Kadima Rehabilitation & Nursing At Lakeside
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Pennsylvania.
- Location
- 245 Old Lake Road, Dallas, Pennsylvania 18612
- CMS Provider Number
- 395730
- Inspections on file
- 34
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Lakeside during CMS and state inspections, most recent first.
The facility did not maintain the required NA-to-resident staffing ratios on multiple reviewed shifts, as shown by weekly staffing records and staff interviews. For a census of 28 residents, the facility was required to staff specific minimum NA levels on day and evening shifts but instead scheduled fewer NAs than mandated, and no additional higher-level staff were present to offset the shortfall. The NHA acknowledged that the required NA-to-resident ratios were not met on the identified shifts.
The facility did not maintain the required LPN-to-resident staffing ratios on several shifts, as shown by a review of weekly staffing records and staff interviews. On four of twenty-one shifts reviewed, the number of LPNs on duty was below the mandated minimum based on the census, including day shifts where LPN coverage was slightly under the required level and a night shift with no LPN coverage at all. No additional higher-level nursing staff were present to offset these shortages, and the administrator acknowledged that required LPN-to-resident ratios were not met on the identified shifts.
The facility did not meet the required minimum RN-to-resident ratio on multiple night shifts, as staffing records showed that no RN was on duty while the census was between 27 and 28 residents, despite regulations requiring at least one RN per 250 residents on all shifts. The Nursing Home Administrator confirmed that the required RN coverage was not provided on these nights.
Surveyors identified multiple deficiencies in food storage and sanitation, including undated frozen food items, lack of a trash can at the handwashing station, improper closure of the dry storage exit door, damaged flooring, missing floor molding, and unsanitary storage of cleaning items in the janitor closet. The FSD confirmed these practices did not meet required standards.
Surveyors identified that three residents did not have accurate MDS assessments completed, including one with dementia who was incorrectly documented as having pneumonia, another with Parkinson's Disease whose range of motion limitations were not properly recorded, and a third with dementia whose antipsychotic medication dose reduction date was inaccurately entered. Staff interviews and record reviews confirmed the MDS inaccuracies.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences.
A resident with Parkinson's Disease, who was cognitively intact, experienced two disruptive incidents involving a family member, including one that required law enforcement intervention and led to the family member being barred from the facility. The facility did not update the resident's care plan to address or assess the resident's psychosocial needs following these events, despite policy requiring care plan revisions after significant changes.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as evidenced by surveyor findings that care was not consistent with the established care plan.
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. The current food service director is not yet certified, and the part-time registered dietitian works remotely without providing in-person oversight. The facility has been without an onsite registered dietitian since early 2024, leading to the deficiency findings.
The facility failed to conduct a comprehensive facility-wide assessment, leading to deficiencies in staffing and service provision. The assessment did not accurately reflect the current staffing situation, with key personnel such as a Director of Rehabilitation and registered dietitian absent. The facility's Resident Matrix indicated residents requiring specific services, but the necessary staff were not available to provide these services. Interviews confirmed the lack of essential rehabilitative and nutrition services, contributing to the deficiency.
The facility failed to comply with regulations requiring a designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program. The previous IP left, and the facility has not appointed a new qualified IP, as confirmed by the Nursing Home Administrator.
A resident with bilateral below-the-knee amputations was not provided with a wheelchair upon admission, preventing participation in activities and therapy. Despite a physical therapy evaluation indicating the need for anti-tipper devices on the wheelchair, the maintenance work order was not completed, leaving the resident without necessary mobility support for five days.
The facility failed to assess and monitor nutritional needs for two residents and deter weight loss for another. A resident with diabetes and dementia did not receive a timely nutritional assessment. Another resident with dysphagia and malnutrition experienced significant weight loss despite tube feeding, with no reweight or evaluation. A third resident with dysphagia and dementia had delayed weight monitoring and significant weight loss without timely notification to the physician or responsible party.
A facility failed to implement physician's orders for a resident with a PEG tube, who was admitted with dysphagia and malnutrition. The resident was to receive continuous tube feeding and dysphagia therapy to transition to a mechanical soft diet. However, there was no evidence that the ordered therapy was provided, and the resident's spouse's inquiry about decreasing tube feeding was met with the need for nutritional gains first.
The facility failed to serve meals at safe and palatable temperatures, as required by federal guidelines. Residents reported that food was frequently cold, and a test tray confirmed that hot meal items were served below the required temperature. The nursing home administrator acknowledged the deficiency.
The facility did not provide routine evening snacks to residents, resulting in a 14.25-hour gap between supper and breakfast, contrary to its policy. Residents expressed a desire for snacks, but they were not routinely offered, and some were unable to access them due to mobility issues. The Nursing Home Administrator could not explain the lack of snack provision.
Two residents did not receive prescribed occupational and speech therapy services due to the absence of key therapy staff at the facility. One resident, with bilateral below-the-knee amputations, did not receive occupational therapy, while another resident with dysphagia and other conditions did not receive continued occupational and speech therapy. The facility lacked an occupational therapist and a speech therapist, leading to the deficiency.
A resident with a history of morbid obesity and mobility issues exhibited repeated abusive behavior towards other residents, including verbal abuse and derogatory language. Despite multiple documented incidents, the facility failed to report these to the State Survey Agency, as confirmed by the NHA.
The facility failed to investigate and report multiple instances of verbal abuse by a resident, Resident M1, towards other residents. Despite documented incidents of yelling, taunting, and derogatory language, the facility did not complete investigations or submit required reports to the State Survey Agency within the mandated timeframe. The Nursing Home Administrator confirmed these failures, indicating a breach of the facility's abuse protection policy.
The facility failed to provide necessary social services following incidents of abuse by a resident with a history of verbal altercations. Despite multiple documented instances of abusive behavior, there was no evidence of social service interventions to support affected residents. Interviews confirmed the lack of assessments and interventions, indicating non-compliance with regulatory requirements for resident well-being.
A facility failed to accommodate a bariatric resident's needs by providing a wheelchair with a maximum weight capacity of 500 pounds, despite the resident weighing 528.6 pounds. The issue was not addressed since the resident exceeded the weight limit in February, as confirmed by the NHA.
A facility failed to refund a resident's personal funds within 30 days of their discharge or death due to departmental miscommunications. The resident's financial account showed a credit balance, but the refund was delayed, violating state regulations on resident rights.
Failure to Maintain Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet required nurse aide (NA) to resident staffing ratios on three of twenty-one reviewed shifts, as identified through a review of weekly staffing records and staff interviews. State regulations effective July 1, 2024, require a minimum of 1 NA per 10 residents on the day shift, 1 NA per 11 residents on the evening shift, and 1 NA per 15 residents on the night shift. For a census of 28 residents, the facility was required to staff 2.8 NAs on the day shift and 2.55 NAs on the evening shift. On one evening shift, the facility staffed 2.13 NAs instead of the required 2.55, and on a separate day shift, the facility staffed 2.53 NAs instead of the required 2.8. On another evening shift, the facility again staffed 2.13 NAs instead of 2.55. The records also showed that there were no additional higher-level staff available on those dates to compensate for the NA shortfalls. In an interview, the Nursing Home Administrator confirmed that the facility did not meet the required NA-to-resident ratios on the identified dates. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency is based solely on staffing levels compared to regulatory requirements for the facility’s census.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to CNAS for 3 shifts. 2.A facility wide audit was completed to ensure ratios were met. CNA sign on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Failure to Maintain Required LPN-to-Resident Staffing Ratios on Multiple Shifts
Penalty
Summary
The facility failed to meet state-required LPN-to-resident staffing ratios on multiple shifts, as identified through review of weekly staffing records and staff interviews. On four of twenty-one shifts reviewed, the number of LPNs scheduled and working did not meet the minimum required ratios of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility’s census. Specifically, on April 8, 2026, the day shift had 1.02 LPNs instead of the required 1.08 for a census of 27 residents. On April 10, 2026, the day shift had 1.03 LPNs instead of the required 1.12 for a census of 28 residents, and the night shift had 0.00 LPNs instead of the required 1.00 for the same census. On April 12, 2026, the day shift had 1.00 LPN instead of the required 1.12 for a census of 28 residents. On these dates, there were no additional higher-level staff available to compensate for the LPN shortfall. In an interview on April 14, 2026, at 2:00 PM, the nursing home administrator confirmed that the facility had not met the required LPN-to-resident ratios on the identified dates. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency is based solely on staffing levels relative to the resident census and regulatory requirements.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to LPNs for 4 shifts. 2.A facility wide audit was completed to ensure ratios were met. LPN sign on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Failure to Provide Required RN Coverage on Night Shifts
Penalty
Summary
The facility failed to meet the regulatory requirement, effective July 1, 2023, to provide a minimum of one RN per 250 residents on all shifts, as evidenced by staffing records and staff interview. A review of the weekly staffing records showed that on four separate night shifts, when the facility census ranged from 27 to 28 residents, there were no RNs scheduled or present, despite the requirement for at least one RN on duty. Specifically, on four identified nights, the RN count was zero against the required minimum of one RN for the existing census. During an interview on April 14, 2026, at 2:00 PM, the Nursing Home Administrator confirmed that the facility did not meet the required RN-to-resident ratio on those dates and shifts. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were documented in the report.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to RNS for 4 shifts. 2.A facility wide audit was completed to ensure ratios were met. RN on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Deficient Food Storage and Sanitation Practices in Dietary Department
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness in the food and nutrition services department. During an initial tour of the dietary department, surveyors observed that the handwashing area lacked a trash can for disposing of paper towels after handwashing. In the freezer, four bags of frozen vegetables and one bag of tater tots were found on the shelf without any date markings. In the dry storage room, the exit door to the outside could not close properly because the metal locking latch was folded back in the door jam, and the floor area in front of the door was worn, soiled, and had cracked floor tiles. Additionally, a six-inch piece of floor molding was missing from the wall near the exit door. Further observation in the janitor closet within the dietary department revealed a sink containing a plastic bin filled with microfiber cloths, aprons, and a container of cleaning wipes. The food service director confirmed at the time of the observations that the dietary department should be maintained in a sanitary manner, and that all food items should be properly dated to ensure safety and quality. These findings indicate that the facility did not follow acceptable practices for food storage and sanitation, as required by professional standards and state regulations.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with dementia, the quarterly MDS inaccurately documented pneumonia in the infection section, despite no evidence in the clinical record that the resident had pneumonia during the seven-day look-back period. The Registered Nurse Assessment Coordinator (RNAC) confirmed the inaccuracy. For another resident with Parkinson's Disease, the initial MDS indicated no impairment in range of motion, while occupational therapy documentation identified functional limitations and a goal to increase shoulder flexion. Observation revealed joint deformities in both hands, and the resident expressed a need for adaptive devices to eat. The RNAC and Director of Rehabilitation could not confirm the accuracy of the MDS coding and entered a correction during the survey. A third resident with moderate dementia and agitation had a quarterly MDS assessment that documented a gradual dose reduction of antipsychotic medication on a specific date. However, physician orders and nursing documentation showed the dose reduction occurred earlier, and the RNAC could not confirm the accuracy of the MDS coding. The Director of Nursing was also unable to provide documentation supporting the accuracy of the MDS for two of the residents. These findings were based on clinical record reviews, resident observations, and staff interviews.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to ensure the resident's readiness and safety during the transition were not followed, resulting in a deficiency related to the transfer/discharge process.
Failure to Update Care Plan After Psychosocial Incident Involving Family Member
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with Parkinson's Disease, despite significant psychosocial events involving the resident's son. The resident, who was cognitively intact as indicated by a BIMS score of 13, experienced two incidents where his son displayed disruptive and hostile behaviors, including verbal aggression and vulgar language toward staff in the resident's presence. On one occasion, law enforcement was required to intervene, resulting in the son being handcuffed and removed from the facility, after which he was prohibited from entering the building. Despite these events, a review of the resident's care plan revealed no evidence that the resident's psychosocial well-being had been evaluated or addressed in relation to the incidents or the subsequent restriction of his son's visitation. Interviews with the Social Worker and the Director of Nursing confirmed that the care plan was not updated to include ongoing assessment of psychosocial needs or related goals following these incidents. This failure was not consistent with the facility's policy, which requires individualized care plans to be revised as information about the resident and their condition changes.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established care plan or the expressed wishes and clinical needs of the resident involved.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian, as required by federal regulatory guidance. The current food service director (FSD), who has been in the position since March 8, 2024, is not yet a certified dietary manager but is enrolled in a class to become one. The facility has a part-time registered dietitian who works remotely and does not provide in-person oversight to the department. Additionally, a regional certified dietary manager provides some oversight support. The facility's assessment indicated the need for two dietitians or other qualified nutrition professionals to serve as the director of food and nutrition services. The facility has been without an onsite registered dietitian since January 5, 2024, and without a full-time qualified director of food and nutrition services since March 8, 2024. The nursing home administrator confirmed these staffing deficiencies and acknowledged that the part-time registered dietitian does not provide in-person oversight or consultation. The lack of a full-time qualified director and the absence of frequent consultations from a qualified dietitian or other clinically qualified nutrition professional led to the deficiency findings.
Facility-Wide Assessment and Staffing Deficiencies
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that accurately reflected the specific resources necessary to care for its resident population. The assessment did not evaluate the diseases, conditions, and limitations of the residents, nor did it inform staffing decisions or the competencies required by staff to deliver necessary care. The facility's assessment, last reviewed on September 30, 2024, did not accurately reflect the current staffing situation, as it failed to account for the absence of key personnel such as a Director of Rehabilitation, Speech Therapist, Occupational Therapist, and Occupational Therapy Assistant. Additionally, the facility has been without an onsite registered dietitian since January 5, 2024, with the current part-time dietitian working remotely without face-to-face interaction with residents. The facility's Resident Matrix indicated a census of 26 residents, including one resident requiring enteral feeding and two new residents needing rehabilitation services. However, the facility lacked the necessary staff to provide these services as outlined in their assessment. Interviews with the Nursing Home Administrator confirmed the absence of essential rehabilitative and nutrition services, which were supposed to be provided according to the facility's assessment. The Food Service Director, who is not yet a certified dietary manager, also highlighted the lack of oversight in the nutrition services department, further contributing to the deficiency.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility was found to be non-compliant with the Centers for Medicare and Medicaid Services regulation S483.80(b)(3), which requires the designation of one or more individuals as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program. The regulation mandates that the IP must work at least part-time onsite at the facility and have primary professional training in relevant fields such as nursing, medical technology, microbiology, or epidemiology. During an interview with the Nursing Home Administrator (NHA), it was confirmed that the facility did not have a designated IP since the previous IP left on October 17, 2024. Additionally, the NHA acknowledged that there was no qualified staff member currently credentialed as an IP at the facility.
Failure to Provide Wheelchair Accommodation for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident, identified as Resident 180, who required safe wheelchair equipment. Resident 180 was admitted with bilateral below-the-knee amputations, diabetes, peripheral vascular disease, and a history of falls. The care plan indicated the need for assistance with mobility and transfers, including the use of a mechanical full-body lift. Despite these needs, the resident reported not having been out of bed since admission due to the lack of a wheelchair, which prevented participation in activities, dining, and therapy. The deficiency was further highlighted by the absence of a wheelchair or specialized seating equipment in the resident's room. Interviews with staff revealed that a physical therapy evaluation determined the need for front and rear anti-tipper devices on the wheelchair to ensure stability. Although a maintenance work order was submitted, it was not completed, and the resident remained without a wheelchair for five days. The Director of Nursing confirmed that the facility did not provide the necessary accommodations in a timely manner, as the maintenance staff had not been present to fulfill the work order until after surveyor inquiry.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to assess, evaluate, and monitor nutritional parameters and develop and implement individualized nutritional interventions for two residents, and deter weight loss for another resident. Resident 1 was admitted with diagnoses including diabetes and dementia, but there was no documented evidence of a nutritional assessment completed within 72 hours of admission. This lack of timely assessment meant that individualized nutritional goals were not established for Resident 1. Resident 22, who was admitted with dysphagia and malnutrition, required a feeding tube for nutritional support. Despite having a physician order for continuous tube feeding and water flushes, Resident 22 experienced significant weight loss of 10.5% over 24 days. There was no evidence of a reweight upon admission or after the significant weight loss, nor was there documentation that the resident's nutritional requirements were evaluated or that the physician and family were informed of the weight loss. Resident 17, who had dysphagia and dementia, was readmitted to the facility but did not have a weight obtained upon readmission. The resident experienced an 8.6% weight loss over 50 days, and a reweight was delayed. Although a dietary note later identified the significant weight loss and recommended health shakes, there was no evidence that the physician or responsible party was notified. The facility's failure to timely identify and address Resident 17's weight loss was confirmed by the Nursing Home Administrator.
Failure to Implement Physician's Orders for Resident with Feeding Tube
Penalty
Summary
The facility failed to implement physician's orders and provide appropriate treatment and services to a resident with a feeding tube. Resident 22, who was admitted with diagnoses including dysphagia, surgical aftercare following surgery for a ruptured appendix, and malnutrition, had a PEG tube placed during hospitalization. The physician ordered a continuous tube feeding of Osmolite 1.5 Cal at 55 ccs per hour with 200 ccs of sterile water every four hours for hydration, along with a puree diet with thin liquids. Additionally, dysphagia therapy was ordered to be provided 3 to 5 times a week for 4 weeks to help the resident transition to a mechanical soft diet. However, the facility did not provide evidence that the ordered dysphagia therapy was administered to advance the resident's diet. Despite the resident's spouse inquiring about decreasing the tube feeding, the physician indicated that nutritional gains were necessary before considering such a change. An interview with the Nursing Home Administrator confirmed the lack of evidence for the provision of treatment and services aimed at restoring oral eating skills for the resident receiving tube feeding.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve meals at safe and palatable temperatures, as required by federal regulatory guidance. According to the facility's Food Temperature Recording Policy, hot foods should be served and held at or above 135 degrees Fahrenheit, while cold foods should be held and served at or below 41 degrees Fahrenheit. However, during a group interview with seven alert and oriented residents, all participants reported that food temperatures were frequently cold. One resident expressed a desire for meals to be at least warm, indicating dissatisfaction with the current food service. A test tray conducted on the Nursing Unit revealed that the hot meal items, including Swedish meatballs, mashed potatoes, mixed vegetables, and coffee, were served at temperatures significantly below the required 135 degrees Fahrenheit. Specifically, the Swedish meatballs and mashed potatoes were at 115 degrees Fahrenheit, mixed vegetables at 105 degrees Fahrenheit, and coffee at 107 degrees Fahrenheit. These temperatures were confirmed to be cold and not palatable, as acknowledged by the nursing home administrator. This deficiency was documented under F801.
Failure to Provide Routine Evening Snacks
Penalty
Summary
The facility failed to ensure the provision of a nourishing evening snack when more than 14 hours elapsed between the supper meal and breakfast the next day for several residents. The facility's policy, last reviewed in February 2024, mandates that there should not be more than a 14-hour span between the evening meal and breakfast unless a nourishing bedtime snack is provided. However, the scheduled mealtimes revealed a 14.25-hour gap between the evening meal and the next day's breakfast. Interviews with residents indicated that snacks were not routinely offered in the evenings, and some residents had to rely on family members to bring them food. During interviews, several residents expressed that they would like to receive an evening or bedtime snack, but these were not routinely offered. One resident mentioned that snacks were available at the nurse's station, but not all residents were able to access them, especially those who could not self-propel their wheelchairs. The Nursing Home Administrator was unable to explain why the residents were not routinely offered and provided with a bedtime snack, indicating a lapse in adherence to the facility's policy and resident care needs.
Failure to Provide Specialized Therapy Services
Penalty
Summary
The facility failed to provide specialized occupational therapy and speech therapy services according to professional standards of practice for two residents. Resident 180, admitted with diagnoses including bilateral below-the-knee amputations and a history of falls, did not receive occupational therapy services as the facility lacked an occupational therapist. Despite a physician's order for occupational therapy, the resident reported not receiving therapy and had not been out of bed since admission. Interviews with staff confirmed the absence of an occupational therapist and a speech therapist at the facility. Resident 22, admitted with conditions such as peritonitis and dysphagia, also did not receive the prescribed occupational and speech therapy services. Although initial evaluations were conducted, there was no documented evidence of continued therapy sessions. The resident's care plan included orders for therapy to address functional decline and swallowing difficulties, but the facility failed to provide these services as prescribed. Interviews with the Nursing Home Administrator confirmed the facility's failure to adhere to its admission agreement and assessment, resulting in the lack of specialized therapy services for both residents. The absence of key therapy staff contributed to the deficiency, as the facility had not had a speech therapist since early November and an occupational therapist since shortly thereafter.
Failure to Report Resident Abuse by a Resident
Penalty
Summary
The facility failed to report multiple instances of resident abuse perpetrated by Resident M1 to the State Survey Agency, as required by their abuse prohibition policy. The policy mandates that any accident or incident, regardless of severity, must be reported to the department supervisor immediately, followed by an investigation and completion of an accident or incident form. However, despite several documented incidents of verbal abuse and aggressive behavior by Resident M1 towards other residents, these were not reported to the appropriate state authorities. Resident M1, who was admitted with diagnoses including morbid obesity, GERD, and mobility issues, exhibited a pattern of abusive behavior. Incidents included yelling at and mocking other residents, using derogatory language, and engaging in loud and argumentative behavior. These behaviors were documented in nursing and behavior notes over several months, yet the facility did not fulfill its obligation to report these incidents to the State Survey Agency. The Nursing Home Administrator confirmed the failure to report during an interview.
Failure to Investigate and Report Resident Abuse
Penalty
Summary
The facility failed to investigate and report multiple instances of resident abuse perpetrated by Resident M1. The facility's policy on abuse protection mandates that all incidents, regardless of severity, must be investigated, and findings reported to the State Survey Agency within five working days. However, the facility did not adhere to this policy. Resident M1, who has diagnoses including morbid obesity, GERD, and mobility issues, was involved in several incidents of verbal abuse towards other residents. These incidents were documented in nursing and behavior notes, detailing instances where Resident M1 yelled, taunted, and used derogatory language towards other residents, causing distress and disruption. Despite the documentation of these incidents, the facility did not provide evidence of completed investigations or submission of the required PB-22 forms to the State Survey Agency within the stipulated timeframe. The Nursing Home Administrator confirmed the failure to investigate and report these incidents as required. The deficiency highlights a significant lapse in the facility's responsibility to protect residents from abuse and comply with state regulations.
Failure to Provide Social Services After Resident Abuse
Penalty
Summary
The facility failed to provide necessary therapeutic social services to assess and address the psychosocial needs of residents following incidents of abuse by Resident M1. The regulatory guidance under S483.40(d) requires facilities to provide or arrange for mental and psychosocial counseling services and to identify non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. However, the facility did not adhere to these guidelines in the case of Resident M1, who was involved in multiple incidents of verbal abuse and altercations with other residents. Resident M1, who was admitted with diagnoses including morbid obesity, GERD, and mobility issues, was documented in several instances of abusive behavior towards other residents. These incidents included yelling, taunting, and using derogatory language, which caused distress among other residents. Despite these repeated occurrences, there was no documented evidence of the facility's efforts to identify the affected residents or provide supportive social service interventions to assist them in coping with the abuse. Interviews with the Director of Social Services and the Nursing Home Administrator confirmed the lack of documented social service assessments and interventions following the episodes of abuse by Resident M1. This deficiency highlights the facility's failure to comply with the regulatory requirements to maintain the mental and psychosocial well-being of its residents, as outlined in the relevant state codes and federal regulations.
Failure to Provide Appropriate Wheelchair for Bariatric Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a bariatric resident, identified as Resident M1, who required safe wheelchair equipment. Resident M1 was admitted with diagnoses including morbid obesity and polyosteoarthritis, and weighed 528.6 pounds as of May 13, 2024. During a facility tour on May 16, 2024, Resident M1 was observed using a bariatric wheelchair with a maximum weight capacity of 500 pounds, which was insufficient for the resident's weight. The resident had exceeded the wheelchair's weight capacity since February 8, 2024, when they weighed 508.2 pounds. The facility was unable to provide documented evidence that the weight capacity issue of the wheelchair had been identified and addressed. An interview with the Nursing Home Administrator confirmed that the resident's weight exceeded the wheelchair's maximum capacity, and the facility had not provided appropriate wheelchair equipment to meet the needs of the bariatric resident. This deficiency was noted under 28 Pa. Code 205.75 Supplies.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to return the personal funds of a resident within 30 days of their discharge or death, as required by regulations. The clinical record review showed that the resident was admitted to the facility and later expired. A financial account statement revealed a credit balance of $9,520, which was later adjusted to $6,584. However, the refund was not issued due to miscommunications within the facility's departments. This was confirmed by a letter from the Principal of the organization and an interview with the Nursing Home Administrator, who acknowledged that the funds were not refunded to the resident's family within the stipulated time frame. The deficiency was identified during a review of clinical records, financial account records, and staff interviews, highlighting a lapse in the facility's management of resident funds. The failure to refund the resident's personal funds within the required timeframe was a violation of the resident's rights as per the applicable state codes.
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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