow facility policy and ensure resident safety as required by federal and state regulations.
Failure to Schedule Follow-Up Urology Appointment for Catheterized Resident
Penalty
Summary
The facility failed to ensure appropriate follow-up care for a resident with an indwelling urinary catheter. The resident, who had a diagnosis of benign prostate hyperplasia with lower urinary tract symptoms, experienced urinary retention and was hospitalized, after which a catheter was inserted. Documentation showed that the resident had a series of urology consults, with the last appointment indicating the need for further discussion of two treatment options with a doctor. However, review of the clinical record did not show that the recommended follow-up appointment was scheduled. This lapse was confirmed by the unit manager, who acknowledged that the facility did not arrange the necessary follow-up for the resident's ongoing catheter management and treatment options, as required by facility policy and resident care standards.
Failure to Document Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy review irregularities were properly addressed for one resident. According to facility policy, when a pharmacist makes a recommendation during the monthly drug regimen review, the physician or prescriber is required to review the recommendation, document any actions taken, and provide a rationale if no changes are made. For one resident, the pharmacist recommended considering a gradual dose reduction of Eszopiclone for insomnia and reevaluating the ongoing use of Cyclobenzaprine due to potential adverse effects. However, documentation showed only an illegible, undated initial and the word 'decline' for the Eszopiclone recommendation, with no evidence that the physician reviewed or addressed the recommendation, nor any rationale provided for declining it. Similarly, for the Cyclobenzaprine recommendation, the physician checked off that the recommendation was declined but did not provide a rationale in the resident's clinical record. Interviews with the DON confirmed the lack of proper documentation and physician response for both recommendations. These findings indicate that the facility did not follow its own policies and procedures for addressing pharmacy recommendations and documenting physician actions and rationales in the resident's health record.
Failure to Provide Timely and Suitable Breakfast to Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Type 2 Diabetes and Anemia did not receive breakfast as required. The resident, who was cognitively intact according to a recent BIMS assessment, had physician orders in place to monitor meal consumption and to receive a no added salt, large portion diet. On the morning in question, documentation on the Medication Administration Record for meal monitoring was left blank for breakfast and both snacks. The resident reported to the nursing supervisor that she did not receive her breakfast, and the supervisor confirmed this, noting that staff may have been confused by a dinner tray left on the resident's table from the previous night. Subsequently, staff brought the resident a cold cereal and milk meal around noon, which the resident refused, stating she did not want cereal for breakfast and that it was too late with lunch approaching. The failure to provide a timely and suitable breakfast, as well as the lack of proper documentation and response to the resident's dietary needs and preferences, led to the deficiency cited under state regulations regarding the responsibility of the licensee and facility management.
Failure to Arrange Required Rheumatology Consultation
Penalty
Summary
The facility failed to provide necessary outside professional services for a resident diagnosed with polymyalgia rheumatica. The resident's progress note indicated that a physiatrist recommended a rheumatology consultation, and the attending physician agreed with this recommendation. However, a review of the clinical record showed no evidence that an appointment with a rheumatologist was scheduled. This lack of follow-through was confirmed by the Unit Manager during an interview.
Incomplete Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that hospice documentation was complete for one resident. The resident, who had multiple diagnoses including senile degeneration of the brain, major depressive disorder, generalized anxiety disorder, unspecified psychosis, hypertension, glaucoma, vitamin B deficiency, muscle weakness, and gait abnormalities, was readmitted to the facility and placed on hospice care. Upon review, it was found that the most recent hospice plan of care and recertification period had expired, and there was incomplete or missing correspondence from the hospice staff providing care. The nursing home administrator confirmed that the last day of hospice was reached and was unable to provide further documentation for the missing notes.
Failure to Implement Effective Infection Control with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) with enhanced barrier precautions for two residents. For one resident with a history of sepsis, C. difficile, MRSA, and ESBL, observations revealed that staff, including a licensed nurse and therapy staff, did not consistently wear the required PPE such as gowns and gloves during high-contact care activities, despite signage and care plans indicating the need for enhanced barrier precautions. Interviews with staff and administration showed confusion and lack of awareness regarding the resident's current precaution status and the appropriate use of PPE, with some staff believing only gloves were necessary or being unaware of the requirements altogether. Another resident with an indwelling catheter also required enhanced barrier precautions, as indicated by door signage. However, a nurse aide was observed providing care without wearing a gown and later admitted to being unaware that a gown was required. These failures were identified through direct observation, review of clinical records, and staff interviews, demonstrating a lack of adherence to established infection control policies and procedures for residents requiring enhanced barrier precautions.
Inadequate Pain Management Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate pain management for Resident R381, resulting in actual harm. The resident, who was admitted with a chronic ulcer wound, chronic leg pain, and other conditions, was not properly assessed for pain and did not receive timely pain medication. Upon admission, the resident was prescribed Oxycodone for severe pain, but the medication was not available, and the resident was instead offered Acetaminophen, which was refused. The resident's pain level was not consistently assessed, and there was a delay in obtaining the prescribed Oxycodone. On October 12, 2024, the resident expressed severe pain and suicidal ideation to a physical therapist, indicating a pain level of 10/10. Despite this, there was no evidence that the physician was notified of the resident's condition. Instead, the resident was placed on 1:1 supervision for suicidal ideation. The Director of Nursing later admitted that the staff did not want to bother the physician over the weekend, which contributed to the delay in pain management. The facility's failure to manage the resident's pain effectively resulted in the resident experiencing uncontrolled pain. The lack of timely medication and proper communication with the physician were significant factors in the deficiency. The facility's policies on emergency medication supplies and pain management were not adequately followed, leading to the resident's continued suffering.
Privacy Breach in Transmission-Based Precaution Signage
Penalty
Summary
The facility failed to ensure the personal privacy and confidentiality of residents' medical information related to signage for enhanced barrier precautions. During an observation tour, it was noted that five out of eight residents on transmission-based precautions had signage on their doors that revealed personal and confidential medical information. This included details about medical devices such as peg tubes, tracheostomies, and catheters, which were visible to anyone passing by. The facility's policy on Resident Rights, revised in September 2020, mandates compliance with all resident rights, including the communication of these rights in an understandable language. Additionally, the facility's Transmission Based Precautions and Isolation policy, last revised in April 2024, requires signage to indicate the type of precautions and instruct visitors to stop at the Nurse's Station before entering. However, the signage observed did not adhere to these policies, as it disclosed specific medical conditions and devices, thereby compromising the residents' right to privacy.
Failure to Follow Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that menus were followed, which resulted in several residents receiving meals that did not match their requests. During lunchtime, a resident complained about receiving chicken and cranberry juice, contrary to her lunch ticket that specified roast beef, brown gravy, creamed spinach, egg noodles, and no cranberry juice. Another resident expressed that he consistently received incorrect meals. The grievance log showed a complaint from a resident about being served the wrong food, which was confirmed during an interview. Additionally, during a resident council meeting, multiple residents voiced concerns that the food served did not match their food tickets.
Failure to Notify Physician of Resident's Fall and Hospitalization
Penalty
Summary
The facility failed to promptly notify a resident's physician of a fall with injury that resulted in hospitalization during a leave of absence. The facility's policy requires that the physician and family be notified as soon as a change in condition is identified and the resident is stable. However, in the case of a resident who went on a leave of absence to church, the facility did not document any evidence of notifying the physician after the resident sustained a fall, which was witnessed and resulted in hospitalization. The resident returned to the facility with pain and an abrasion on the right thumb, and pain on the right side, for which as-needed pain medication was administered. Despite the facility's policy outlining the need for prompt notification of significant changes in condition, including accidents or incidents, the clinical record lacked documentation of physician notification. This deficiency was confirmed during an interview with the Regional Nurse.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to accurately complete a resident assessment related to discharge status for one resident. A review of the clinical records and staff interviews revealed that the discharge Minimum Data Set (MDS) for a resident was inaccurately coded. The nursing note dated July 31, 2024, indicated that the resident was discharged to home, while the MDS assessment for the same date incorrectly coded the discharge status as a short-term general hospital (acute hospital). This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator on November 1, 2024.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident who complained of headache, dizziness, and lightheadedness. The resident's nurse practitioner ordered lab work, including a CBC, CMP, urine culture and sensitivity, and an EKG. The urine sample was initially collected on the night shift but was not sent to the lab promptly. A second urine sample was collected and sent to the lab, but the container leaked, and the sample was discarded. The lab attempted to contact the facility, but no follow-up was completed, and no new urine sample was sent out.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify a resident's physician about abnormal laboratory test results. Resident R107, who had complained of headache, dizziness, and lightheadedness, had lab work ordered by a nurse practitioner, including a CBC, CMP, urine culture and sensitivity, and an EKG. Although the lab work was completed, the results were not printed from the lab electronic system, and there was no evidence that the physician was notified of the results. The CBC and CMP results, completed on October 19, 2024, showed some values flagged as out of range, including a blood sodium level of 133, which is below the normal range of 136-144.
Inadequate Call Bell System for Resident
Penalty
Summary
The facility failed to ensure that the call bell system in Resident R21's room was functional and accessible. During an observation, it was noted that the wired call bell had been removed from the wall, leaving the resident with a tap bell placed across from the foot of the bed, out of reach. The resident reported using the bell to call for staff, but no one responded. On one occasion, the resident pressed the tap bell at 1:49 p.m. to request assistance after an incontinence episode, but staff did not respond until 1:58 p.m., despite being present at the nurse's station. Employee E4, responsible for Resident R21, was unaware that the resident did not have a corded call bell. Further observations revealed that the tap bell was not audible at the nurse's station, where music was playing, and staff, including a registered nurse passing medication nearby, did not hear it. On another occasion, the resident pressed the tap bell multiple times to request assistance for lunch preparation, but there was no response until 11:27 a.m. Interviews with the Nursing Home Administrator and the Regional Nurse confirmed that the call system provided for Resident R21 was inadequate, violating the electric requirements for existing construction as per 28 Pa. Code 205.67(j).
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of continuing education per year, as evidenced by the review of personnel files and staff interviews. Specifically, three out of five nurse aide personnel files reviewed, including those of Employees E6, lacked documentation of the mandatory continuing education hours. During an interview, the Nursing Home Administrator confirmed the absence of these educational records for the employees at the time of the survey. This deficiency is a violation of the Pennsylvania Code, which mandates specific personnel policies and staff development requirements.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident requiring continuous oxygen therapy received the prescribed services according to physician orders. The resident, who was admitted in September 2022 for acute respiratory failure with hypoxia, was observed by family members on multiple occasions without the oxygen mask, despite an order for 2 liters of oxygen to be administered continuously via nasal cannula. A grievance was logged by the family, noting this was the third occurrence in a month. A nursing assistant admitted to removing the oxygen mask while providing care on May 14, 2024, and forgetting to replace it, which contributed to the deficiency.
Failure to Maintain Comfortable Temperature in B Wing
Penalty
Summary
The facility failed to maintain a safe and comfortable environment on the B wing nursing care unit. During an interview, a resident reported that the hallway temperature was uncomfortably cold, necessitating keeping her room door closed. She had communicated this concern to the nursing supervisor and during a resident council meeting. An observation tour conducted with the director of maintenance confirmed the hallway temperature was 69 degrees. The director explained that the fire doors at each end of the hallway were closed due to a malfunction in the magnetic door lock system, creating a compartment that trapped cold air from the air conditioning system, leading to the temperature drop.
Failure to Perform Immediate CPR for Full Code Resident
Penalty
Summary
The facility failed to ensure that CPR was provided in accordance with established facility policy for a resident who had elected to be Full Code. The incident involved Resident 207, who was found unresponsive by a licensed nurse, Employee E6. Instead of initiating CPR immediately, Employee E6 mistakenly identified the resident as having a Do Not Resuscitate (DNR) order by looking up the wrong resident in the computer system. This error led to a delay in starting CPR, as Employee E6 left the resident's room to inform the Nursing Supervisor, Employee E30, who also believed the resident was a DNR based on the incorrect information provided by Employee E6. It was only after the Acting DON and the Physician Assistant (PA) confirmed that the resident was a Full Code that CPR was initiated, approximately 14 minutes after the resident was found unresponsive. The delay in initiating CPR was further compounded by the actions of the staff. Employee E6, after misidentifying the resident's code status, left the room to use the computer and get the supervisor, instead of starting CPR immediately. Employee E30, the Nursing Supervisor, also did not verify the resident's code status promptly and relied on the incorrect information provided by Employee E6. The Acting DON and the PA eventually confirmed the resident's Full Code status and called for CPR to be initiated, but this was significantly delayed. The facility's failure to perform CPR immediately for a resident who had elected to be Full Code created a situation of Immediate Jeopardy. The delay in initiating CPR was due to the misidentification of the resident's code status and the subsequent actions of the staff, which did not align with the facility's policy and the American Heart Association guidelines. The resident was eventually transported to the hospital with a pulse after the paramedics took over CPR, but the initial delay in providing life-saving measures was a critical deficiency in the facility's response.
Failure to Provide Timely CPR Due to Misidentification of Code Status
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility by not ensuring that Cardio Pulmonary Resuscitation (CPR) was provided in accordance with established facility policy for a resident, resulting in an Immediate Jeopardy situation. The resident, who had a physician's order for Full Code, was found unresponsive by a licensed nurse. The nurse mistakenly identified the resident as Do Not Resuscitate (DNR) due to looking up the wrong resident in the computer system. This error led to a delay in initiating CPR, as the nurse informed the Nursing Supervisor, who then informed the Acting Director of Nursing (DON) that the resident was a DNR. It was only after the Physician Assistant (PA) confirmed that the resident was a Full Code that CPR was initiated and 911 was called. The paramedics were able to obtain a pulse and transported the resident to the hospital, but the delay in starting CPR was significant, lasting approximately 14 minutes from the time the resident was found unresponsive to when CPR was initiated. Interviews with the involved staff confirmed the sequence of events and the miscommunication regarding the resident's code status. The licensed nurse admitted to looking up the wrong resident in the computer system and leaving the room to get the supervisor, which contributed to the delay. The nurse aide and the Nursing Supervisor also confirmed the timeline and actions taken, including the removal of the resident's Foley catheter and preparing the resident for family viewing under the mistaken belief that the resident was a DNR. The Acting DON and the PA confirmed that they realized the resident was a Full Code only after checking the records, leading to the initiation of CPR and calling 911. The facility's camera footage corroborated the timeline provided by the staff, showing the delay between the nurse and the supervisor entering the resident's room and the initiation of CPR. The Nursing Home Administrator, DON, and Acting DON acknowledged the delay and the misidentification of the resident's code status, which contributed to the Immediate Jeopardy situation. The deficiency was identified as a failure to fulfill essential duties and responsibilities, as outlined in the job descriptions for the Nursing Home Administrator and the Director of Nursing, leading to a critical lapse in resident care.
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.
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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.
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