Highland Manor Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Exeter, Pennsylvania.
- Location
- 750 Schooley Avenue, Exeter, Pennsylvania 18643
- CMS Provider Number
- 395566
- Inspections on file
- 30
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Highland Manor Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain cleanliness and order in the laundry department and the second hallway ice machine area. The ice machine lacked an air gap and drained directly into a floor drainpipe, with a sticky black substance present on the floor. In the laundry area, both dirty and clean sections were cluttered with debris, overflowing garbage, soiled items, and visible dirt, with clean linens and equipment in direct contact with the floor. These unsanitary conditions were confirmed by the Nursing Home Administrator.
Several residents experienced significant delays in staff response to call bells, particularly when needing incontinence care or toileting assistance. Residents reported frequent waits of over an hour, with some left in soiled briefs for extended periods. Staff were observed entering rooms, turning off call bells, and leaving without providing care, resulting in residents remaining in distress and without timely assistance.
A resident with severe cognitive impairment sustained a fractured humeral neck, but the LTC facility failed to conduct a thorough investigation into the injury's origin. The resident fell from bed during care, initially showing no signs of fracture or pain. Five days later, an X-ray revealed a humeral fracture, but the facility did not document any investigation into the injury's cause, attributing it to the fall without evidence.
A resident at risk for falls did not have the required bilateral fall mats in place as per their care plan. Observations confirmed the absence of mats, and staff acknowledged the oversight. The DON confirmed the facility's responsibility to implement care plan interventions.
A facility failed to follow physician orders for a resident with chronic lung conditions, who was prescribed the use of an incentive spirometer every two hours while awake. Despite the order, there was no documented evidence of the treatment being implemented from mid-November to mid-December. The issue was compounded when the resident's thoracic surgeon reported ongoing problems with the resident's lung not expanding, leading to further medical intervention.
A resident at risk for skin breakdown developed a deep tissue injury on the right heel despite having a care plan with interventions like floating heels and weekly skin assessments. The facility did not update the care plan with revised pressure-relieving interventions after the injury was discovered, and there was a lack of consistent completion of preventative tasks by staff.
A resident with low back pain and muscle weakness received narcotic pain medications without attempts at non-pharmacological interventions. The facility's records showed multiple administrations of Tramadol and Oxycodone without prior non-drug interventions, confirmed by staff interviews.
A physician failed to respond to a pharmacist's recommendation for a gradual dose reduction of Abilify for a resident with major depressive disorder and schizophrenia. The consultant psychiatric CRNP addressed the recommendation instead, and the physician did not document justification for the continued use of the medication.
The facility did not document the accounting and disposition of medications for a resident who was admitted and then discharged after expiring. Upon review, there was no evidence in the clinical record of the resident's remaining medications or their disposition, which was confirmed by the Nursing Home Administrator.
The facility did not maintain proper exit signage as required by NFPA 101 standards. An observation revealed that the illuminated exit sign at the B Hall Nurse's Station was partially obscured by a ceiling mirror, affecting one of two floors. This issue was confirmed during an exit interview with the facility's management team.
The facility did not maintain proper hazardous area enclosures, as observed in two locations. A storage room door was tied open, and a Laundry door needed adjustment to latch fully. These issues were confirmed during an exit interview with facility management.
The facility failed to maintain the automatic sprinkler system, as observed when sprinkler head assemblies in the Laundry area were found "loaded" with lint. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager.
The facility failed to maintain smoking regulations, as cigarette butts were found in a trash receptacle at the outdoor smoking location, and the area lacked a noncombustible receptacle with a self-closing lid for ashtrays. This deficiency was confirmed during an exit interview with facility management.
The facility did not adhere to the required fire drill procedures, as ten out of twelve drills were conducted within one week of each other, failing to meet the standard of varying times and conditions. This issue was confirmed by the Facility Administrator and management team.
The facility did not maintain fire door inspection records for the past year, with the last inspection conducted in March 2023. This deficiency affected both floors and was confirmed during an exit interview with the facility's management team.
The facility failed to maintain the generator set as required, lacking weekly battery voltage readings. This deficiency was observed during a documentation review and interview, affecting both floors. The absence of these readings indicates non-compliance with NFPA 101 and NFPA 110 maintenance protocols.
The facility failed to maintain a clean and safe environment, with observations of black substance buildup in showers, cracked tiles, and mold-like substances in various areas. Water damage and mildew odors were noted, along with peeling joint tape and brown water stains on ceilings. These deficiencies were confirmed by the Nursing Home Administrator.
The facility failed to provide timely responses to residents' requests for assistance, as evidenced by five residents reporting extended wait times for staff to respond to their nurse call bell system. This resulted in residents being left in the bathroom for long periods, soiling themselves, and feeling the need to perform tasks independently due to delayed assistance. The DON confirmed the expectation for dignity and respect but could not explain the untimely responses.
The facility failed to ensure fresh water was consistently readily accessible to residents, affecting five out of 14 residents reviewed. Residents reported having to ask for water, and observations revealed outdated water cups and lack of accessible water. Staff interviews confirmed these findings, and the facility did not adhere to its policy of providing fresh water every shift and changing cups every three days.
Failure to Maintain Sanitary Conditions in Laundry and Ice Machine Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and orderly environment in both the laundry department and the second hallway ice machine area. The ice machine was found to be draining directly into a floor drainpipe without an air gap, which is necessary to prevent contaminated water from backing up into the potable water supply or the ice consumed by residents. The floor beneath the drainage pipe was covered with a thick layer of sticky black material, indicating a lack of proper cleaning and maintenance. In the laundry department's dirty room, two slop sinks were filled with lint, debris, plastic hangers, and a plastic bag containing soiled wheelchair or lift belts, with a leaking faucet observed. The area also contained a dirty mop bucket with garbage and broken equipment, an overflowing garbage can, and floors littered with plastic, paper, dirty gloves, and clumps of lint, all with a buildup of sticky black substance. The clean area was similarly unkempt, with overflowing garbage, visible dirt, dried liquid stains, used gloves, and a large pile of lint on the floor. Clean linen and clothing racks had mechanical lift pads in direct contact with the floor, and a dirty washcloth was also found on the floor. These conditions were confirmed by the Nursing Home Administrator during the survey.
Failure to Respond Timely to Resident Requests for Assistance
Penalty
Summary
The facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by not responding in a timely manner to residents' requests for assistance. Multiple residents reported and were observed to have experienced significant delays in staff response to call bells, particularly when in need of incontinence care or assistance with toileting. For example, one resident activated her call bell at 9:41 AM for hygiene care after a bowel movement and did not receive assistance until 12:30 PM, despite her daughter notifying the nurse on duty. Another resident reported frequent waits of over an hour for staff to answer her call bell, resulting in repeated episodes of soiling herself. Observations confirmed that a resident was left in a visibly soiled brief for at least 35 minutes after activating the call bell, with staff entering the room, turning off the call bell, but not providing care until much later. Additional interviews revealed that residents often waited extended periods, sometimes over an hour, for staff to respond to their needs, especially during certain shifts and weekends. In some cases, staff would enter the room, turn off the call bell, and leave without providing the requested assistance, stating they would return but failing to do so in a timely manner. The DON confirmed that staff are not supposed to turn off call bells until care is provided. These actions and inactions resulted in residents being left in soiled conditions and experiencing distress while waiting for basic care needs to be met.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident who sustained a fractured humeral neck. The facility's policy requires that incidents of unknown origin be reported and investigated thoroughly, including reviewing events leading up to the incident and interviewing staff. However, the facility did not follow this policy in the case of the resident who was severely cognitively impaired and unable to explain the injury. The resident was involved in a fall from bed during care, where they landed on their knees on a fall mat. Initial assessments and X-rays did not reveal any fractures or acute findings, and the resident did not exhibit signs of pain immediately following the fall. It was only five days later that the resident showed signs of shoulder pain, and an X-ray revealed a humeral fracture, which was suspected to be a refracture of an old injury. Despite the discovery of the fracture, the facility did not document any attempts to investigate the source of the injury. The Director of Nursing confirmed that there was no evidence of an investigation into how the resident sustained the humeral neck fracture, and the facility attributed the injury to the fall without documented evidence. This lack of investigation into the injury of unknown origin constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Plan Of Correction
Step I - Unable to retroactively address for Resident 23. Step 2 - Review of last 30 days of falls to assure there was no occurrence of injury noted few days later attributed to fall. DON or designee. Step 3 - Education to nursing staff that occurrences of injury few days later require an investigation to assure injury was not related to something other than the fall. Staff educator or designee. Step 4 - Random audits on incidents with injury noted days later to assure the investigations occur. Weekly times 4, monthly times 2 - DON or designees. Step 5 - Results of audits to QAPI. Monthly times 2.
Failure to Implement Fall Prevention Plan
Penalty
Summary
The facility failed to implement a person-centered fall and injury prevention plan for Resident 104, who was at risk for falls due to decreased mobility, medications, and a history of falls. The care plan for this resident included the use of bilateral fall mats on the sides of the bed, which were initiated on December 13, 2024. However, observations on December 17, 2024, revealed that the mats were not in place while the resident was in bed, despite the care plan intervention requiring them. The deficiency was confirmed by Employee 5, a Registered Nurse, who acknowledged that the mats were not in place as per the care plan. Additionally, the Director of Nursing confirmed that it was the facility's responsibility to ensure the implementation of interventions developed in each resident's comprehensive person-centered care plan. The failure to implement the care plan intervention for bilateral mats was a lapse in mitigating the resident's risk of injury from falls.
Plan Of Correction
Step 1 - Mats were added to floor bilaterally when resident 104 was in bed. Step 2 - Review of current residents with falls in past 30 days to assure that fall mats on plan of care are in place for resident. DON or designee. Step 3 - Education to nursing personnel on importance of implementation of fall preventatives to prevent injuries on residents with falls are in place as specified on care plans. Staff educator or designee. Step 4 - Random audits for residents with fall risk to assure that care planned items are in place for resident. Weekly times 4 monthly times 2. DON or Designee. Step 5 - Results to QAPI monthly times 2.
Failure to Implement Physician Orders for Lung Treatment
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice by not following physician orders for a medical treatment for a resident with chronic lung conditions. Resident 15, who was admitted with diagnoses including pneumothorax and post coronary artery bypass, had a physician's order dated November 18, 2024, to use an incentive spirometer every two hours while awake. This device is intended to exercise the lungs and prevent infections by expanding them. However, a review of the resident's medication and treatment administration records from November 18, 2024, through December 17, 2024, showed no documented evidence that the spirometry orders were implemented. The deficiency was further highlighted when the facility received a call from the resident's thoracic surgeon on December 17, 2024, indicating that the resident's chest tube was not draining and the lung was not expanded, an issue that had persisted since the resident's hospital stay. The Director of Nursing confirmed during an interview on December 18, 2024, that there was no documented evidence of the spirometry treatment being carried out as prescribed. This lack of adherence to the physician's orders and failure to document the treatment contributed to the deficiency identified by the surveyors.
Plan Of Correction
Step 1 - Unable to retroactively fix this issue for resident 15. Step 2 - Review of residents in facility to assure there are no other residents that are using incentive spirometry without orders. DON or designee Step 3 - Education to nursing staff on need for orders from MD and documentation requirements for resident who are to utilize special equipment. Staff Educator or Designee Step 4 - Random audits of resident requiring special equipment to assure MD orders and required documentation is in place. Weekly times 4 monthly times 2 - DON or Designee Step 5 - Results to QAPI Monthly times 2
Failure to Prevent Pressure Injury Development
Penalty
Summary
The facility failed to prevent the development of a pressure injury for a resident identified as being at risk for skin breakdown. The resident, who had diagnoses including dementia, muscle wasting, and a history of a femoral neck fracture, was admitted with a care plan that included interventions such as floating heels while in bed, weekly skin assessments, and a pressure redistribution mattress. Despite these measures, a deep tissue injury (DTI) was discovered on the resident's right heel during morning care by a hospice aide. The injury was reported, and the facility's contracted wound healing specialists were notified. However, the facility did not revise the resident's care plan to include updated pressure-relieving interventions following the discovery of the injury. The resident's clinical records and facility documentation revealed a lack of consistent completion of preventative pressure injury tasks by staff. The Director of Nursing confirmed that the facility did not develop and implement necessary interventions to prevent the pressure injury after the resident's condition changed significantly and hospice services were initiated. This deficiency was identified as a failure to adhere to resident care policies and nursing services regulations as outlined in the Pennsylvania Code.
Plan Of Correction
Step 1 - Unable to retroactively fix resident 26, wound has already resolved. Step 2 - Review of residents deemed high risk for pressure ulcers to assure documentation in place or added to documentation for preventatives. DON or Designee. Step 3 - Education to nursing staff on completing and documenting preventative measures to prevention of pressure ulcers. Staff Educator or designee. Step 4 - Random audits of residents at high risk to assure preventative documentation is in place. Weekly times 4, Monthly times 2 - DON or designee. Step 5 - Results reported to QAPI Monthly times 2.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not attempting non-pharmacological interventions before administering narcotic pain medications. Resident 33, who was admitted with diagnoses including low back pain and muscle weakness, had physician orders for Tramadol and Oxycodone to be given as needed for pain. During November and December 2024, the resident received these medications multiple times without any documented attempts of non-pharmacological interventions prior to administration. The clinical record review and staff interviews confirmed that the facility did not consistently attempt or document non-pharmacological interventions before administering PRN narcotic pain medications. The Nursing Home Administrator and Director of Nursing acknowledged the lack of evidence for such interventions, which is a requirement under 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services.
Plan Of Correction
Step 1 - R-33 MAR was updated to include documentation of non-pharmacological interventions on 12/19/2024. Step 2 - Review of residents receiving prn pain medications to assure the "NPI" documentation in place. Step 3 - Education to licensed staff on the importance of offering and documenting non-pharmacological interventions prior to giving PRN pain medications. Step 4 - Random audits of residents receiving PRN pain medications to assure non-pharmacological interventions are in place and documentation completed. Weekly times 4 monthly times 2. DON or Designee. Step 5 - Results to QAPI Monthly times 2.
Physician Inaction on Pharmacist's Medication Review
Penalty
Summary
The attending physician failed to act upon pharmacist-identified irregularities in the medication regimen of a resident diagnosed with major depressive disorder and schizophrenia. The resident was prescribed Abilify, an antipsychotic medication, and the consultant pharmacist recommended a review for a gradual dose reduction. However, the attending physician did not document an appropriate response or provide justification for the continued use of Abilify in the resident's clinical record. Instead, the facility's consultant psychiatric CRNP responded to the pharmacy recommendation and signed off on it. An interview with the Director of Nursing confirmed that the attending physician did not provide the necessary documentation or justification for the medication regimen.
Plan Of Correction
Step 1 - Medical Director reviewed the pharmacy recommendations and noted the rational and justification for continued use of Abilify and reason for rejection of the GDR. Step 2 - Going forward when CRNP reviews and gives responses to pharmacy recommendations they will be reviewed and signed off by Medical Director. Step 3 - Education to CRNP's and medical director for need of review and signing off of pharmacy recommendations. Step 4 - Audits will be completed going forward of pharmacy recommendations to assure medical director signs off in agreement prior to adding to resident's chart. Monthly times 3. DON or designee. Step 5 - Results to QAPI monthly times 2.
Failure to Document Medication Disposition for Discharged Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 121 upon discharge. Resident 121 was admitted to the facility on November 19, 2024, and expired and was discharged on November 21, 2024. Upon review of the clinical record during a survey ending on December 19, 2024, there was no documented evidence of the accounting of the resident's remaining medications or their disposition. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 19, 2024, at 2:00 PM.
Plan Of Correction
Step I - Unable to retroactively address for closed chart for resident 121. Step 2 - Unable to go back and fix for any discharged resident. Step 3 - Education to licensed staff on disposition of medications for discharged and expired residents. Staff educator or designee. Step 4 - Random review of discharged residents to assure disposition of medications is completed and documented at time of discharge. Weekly times 4 monthly times 2. DON or designee. Step 5 - Results to QAPI monthly times 2.
Exit Signage Obscured by Ceiling Mirror
Penalty
Summary
The facility failed to maintain proper exit signage in accordance with NFPA 101 standards, specifically affecting one of two floors. During an observation on December 10, 2024, at 11:35 a.m., it was noted that the illuminated exit signage at the B Hall Nurse's Station was partially obscured by a ceiling mirror. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager later that day.
Plan Of Correction
- The illuminated exit signage by B side nurses' station was moved to provide visibility. - The exit signage throughout the facility was assessed to ensure exit signage is not obscured. - Maintenance Director will be educated by NHA/designee to ensure illuminated exit signages are visible and unobscured. - Illuminated exit signage will be randomly audited monthly x3 by Maintenance Director/designee to ensure signage is unobscured and visible. Trends will be reviewed at QAPI monthly.
Hazardous Area Enclosure Deficiencies
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures in two specific locations, affecting one of the two floors. During an observation on December 10, 2024, it was noted that the storage room door within the Building Services Corridor was improperly held open by unapproved means, specifically being tied open. Additionally, the Laundry door was found to require adjustment to ensure it could fully latch. These deficiencies were confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager.
Plan Of Correction
- The unapproved means of holding the storage room door open was immediately removed. The laundry room door was adjusted to ensure the door closes properly. - The hazardous areas throughout the facility will be assessed to ensure doors are closed and free of unapproved means of holding the door open and doors closing properly. - Staff will be educated by Maintenance Director/designee to ensure doors to hazardous areas are not obstructed and properly closed. Maintenance Director will be educated by NHA/designee to ensure doors to hazardous areas close properly with door closures. - The doors to hazardous areas will be randomly audited monthly x3 by the maintenance director to ensure proper closure. Trends will be reviewed at QAPI meeting monthly.
Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by an observation on December 10, 2024. During the inspection, it was noted that the automatic sprinkler head assemblies located within the Laundry area were "loaded" with lint. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager on the same day.
Plan Of Correction
- The sprinkler head assemblies located in the laundry area were immediately cleaned and free of lint. - The sprinkler head assemblies throughout the facility were checked to ensure clean and free of debris. - Maintenance Director will be educated by NHA to ensure sprinkler head assemblies are clean and free of debris. - The sprinkler head assemblies will be randomly audited by the maintenance director to ensure the sprinkler head assemblies are clean and free of debris. Trends will be reviewed at QAPI meeting monthly.
Smoking Regulations Deficiency
Penalty
Summary
The facility failed to maintain smoking regulations in one location, affecting one of two floors. During an observation on December 10, 2024, at 12:07 p.m., cigarette butts were found in a trash receptacle at the outdoor smoking location. Additionally, the area did not have a noncombustible receptacle with a self-closing lid for emptying ashtrays, as required by the smoking regulations. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager on the same day between 12:20 p.m. and 12:35 p.m.
Plan Of Correction
- The cigarette butts were immediately removed from the trash bin. A noncombustible receptacle, with self-closing lid was provided by the smoking area to empty ashtrays. - The facility will be assessed to ensure no other trash receptacles are used to discard cigarette waste. Staff will be educated by Maintenance Director/designee on proper disposal of cigarette butts. Maintenance Director will be educated by NHA/designee to ensure proper receptacles are available by the smoking area. - Smoking area will be audited monthly x3 by maintenance director/designee to ensure cigarette butts are disposed of properly and proper receptacles are available by the smoking area.
Failure to Conduct Fire Drills at Varying Times
Penalty
Summary
The facility failed to maintain proper fire drill procedures, as evidenced by the documentation review and interview. Specifically, it was observed that ten out of the twelve required fire drills were conducted within one week of each other, which does not meet the requirement of holding fire drills at varying times and conditions. This deficiency affected both floors of the facility. During the exit interview, the Facility Administrator, Facilities Manager, and Regional Facilities Manager confirmed the fire drill deficiencies.
Plan Of Correction
- Unable to correct the 10 out of 12 fire drills conducted within 1 week of one another. - Fire drills will be conducted on different days and times throughout the year. NHA will educate Maintenance Director/designee to ensure fire drills are conducted at least quarterly on each shift on different days and times throughout the year. - Fire drills will be audited monthly x3 by Maintenance Director/designee to ensure drills are completed at least quarterly on each shift on different days and times throughout the year. Trends will be reviewed at QAPI meeting monthly.
Failure to Maintain Fire Door Inspection Records
Penalty
Summary
The facility failed to maintain fire doors as required, affecting both floors of the building. During an observation on December 10, 2024, it was found that the facility lacked fire door inspection data for the previous twelve-month period, with the last inspection having been performed in March 2023. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager.
Plan Of Correction
- The fire doors were inspected and documented. - Fire doors will be inspected per regulation. - Maintenance Director will be educated on fire door inspection by NHA/designee. - Audit of fire door inspection will be conducted by maintenance director annually. Trends will be reviewed at QAPI meeting.
Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the generator set as required, which was evidenced by the lack of weekly battery voltage readings. This deficiency was observed during a documentation review and interview process, affecting both floors of the facility. The absence of these readings indicates a failure to comply with the maintenance and testing protocols outlined in NFPA 101 and NFPA 110, which require regular inspections and testing to ensure the generator's functionality. During an observation on December 10, 2024, at 11:28 a.m., it was noted that the facility did not have the necessary documentation for weekly battery voltage readings. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager later that day. The lack of these readings suggests that the facility did not adhere to the required maintenance schedule, potentially impacting the reliability of the emergency power system.
Plan Of Correction
- Unable to correct missing generator battery voltage readings. - Battery voltage reading will be conducted weekly. - Maintenance Director will be educated on generator battery voltage readings and documentation of same. - Generator battery voltage readings will be audited monthly by maintenance director/designee to ensure voltage is accurate and documented. Trends will be reviewed at QAPI meeting monthly.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an unclean and unsafe environment for residents. Observations revealed significant issues, including a black substance buildup on the caulking around the shower in the 200 hall and cracked tiles in the center hall shower room. Additionally, the soiled utility room in the center hall had a large amount of black mold-like substance on the walls around the hopper, which was leaking water, and there was a strong smell of mildew present. Further observations noted water damage and mold-like substances in various areas, including room [ROOM NUMBER], which had water damage to the ceiling, old brown water stains, and a dead earwig on a bath blanket. The center hallway also had water damage with brown stains on the ceiling and a piece of plywood covering a hole. The hallway in front of the dining room had brown water stains on the ceiling, with joint tape peeling away and a black substance underneath. These conditions were confirmed by the Nursing Home Administrator, indicating a failure to maintain a clean and sanitary environment for residents.
Failure to Respond Timely to Residents' Requests for Assistance
Penalty
Summary
The facility failed to provide care in a manner and environment that promotes each resident's quality of life by not responding timely to residents' requests for assistance. This was evidenced by experiences reported by five residents who stated that they had to wait extended periods for staff to respond to their requests via the nurse call bell system. Resident 14 reported being left in the bathroom for long periods when his assigned aide was off the floor, and staff did not provide necessary assistance. Resident 11 mentioned waiting over an hour to use the bathroom, resulting in soiling herself. Resident 9 experienced a 2.5-hour wait for assistance after activating the call bell, leading to soiling herself and requiring a complete change of bed linens. Resident 13 stated he had learned to do everything for himself due to long wait times for staff assistance. Resident 10 reported waiting over an hour for staff to answer his call bell, particularly during the evening shift, and felt that short staffing was a problem in the facility. The Director of Nursing (DON) confirmed that it is her expectation for all residents to be treated with dignity and respect but was unable to explain why multiple residents reported untimely staff response times. The deficiency was noted during a review of minutes from the Residents' Council meeting and resident and staff interviews, which highlighted the negative impact on residents' quality of life due to perceived inadequate staffing and delayed responses to their needs.
Failure to Ensure Fresh Water Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that fresh water was consistently readily accessible to residents, which is necessary to promote adequate hydration, resident preference, and comfort. This deficiency was observed in five out of 14 residents reviewed. Resident 11 expressed frustration about having to consistently ask staff for fresh drinking water, which was not routinely provided. Resident 9 reported that staff did not provide fresh drinking water every shift, and the only water she received was from her breakfast tray. Observations revealed that the water cups in the rooms of Residents 9, 12, and 13 were dated six days prior, and Resident 12's cup was out of reach. Resident 13 mentioned that he had to get water himself as no staff provided it. Resident 2 had no water cup or beverage available, despite being independent with self-feeding and drinking thin liquids. Interviews with staff confirmed the observations. Employee 1, a nurse aide, acknowledged that the water cups in the rooms of Residents 11, 12, and 13 were dated six days ago. Employee 2, an LPN, confirmed the absence of fresh water or another beverage for Resident 2. The Director of Nursing (DON) stated that the facility policy required water pass to be conducted once per shift and as needed, with straws, cups, and lids to be changed every three days. The DON and the Nursing Home Administrator (NHA) confirmed that the facility failed to adhere to this policy, resulting in the deficiency of not providing clean water drinking cups every three days and not ensuring fresh ice water was readily accessible to residents as preferred to promote adequate hydration and comfort.
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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