Pennypack Rehab And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 8015 Lawndale Avenue, Philadelphia, Pennsylvania 19111
- CMS Provider Number
- 395135
- Inspections on file
- 27
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Pennypack Rehab And Care Center during CMS and state inspections, most recent first.
A resident's personal funds were not properly accounted for, as required by facility policy. The business office manager and administrator confirmed there was no documentation or record of financial transactions for the resident, despite the facility accepting responsibility for managing the resident's funds. Both staff members were also unaware of the sources of payment scheduled for the resident's account.
A resident with multiple medical conditions experienced two falls, but nursing staff did not assess, monitor, or document the incidents as required by facility policy. No vital signs were recorded, no clinical notes were made, and the physician was not notified until days later. This deficiency was confirmed through staff interviews and record review.
A resident was not informed of the services available or the charges for those services, including costs not covered by Medicare or Medicaid, at admission or during their stay. The admission agreement lacked required rate information, and no documentation was provided to the resident regarding service charges.
Surveyors found that multiple opened food items in the dietary department were not properly labeled with both an open date and a use by date, as required by facility policy. The Food Service Director confirmed that these labeling practices were not followed, resulting in a deficiency related to food storage and safety standards.
A resident with diabetes, hypertension, a pressure ulcer, and heart failure reported that a nurse aide caused pain to a pressure ulcer and delayed care. The facility's investigation was incomplete, as the accused aide was not questioned about the specific allegations and four additional staff present during the shift were not interviewed.
A resident admitted for short-term rehabilitation and later discharged home did not have a required discharge MDS assessment completed, as confirmed by the DON and review of clinical records and facility policy.
A resident admitted with severe protein calorie malnutrition did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. The absence of this care plan, specifically addressing nutrition and weight status, was confirmed by the facility dietician and was not rectified until a comprehensive care plan was created several days later.
A licensed nurse administered a lidocaine 4% patch to a resident instead of the prescribed 5% patch due to unavailability of the correct strength in the medication cart and lack of knowledge on how to obtain it, resulting in failure to follow physician orders during medication administration.
A resident receiving enteral nutrition did not have their tube feeding supplies properly labeled with dates, and the recommended increase in tube feeding rate by the dietician was not implemented. The dietician communicated the recommendation to the DON, but the order was not entered or followed, and water flushes were not set at the correct rate as ordered.
A resident with COPD was observed receiving oxygen at 2 L/min via nasal cannula, despite a physician's order for 3 L/min every shift for SOB. The resident was unaware of the incorrect setting, and a nurse confirmed the discrepancy before adjusting the flow to the ordered rate.
A resident with cancer, heart failure, renal failure, and dementia did not have any documented physician or practitioner visits for several months, with the last recorded visit occurring many months prior. The DON confirmed the absence of required physician documentation in the clinical record.
A container of unlabeled and undated food was found stored in a medication room refrigerator alongside vaccines. An LPN present was unable to identify the owner or the date the food was placed there, which was not in accordance with facility policies requiring proper labeling and separation of personal food items from medications.
The facility did not meet the required nurse aide to resident ratios during several shifts, as evidenced by a review of nursing schedules and confirmed by the Administrator and DON. The shortfall in nurse aide service hours occurred on multiple days and shifts, failing to provide the minimum required care for the resident census.
The facility did not meet the required LPN staffing ratios on the day shift for three consecutive days. On these days, the facility provided fewer LPN service hours than required for the resident census, as confirmed by the Administrator and DON.
The facility did not meet the required RN staffing ratios during overnight shifts for five consecutive nights. The facility provided significantly fewer RN service hours than the required 8 hours per shift, with a resident census ranging from 48 to 50. This deficiency was confirmed by the Administrator and DON.
A newly admitted resident with a complex medical history, including cerebral edema and seizure disorder, experienced a significant medication error when the facility failed to transcribe Depakote into their Medication Administration Record as per hospital discharge instructions. The error was confirmed by the Interim DON.
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for two residents. One resident was transferred due to severe abdominal pain and acute kidney failure, while another was transferred following a change in condition after joint replacement. The Nursing Administrator confirmed the lack of written notices for these transfers.
The facility failed to maintain an effective infection control program, as observed in the handling and storage of soiled and clean linens. Dirty hospital gowns were stored outside in large containers, and the laundry room was congested with insufficient separation of clean and soiled items. Additionally, clean linens were stored in racks without doors in shower rooms, alongside soiled linens in plastic bags, leading to potential contamination.
A facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident before the termination of Medicare A services. The resident's last covered day was in late June, but the NOMNC was not provided until mid-July, contrary to the facility's policy requiring notice at least two days prior to service termination. This was confirmed by the Nursing Home Administrator.
A deficiency was identified in the improper completion of the PASRR for a resident with multiple mental health disorders, including Major Depressive Disorder and Schizoaffective Disorder. The PASRR Level I form did not correctly indicate outcomes related to chronic disability, as confirmed by the DON.
A resident with multiple diagnoses, including dementia and lack of coordination, fell and sustained a hematoma. Despite a high fall risk score upon readmission, the resident's fall prevention care plan was not updated. The DON confirmed the care plan was not revised, violating several regulations.
A resident with severe cognitive impairment and multiple medical conditions, including pressure ulcers, did not receive adequate pain management. Despite being on a scheduled pain medication regimen, the resident frequently experienced severe pain, with levels documented as very strong to the worst possible. The facility failed to monitor and assess the effectiveness of the pain medication, and there was no evidence of appropriate response to the resident's severe pain prior to a change in medication.
The facility experienced a medication error rate of 11.54%, exceeding the acceptable threshold. Errors included administering the wrong form of Aspirin, incorrect dosage of Calcium with Vitamin D, and preparing to give Senna Plus instead of the prescribed Senna. These errors were confirmed by the LPNs involved.
A facility failed to implement its abuse policy when a resident reported being harmed by a nurse aide. The incident was not immediately reported to the appropriate authorities, and the nurse aide continued to work in the same area as the resident. Interviews revealed a lack of clear communication and proper reporting, resulting in a delay in addressing the resident's injury.
A resident reported that a CNA pushed her wheelchair into her bed, causing injury. Despite the resident's complaint and visible bruising, the incident was not immediately reported to the administrator or other required officials. The delay in reporting and investigating the incident was evident as the Director of Nursing only became aware of the situation the following day when she found a witness statement on her desk and initiated an investigation.
Failure to Maintain Resident Personal Funds Accounting
Penalty
Summary
The facility failed to maintain separate accounting and records for a resident's personal funds that were entrusted to the facility. According to the facility's policy, the business office manager was responsible for keeping detailed accounting records for each resident's personal needs account, including the date of admission, all deposits and withdrawals, the names of individuals involved in transactions, and receipts for charges and interest earned. However, for one resident who was admitted after a hospital stay for a cerebral vascular accident, right arm weakness, and atrial fibrillation, and who was cognitively intact, there was no documentation available to show that a personal funds account was established or maintained in accordance with generally accepted accounting principles. Interviews with the administrator and business office manager confirmed that the facility had no records of accounting or financial transactions for this resident's funds, despite having accepted responsibility for managing the resident's financial affairs. Additionally, both staff members were unaware of what insurances, pensions, or private pay funds were scheduled to be deposited into the resident's account to pay for their stay. This lack of documentation and awareness was identified through interviews, review of clinical records, and examination of the facility's policies and procedures.
Failure to Assess and Monitor Resident After Falls
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and monitored following two fall incidents. According to the facility's policy, staff are required to evaluate residents for possible injuries, record vital signs, notify the physician, and document any observed symptoms after a fall. However, after a resident with dementia, anxiety, mild intellectual disabilities, lack of coordination, and dysphagia experienced two falls, there was no evidence in the clinical record that nursing staff performed any assessments or documented the incidents. The nursing supervisor who discovered the resident on the floor did not complete an assessment, stating it was the responsibility of the next shift. The licensed nurse on the following shift also did not perform or document any assessment after witnessing the resident slide off the chair and fall again shortly after. Additionally, there was no documentation that the resident's physician was notified of either fall at the time they occurred. The physician confirmed that notification was not received until several days later, despite facility policy requiring timely notification. The lack of assessment, documentation, and physician notification following the falls was confirmed through staff interviews, review of clinical records, and facility documents.
Failure to Inform Resident of Service Charges and Coverage
Penalty
Summary
The facility failed to inform a resident, at the time of admission and during their stay, about the services available and the charges for those services, including any charges for services not covered under Medicare or Medicaid. Review of the clinical record and admission agreement for the resident showed that the section detailing charges for services not covered was left blank, and no documentation was provided to the resident regarding available services and associated costs. An interview with the business office manager confirmed that the rate information should have been provided to the resident upon admission, but this was not done.
Failure to Properly Label and Date Opened Food Items in Dietary Department
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the dietary department, surveyors observed multiple food items that had been opened but were not properly labeled with both an open date and a use by date, as required by the facility's Food Storage Policy. Specifically, bags of frozen green beans and carrots, a pack of frozen hamburgers, a gallon of milk, a container of Italian dressing, and a container of soy sauce were all found either missing a use by date or, in the case of the soy sauce, missing both an open date and a use by date. The Food Service Director confirmed during the tour that all food items should display both the date they were opened and a use by date, in accordance with facility policy. The lack of proper labeling and dating of these food items constituted a failure to follow established procedures for food safety and storage, as outlined in the facility's own policy and professional standards.
Incomplete Investigation of Abuse/Neglect Allegation
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of potential abuse/neglect involving a resident with multiple medical conditions, including diabetes, hypertension, a pressure ulcer on the left hip, and heart failure. The resident reported that a nurse aide shoved a bed pan under him, causing severe pain to his pressure ulcer, and delayed providing care after the resident had a bowel movement. The incident was reported to the State Survey Agency, and the facility initiated an investigation. However, the investigation was incomplete. The statement obtained from the accused nurse aide did not address the specific allegations made by the resident, and there was no evidence that the facility questioned the aide about the incident. Additionally, although two licensed nurses provided witness statements, four other staff members who were present during the shift were not interviewed, and there was no documentation of their input. The lack of comprehensive staff interviews and failure to address the resident's specific allegations resulted in an incomplete investigation.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a required discharge Minimum Data Set (MDS) assessment for one resident who was admitted for short-term rehabilitation and subsequently discharged home. According to the facility's policy, the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments by the interdisciplinary team. Clinical record review showed that the resident was discharged, but no discharge MDS assessment was found in the records. This was confirmed during an interview with the Director of Nursing, who acknowledged that the discharge MDS had not been completed for the resident.
Failure to Develop Baseline Care Plan for New Admission with Malnutrition
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one newly admitted resident diagnosed with severe protein calorie malnutrition. According to facility policy, a baseline care plan must be created within 48 hours to address the resident's immediate health and safety needs, including initial goals, physician orders, and dietary orders. Review of the clinical record for this resident showed no documented evidence of a baseline care plan addressing the resident's nutritional status and weight until several days after admission, when a comprehensive care plan was eventually developed. The absence of a baseline care plan was confirmed during an interview with the facility dietician, who acknowledged that no such plan was in place for the resident's nutrition. The deficiency was cited under 28 Pa Code 211.10(c) Resident care policies and 28 Pa Code 211.12(d)(5) Nursing services, as the facility did not follow its own policy or regulatory requirements for timely care planning upon admission.
Failure to Administer Medication as Ordered by Physician
Penalty
Summary
A deficiency occurred when a licensed nurse administered a lidocaine 4% patch to a resident's left shoulder during the morning medication pass, despite the physician's order specifying a lidocaine 5% patch. The nurse prepared and applied the 4% patch because only that strength was available in the medication cart and was unaware of where to obtain the correct 5% patch. Facility policy requires medications to be administered in accordance with prescriber orders, but this was not followed in this instance. The nurse confirmed the discrepancy during an interview, acknowledging the administration of the incorrect medication strength.
Failure to Implement Dietician Recommendations and Properly Label Enteral Feeding Supplies
Penalty
Summary
The facility failed to ensure appropriate enteral feeding practices for a resident receiving tube feedings. Observations revealed that the resident's Glucerna 1.5 tube feeding was infusing via a pump, but the bottle was not labeled with the date it was opened, and the water flush bag lacked both a name and date label. A licensed nurse was unaware of when the Glucerna bottle was opened, as it was already infusing at the start of her shift. Additionally, the water flushes were not set at the correct rate as ordered by the physician. Review of the clinical record showed that the registered dietician had recommended an increase in the tube feeding rate due to the resident's weight loss, but this recommendation was not implemented. The dietician stated she communicated her recommendations to the Director of Nursing, who was responsible for entering the order, but was unaware that the changes had not been made. The facility's policy required that recommendations from the dietician be communicated and followed up with appropriate documentation, which did not occur in this instance.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of chronic obstructive pulmonary disease (COPD) did not receive supplemental oxygen as ordered by the physician. The physician's order specified that the resident should receive oxygen at 3 liters per minute via nasal cannula every shift for shortness of breath. However, during an observation, the resident was found with the oxygen concentrator set at 2 liters per minute instead of the prescribed 3 liters per minute. The resident was unaware that the oxygen flow was set incorrectly and did not know who had adjusted it. A licensed nurse confirmed the physician's order for 3 liters per minute and, upon joint observation, verified that the concentrator was set at 2 liters per minute before adjusting it to the correct setting. This failure to administer oxygen at the prescribed rate constituted a deviation from both the physician's order and the facility's policy on oxygen administration.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident received required physician visits as mandated. Clinical record reviews and staff interviews revealed that a resident with multiple diagnoses, including cancer, heart failure, renal failure, and dementia, had not been seen by a physician or practitioner for an extended period. Specifically, there were no physician or practitioner notes in the resident's clinical record from November 2024 through June 2025, and the last documented physician visit occurred in August 2024. The Director of Nursing confirmed the absence of any physician or practitioner notes for this resident during the specified timeframe.
Unlabeled Food Stored with Vaccines in Medication Room Refrigerator
Penalty
Summary
A deficiency was identified when a container of food, which was neither labeled nor dated, was found stored in a refrigerator within the A/B wing medication storage room that also contained vaccines. This observation was made during a facility tour with a licensed nurse, who confirmed that she did not know the owner of the food or when it had been placed there. Review of facility policies revealed that medications are to be stored separately from food and that any food brought by family or visitors for residents must be labeled and stored in a manner that distinguishes it from facility-prepared food. The presence of unlabeled and undated food in a medication room refrigerator was not in accordance with these policies.
Facility Fails to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios as required by regulations effective July 1, 2023. Specifically, the facility did not have the required number of nurse aides per residents during various shifts from March 6, 2025, to March 10, 2025. On the day shift, the facility was short of the required nurse aide hours on March 7, March 8, and March 9, 2025. Similarly, the evening shift was understaffed on March 7 and March 9, 2025. The overnight shift also did not meet the required staffing levels on March 6 and March 8, 2025. The deficiency was confirmed through a review of nursing schedules and an interview with the Administrator and Director of Nursing on March 19, 2025. The facility's failure to meet the staffing requirements was evident in the shortfall of nurse aide service hours compared to the minimum required hours for the resident census on the specified dates. This lack of adequate staffing was acknowledged by the facility's administration during the interview.
Plan Of Correction
1. The facility reviewed the CNA ratios from March 6, 2025 through March 10, 2025. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on CNA ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to ensure ratios are met. 4. DON/designee will conduct daily audits to verify CNA ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios for Licensed Practical Nurses (LPNs) on the day shift for three consecutive days. Specifically, on March 8, 2025, the facility provided only 15.50 hours of LPN service for a census of 49 residents, falling short of the required 15.68 hours. On March 9, 2025, the facility provided 15.73 hours of LPN service for a census of 50 residents, below the required 16.00 hours. Similarly, on March 10, 2025, the facility again provided only 15.68 hours of LPN service for a census of 50 residents, not meeting the required 16.00 hours. This deficiency was confirmed in an interview with the Administrator and Director of Nursing on March 19, 2025.
Plan Of Correction
1. The facility reviewed the LPN ratios for March 8th, 9th, and 10th. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on LPN ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to ensure ratios are met. 4. DON/designee will conduct daily audits to verify LPN ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.
Failure to Meet RN Staffing Ratios on Overnight Shifts
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios of one Registered Nurse (RN) per 250 residents during the overnight shift for five consecutive nights from March 6, 2025, to March 10, 2025. A review of the nursing schedules revealed that on these dates, the facility provided significantly fewer RN service hours than the required 8 hours per shift, despite having a resident census ranging from 48 to 50. Specifically, the facility provided only 1.59 hours on March 6, 0.83 hours on March 7, 0.75 hours on March 8, 1.13 hours on March 9, and 0.90 hours on March 10. This deficiency was confirmed in an interview with the Administrator and Director of Nursing on March 19, 2025.
Plan Of Correction
1. The facility reviewed the RN ratios from March 6, 2025 through March 10, 2025. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on RN ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to add an LPN in place of the RN due to the waiver related to our building size to ensure ratios are met. 4. DON/designee will conduct daily audits to verify nursing ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.
Failure to Transcribe Medication Orders for New Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident was free from significant medication errors. Upon admission, the facility's policy required the admitting nurse to review the transfer record and notify the attending physician to review the admission medications. However, for one resident, this process was not followed correctly. The resident, who was admitted for skilled nursing care following a hospital discharge, had a list of prescribed medications that included Depakote 500 milligrams to be taken every 12 hours. Despite the hospital discharge summary indicating this medication, it was not transcribed into the resident's orders and Medication Administration Record as per physician instructions. The resident's medical history included cerebral edema, pulmonary embolism, diabetes, seizure disorder, and Cushing's syndrome. The error was confirmed during an interview with the Interim Director of Nursing, who acknowledged the transcription error. This oversight in medication management led to a significant medication error, as the prescribed Depakote was not administered according to the hospital's discharge instructions.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the representative of the Office of the State Long Term Care Ombudsman regarding the transfer of two residents to the hospital. Resident R2, who was admitted with neuromuscular dysfunction of the bladder and an infection due to an indwelling urethral catheter, was transferred to the hospital on two occasions: once for severe abdominal pain and blood in the urine, and later for acute kidney failure. Resident R36, admitted for aftercare following a joint replacement, was transferred to the hospital due to a change in condition. The Nursing Administrator confirmed that no written notices of these hospital transfers were provided to the Ombudsman for either resident. This deficiency was identified through a clinical record review and staff interview, revealing a failure to comply with the requirement to notify the Ombudsman of resident transfers, as mandated by 28 Pa. Code 201.29(h) regarding resident rights.
Inadequate Infection Control in Laundry and Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection control program concerning the handling of soiled and clean linens. Observations revealed that the facility's outside dumpster area contained large blue containers filled with dirty hospital gowns, which were waiting to be picked up by a laundry service. The laundry room, located in the basement, was accessible through a dusty and stained wooden staircase. The room was congested with various items, including clean and soiled clothing, housekeeping supplies, and mop heads, which were not sufficiently separated. The floor was dirty with black sticky particles, peeled paint, and rusted metal parts, and there was no clear designated area for soiled and clean items, leading to potential contamination. Further observations in the facility revealed that clean linens were stored in racks without doors, covered only by drapes, in shower rooms near resident rooms B6 and A10. Soiled linens were stored in the same shower rooms in plastic bags. These findings were confirmed with the Housekeeping Director, indicating a lack of proper separation and storage of clean and soiled linens, which is crucial for preventing contamination and maintaining an effective infection control program.
Failure to Timely Issue NOMNC
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident, identified as Resident R25, prior to the termination of Medicare A services. According to the facility's policy, a NOMNC should be issued at least two calendar days before the end of Medicare-covered services. Resident R25 was admitted with Medicare insurance for skilled nursing care, and their last covered day of Part A service was June 28, 2024. However, the NOMNC was not issued until July 17, 2024, which was after the termination of services. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to issue the NOMNC in a timely manner, as required by the facility's policy and regulations under 28 Pa. Code 201.29(f) regarding resident rights.
Improper Completion of PASRR for Resident with Mental Health Disorders
Penalty
Summary
The deficiency identified in the report pertains to the improper completion of the PASRR (Preadmission Screening and Resident Review) for a resident, referred to as Resident R16. The PASRR is a federally mandated process designed to identify individuals with mental illness or intellectual disabilities, ensure appropriate placement, and guarantee they receive necessary services. Resident R16 was admitted to the facility with several mental health diagnoses, including Major Depressive Disorder, Post-Traumatic Stress Disorder, Schizoaffective Disorder, and Anxiety Disorder. Despite these significant mental health conditions, the PASRR Level I form for Resident R16 did not appropriately indicate the outcomes that may or may not lead to chronic disability. The deficiency was confirmed through an interview with the Director of Nursing, who acknowledged the oversight. The report highlights that the PASRR Level I screening, which is required for all individuals considering admission to a Medicaid-certified nursing facility, was not completed correctly for Resident R16. This oversight could potentially impact the resident's placement and the services they receive, although the report does not explicitly state these consequences.
Failure to Revise Fall Prevention Care Plan
Penalty
Summary
The facility failed to revise the care plan for fall prevention for Resident R25, who was admitted on April 10, 2019, with diagnoses including unspecified dementia, anxiety disorder, unspecified glaucoma, muscle wasting and atrophy, and unspecified lack of coordination. On April 3, 2024, Resident R25 fell outside another resident's room, resulting in a hematoma on the left side of the forehead, and was subsequently sent to the hospital for evaluation and treatment. Upon readmission on April 8, 2024, a Fall Risk Evaluation was conducted, resulting in a Fall Risk Score of 21.0. Despite the fall and the updated fall risk evaluation, the care plan for Resident R25, which was initiated on January 5, 2023, and had a target date of April 2, 2024, was not updated or revised to reflect the new interventional status. This lack of revision and updating of the care plan was confirmed by the Director of Nursing on August 26, 2024. The deficiency was noted under the regulations 28 Pa Code 211.5(f) Clinical records, 28 Pa Code 211.11(d) Resident Care Plan, and 28 Pa Code 211.12(c)(d)(3) Nursing services.
Inadequate Pain Management for Resident with Severe Pain
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R38, who was documented with severe pain. The facility's policy for pain assessment and management, revised in October 2022, outlines a process that includes assessing for pain, implementing interventions, and monitoring the effectiveness of pain management. However, the facility did not adhere to this policy for Resident R38, who was admitted with multiple complex medical conditions, including a cerebral infarction, Parkinson's disease, and several pressure ulcers. The resident was assessed as severely cognitively impaired and completely dependent on staff for daily activities. Despite being on a scheduled pain medication regimen, the resident did not receive non-medication interventions for pain, and there was no evidence of appropriate monitoring for the effectiveness of the pain medication administered. Observations and records revealed that Resident R38 frequently experienced severe pain, with pain levels documented as very strong to the worst possible (8-10) during May, June, and July 2024. The resident's care plan included interventions to monitor and report signs of non-verbal pain, but there was no evidence that the facility responded appropriately to the resident's severe pain prior to a change in medication on August 2, 2024. Interviews with nursing staff confirmed that the resident's pain regimen was changed to Percocet as needed, but the facility could not demonstrate that they had adequately addressed the resident's pain prior to this change. This deficiency was identified under 28 Pa. Code 211.12(c) and 28 Pa. Code 211.12(d)(1-3) regarding nursing services.
Medication Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by errors observed during medication administration for three out of four residents. On August 21, 2024, a Licensed Nurse, Employee E3, administered the incorrect form of Aspirin to a resident. The physician's order specified Aspirin Enteric-Coated (EC) Tablet Delayed Release 81 MG, but the nurse administered a regular chewable tablet instead. This discrepancy was confirmed during an interview with the nurse. Additionally, another Licensed Nurse, Employee E4, administered the wrong dosage of Calcium with Vitamin D to a different resident. The physician's order required a 500-400 MG-UNIT tablet, but the nurse administered a 600 mg/10 mcg (400 IU) tablet. Furthermore, Employee E4 was observed preparing to administer Senna Plus to a resident, contrary to the physician's order for Senna Oral Tablet 8.6 MG. The administration was prevented, and the nurse confirmed the error. These incidents contributed to a medication error rate of 11.54% at the facility.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy for a resident, leading to an incident where a nurse aide allegedly caused harm. The resident, who has a history of mental health and physical conditions, reported that a nurse aide pushed her wheelchair into her bed, causing her knee to be hit and resulting in pain and bruising. The resident also claimed that the nurse aide threatened her verbally. Despite the resident's complaints and visible injury, the incident was not immediately reported to the appropriate authorities as required by the facility's policy. The incident occurred when the resident was sleeping, and the nurse aide was moving the resident's wheelchair. The resident's complaints were initially addressed by a licensed nurse who noted the incident and informed the physician, but the required immediate reporting to the administrator and other officials was not done. The nurse aide involved was not removed from the unit immediately and continued to work in the same area as the resident for the rest of the shift. Interviews with various staff members revealed a lack of clear communication and proper reporting of the incident. The social worker assumed that the necessary reporting had been completed due to the commotion in the hallway, but it was later confirmed that the incident was only reported to social services. The facility's failure to follow its abuse policy resulted in a delay in addressing the resident's injury and ensuring the safety of the resident from the alleged perpetrator.
Failure to Timely Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a timely investigation to rule out neglect and/or abuse for a resident. The incident began when the resident reported that a CNA pushed her wheelchair into her bed, causing her knee to be hit and resulting in pain. Despite the resident's complaint and visible bruising on her knee, the incident was not immediately reported to the administrator or other required officials as per the facility's policy. The delay in reporting and investigating the incident was evident as the Director of Nursing only became aware of the situation the following day when she found a witness statement on her desk and initiated an investigation. Interviews with various staff members revealed that there was confusion and a lack of immediate action following the resident's complaint. The licensed nurse who first addressed the resident's complaint did not report the incident to the administrator or other officials. Instead, the nurse documented the incident and notified the doctor, but no further action was taken to report the alleged abuse. The social worker, who was also informed of the incident, assumed that the necessary reporting had been completed by others and did not take further steps to ensure the incident was reported as required. The failure to follow the facility's abuse policy resulted in a delay in the investigation of the resident's complaint. The resident's account of the incident, along with the visible injury, was not promptly addressed, and the required notifications to state and local agencies, as well as other officials, were not made in a timely manner. This lack of immediate action and communication among the staff led to a significant delay in addressing the resident's allegations of abuse and neglect.
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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