Philadelphia Protestant Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 6500 Tabor Road, Philadelphia, Pennsylvania 19111
- CMS Provider Number
- 395961
- Inspections on file
- 21
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Philadelphia Protestant Home during CMS and state inspections, most recent first.
Surveyors found that all rated doors inside a stairwell enclosure between Personal Care and Skilled Nursing failed to positively latch, and a hollow wooden door of unknown fire rating was sealed within a fire-rated wall. These issues were confirmed by facility staff.
Surveyors determined that the facility did not provide documentation of two required semi-annual inspections for the kitchen fire suppression system. This was confirmed by facility leadership during the survey exit interview.
Surveyors found that the facility did not maintain or inspect its fire alarm system as required, with missing documentation for smoke detector sensitivity testing, annual and semi-annual inspections, and multiple device troubles indicated on the fire alarm panel. Facility leadership confirmed the lack of records and the ongoing alarm issues.
Surveyors found that the facility did not have a required fire watch policy in place for situations when the fire alarm system is out of service for more than four hours in a 24-hour period. This was confirmed through document review and interviews with the Maintenance Supervisor and Director of Safety/Security.
The facility did not maintain required documentation for fire sprinkler system inspections and testing, including supervisory devices, alarm devices, main drain tests, control valves, and other components. Additionally, a damaged sprinkler head was observed, and facility leadership confirmed the absence of inspection reports and the damaged equipment.
The facility did not provide documentation for annual fire extinguisher maintenance and technician certification, and a fire extinguisher in the main kitchen was found blocked. These deficiencies were confirmed by facility leadership during the survey.
The facility did not provide documentation for the annual 90-minute load test and annual fuel quality test of the emergency generator, as confirmed by the Maintenance Supervisor and Director of Safety/Security. This failure affected the entire facility and indicated non-compliance with required emergency power system maintenance and testing.
Surveyors found that medical gas cylinders were improperly stored and identified on all four floors, with excessive numbers of tanks and freestanding cylinders in multiple oxygen closets. These practices did not meet NFPA requirements for gas cylinder storage, as confirmed by facility leadership during the exit interview.
Surveyors found that the door to a third-floor trash room, classified as a hazardous area, did not self-close or positively latch as required. This issue was confirmed by facility staff during the inspection.
Surveyors found that two resident rooms had wooden door wedges holding corridor doors open, preventing them from closing as required for fire safety. Facility staff confirmed that the wedges impeded proper door closure.
The facility did not conduct or document nine of twelve required quarterly fire drills, with missing records for all shifts in three separate quarters, as confirmed by facility leadership during interviews and document review.
A resident room was found to have an outlet multiplier and extension cord in use, contrary to NFPA 101 requirements that prohibit using such devices as substitutes for fixed wiring. The unauthorized use was confirmed by facility staff during the survey.
Surveyors found that the facility did not review or update its Emergency Preparedness Plan within the required annual timeframe. Documentation confirming the annual review was not available, and this deficiency was confirmed during interviews with the Maintenance Supervisor and Director of Safety/Security.
Surveyors found that the Emergency Preparedness Plan did not include required policies and procedures for addressing the resident population, including persons at-risk, available emergency services, and continuity of operations. Facility leadership confirmed the absence of this documentation, affecting the entire facility.
The facility did not maintain documentation of cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials as required in its emergency preparedness plan, and this was confirmed by facility leadership during survey interviews.
Surveyors found that the facility did not conduct or document the required annual full-scale emergency exercise or an additional exercise, as confirmed by interviews with facility leadership and a lack of supporting documentation.
The facility did not notify the Department of Health before starting major renovations, failed to obtain required plan approvals, and lacked up-to-date Life Safety Code floor plans and a carbon monoxide alarm evacuation policy with staff in-service, as confirmed by facility leadership.
Surveyors determined that the facility did not conduct or document the required annual 90-minute test of battery backup emergency lighting. This was confirmed by facility leadership during the survey process.
Surveyors found that grievance forms were not readily accessible to residents on three nursing units, contrary to facility policy and federal requirements. Instead, staff reported that the social worker typically interviews individuals with concerns and completes the forms, limiting residents' ability to file grievances independently or anonymously.
A resident with multiple medical conditions who required extensive transfer assistance was put to bed by staff against their wishes, following a nurse's directive. The resident later reported bruising and soreness, and an internal investigation confirmed a violation of the resident's right to participate in their care decisions.
A resident with a history of depression, anxiety, hyperlipidemia, and acute kidney failure exhibited repeated inappropriate sexual comments and anxiety-related behaviors toward staff, as documented in nursing notes. Despite these incidents, the care plan was not updated to address the resident's inappropriate sexual behavior, contrary to facility policy and regulatory requirements.
A brown pill capsule, not identified as belonging to any resident, was found on a pantry area next to resident dining tables. An LPN confirmed the pill did not match any medications dispensed on the unit. Facility policy requires secure medication administration and supervision, but the presence of the pill in a resident-accessible area demonstrates a lapse in maintaining a safe environment.
Two nurse aides did not complete the required 12 hours of annual in-service training, and the facility could not provide documentation to show compliance with federal training requirements. This was confirmed through review of records and interviews with the DON and administrator.
The facility's arbitration agreement failed to meet federal regulatory requirements, affecting 102 residents. The agreement lacked necessary language stating it was not a condition for admission or continued care, did not allow for rescission within 30 days, and did not ensure open communication with officials. The facility administrator confirmed these deficiencies.
A resident with severe cognitive impairment and a history of wandering was able to elope from the facility due to inadequate supervision and the absence of a wander-guard device. Despite expressing a desire to leave and exhibiting increased confusion, the resident exited the nursing unit undetected, using an elevator that did not alarm due to the lack of a wander-guard. The resident was later found outside the facility, highlighting a failure in maintaining resident safety.
A facility failed to document the rationale and duration for a PRN order of Ativan for a resident, as required by regulations. The resident's clinical record did not include the necessary documentation from the attending physician or prescribing practitioner, which was confirmed by the Nursing Home Administrator.
Failure to Maintain Fire Resistive Rating of Exit Stair Enclosures
Penalty
Summary
Surveyors observed that the facility failed to maintain the fire resistive rating of exit stair tower enclosures across all four levels of the component. On the ground floor, all four rated doors inside the stairwell enclosure leading to the stair tower between Personal Care and Skilled Nursing did not positively latch. Additionally, a hollow wooden door, of unknown fire rating, was found sealed within a door frame set in a cinder block wall inside the stairway enclosure. These findings were confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
All non-latching doors have been adjusted and doors now latch appropriately. Doors will be monitored during environmental rounds by maintenance staff. The hollow area identified was tested and no door present behind sheetrock. That area consists of two layers of 5/8" sheetrock. Inspection holes were filled with red fire stop caulking to maintain fire barrier.
Failure to Complete Required Kitchen Fire Suppression System Inspections
Penalty
Summary
The facility failed to ensure that the kitchen fire suppression system underwent the required semi-annual inspections. During a documentation review, surveyors found that the facility could not provide records showing that two of the mandated semi-annual inspections had been completed for the kitchen fire suppression system. This was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security, who acknowledged that the inspection reports were not available at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Semi-annual inspections were completed. Facility will ensure documentation of testing is available for survey team during all inspections.
Failure to Maintain and Inspect Fire Alarm System
Penalty
Summary
The facility failed to maintain and inspect its fire alarm system as required, impacting the entire building. During document review, the facility was unable to provide records of smoke detector sensitivity testing within the past two years, annual inspection and testing, semi-annual visual inspections, semi-annual valve supervisory switch checks, and semi-annual testing of vane and pressure switch waterflow alarm devices. Additionally, observation revealed that the fire alarm panel displayed 95 device troubles at the time of the survey. These findings were confirmed in an exit interview with the Maintenance Supervisor and Director of Safety/Security, who acknowledged the lack of required documentation and the presence of multiple device troubles on the alarm panel.
Plan Of Correction
Fire alarm system was inspected on January 6th & 7th, 2025, and documentation received from contractor. Facility will ensure documentation is available for survey team. Facility will ensure that any troubles identified on fire panel are promptly addressed and contractor is notified if necessary.
Missing Fire Watch Policy During Fire Alarm Outage
Penalty
Summary
The facility failed to maintain required policies for the fire alarm system, specifically lacking a fire watch policy to implement in the event the fire alarm system was out of service for more than four hours in a 24-hour period. During a document review, it was found that there was no such policy available, which is necessary to ensure safety when the fire alarm system is not operational. This finding was confirmed during an interview with the Maintenance Supervisor and Director of Safety/Security.
Plan Of Correction
Fire watch policy in place. Facility will ensure policy is available for survey team during all inspections.
Failure to Maintain and Inspect Fire Sprinkler System
Penalty
Summary
The facility failed to maintain, inspect, and test its fire sprinkler system as required, as evidenced by the absence of documentation for quarterly and annual testing and inspection activities. Specifically, there was no documentation available for the inspection and testing of supervisory devices, mechanical waterflow alarm devices, main drain tests, control valves, sprinkler gauges, internal valve inspections, internal pipe inspections, and obstruction investigations for the required periods. Additionally, during an observation, a sprinkler head was found to be damaged, with a frangible bulb missing its fluid. The Maintenance Supervisor and Director of Safety/Security confirmed that the required inspection reports were not on-site and acknowledged the damaged sprinkler head.
Plan Of Correction
Sprinkler system was inspected January 20th - 24th, 2025, and documentation was received from the contractor. The facility will ensure documentation is available for the survey team during all inspections. The contractor has been contacted to repair a broken sprinkler head identified during the survey. Maintenance team will monitor sprinkler heads during environmental rounds.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers as required. During document review, the facility was unable to provide the annual maintenance report and the certificate for the technician who performed the annual fire extinguisher maintenance and testing. Additionally, an on-site observation revealed that a fire extinguisher located inside the main kitchen, on the kitchen side wall of the dietary office, was blocked. These findings were confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. No information regarding residents or their medical conditions was included in the report.
Plan Of Correction
Fire extinguisher inspection was completed on 3/7/2025. Facility will ensure documentation of inspection and technician's certificate are available for survey team during all inspections. Cart removed from in front of blocked fire extinguisher. Staff will be educated to ensure fire extinguishers are not blocked. Supervisors will audit weekly for 4 weeks to ensure fire extinguisher is not blocked.
Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator as required by NFPA standards, affecting the entire facility. During a document review, it was found that the facility could not provide documentation for the annual 90-minute load test and the annual fuel quality test for the emergency generator. These tests are necessary to ensure the generator and its associated equipment are capable of supplying power within the required timeframe and that the fuel used is of appropriate quality. Interviews with the Maintenance Supervisor and Director of Safety/Security confirmed that the documentation for these required tests was missing. The absence of these records indicates that the facility did not complete or could not verify completion of essential maintenance and testing procedures for the emergency power system.
Plan Of Correction
Contractor has been contacted to schedule annual 90-minute load test and fuel quality test. Director of Maintenance will ensure tests are conducted annually and that documentation is available for survey team during all inspections.
Improper Storage and Identification of Medical Gas Cylinders
Penalty
Summary
Surveyors observed that the facility failed to properly store and identify medical gas cylinders across all four floors. Specifically, on the fourth, third, and second floors, oxygen closets adjacent to rooms 4815, 3815, and 2815 each contained more than 12 tanks, with the third floor also having 2 freestanding cylinders. On the first floor, the oxygen closet in the service corridor contained approximately 50 stored cylinders and 15 freestanding cylinders. These storage practices did not comply with NFPA 101 and NFPA 99 requirements for gas cylinder storage, including limitations on the number of cylinders, proper enclosure, and segregation of full and empty cylinders. The improper storage was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. The report does not mention any specific residents or patient conditions related to the deficiency, nor does it describe any immediate consequences resulting from the improper storage. The deficiency was based solely on the observed storage conditions and the facility's failure to meet regulatory standards for medical gas cylinder management.
Plan Of Correction
Oxygen storage capacity will be limited to 12 full tanks on the 2nd, 3rd, and 4th floors, and 50 full tanks on the 1st floor. Staff educated on storage capacity and that all tanks must be placed in holders and not free-standing. Nurses will audit at the beginning of each shift, and supervisors will perform random audits to monitor compliance.
Deficient Self-Closing and Latching Door in Hazardous Area
Penalty
Summary
Surveyors observed that the facility failed to ensure the door to the trash room on the third floor was self-closing and positively latching, as required for hazardous area enclosures. During the inspection, it was noted that the rated door did not close automatically or latch securely when tested. This deficiency was confirmed during an exit interview with the Maintenance Supervisor and the Director of Safety/Security, who acknowledged that the door did not function as required.
Plan Of Correction
Door has been fixed and is latching appropriately. Doors will be monitored during environmental rounds by maintenance staff.
Corridor Doors Blocked Open with Wedges
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with fire safety regulations on two of four levels. Specifically, during an inspection, it was found that a resident room on the fourth floor and another on the second floor each had a wooden door wedge holding the door open. These wedges prevented the doors from closing as required to resist the passage of smoke and maintain corridor safety. The Maintenance Supervisor and Director of Safety/Security confirmed during an exit interview that the use of door wedges inhibited the proper closing of the doors. The deficiency was identified through direct observation and staff confirmation, with no mention of any specific resident conditions or medical histories related to the incident.
Plan Of Correction
Door stops have been removed from doors. All other rooms checked for door stops and none noted. Staff will be educated to not use door stops. Residents and families will be educated upon admission that door stops cannot be used, and current residents will be educated regarding door stops at the next resident council meeting. The resident welcome book has been updated to include education regarding door stops and will be distributed to all residents upon admission and to all current residents.
Failure to Conduct and Document Required Quarterly Fire Drills
Penalty
Summary
The facility failed to ensure that the required quarterly fire drills were conducted and properly documented for nine out of twelve required instances. Specifically, there was no documentation available to confirm that fire drills had been conducted on all shifts for the 1st, 3rd, and 4th quarters. This was determined through interviews and a review of facility records, during which the facility was unable to provide the necessary logs to demonstrate compliance with fire drill requirements. The Maintenance Supervisor and Director of Safety/Security confirmed the absence of documentation for the specified shifts and quarters during the exit interview. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
Missing fire drill documentation is on hand. Director of Safety & Security will ensure fire drills are conducted and that documentation is available for survey team during all inspections.
Improper Use of Extension Cord and Outlet Multiplier
Penalty
Summary
The facility failed to comply with NFPA 101 requirements regarding the use of electrical equipment, specifically power cords and extension cords. During an observation on the third floor, a resident room was found to have an outlet multiplier and an extension cord in use, which is not permitted as a substitute for fixed wiring. This unauthorized use was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. The deficiency was identified on one of four floors within the facility, and the report documents the direct observation and confirmation of the improper use of electrical equipment.
Plan Of Correction
Extension cord and outlet multiplier have been removed. Resident rooms will be audited with weekly environmental rounds. Staff will be educated to notify maintenance if extension cord is found. Residents will be educated at next resident council meeting. All new residents and families will be educated upon admission.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, as required by federal regulations. During an interview and document review, it was found that the Emergency Preparedness Plan had not been reviewed or updated within the required timeframe. This deficiency was identified through documentation review and confirmed during interviews with the Maintenance Supervisor and Director of Safety/Security. No documentation was available to demonstrate that the annual review and update of the Emergency Preparedness Plan had occurred. The lack of updated records affected the entire facility, as the plan is intended to address emergency preparedness for all residents and staff. There were no specific residents or patient medical histories mentioned in relation to this deficiency.
Emergency Preparedness Plan Lacks Required Resident Population Policies
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan included policies and procedures addressing the resident population, specifically persons at-risk, the types of services the facility could provide during an emergency, and continuity of operations such as delegations of authority and succession plans. This deficiency was identified through document review and interviews conducted on June 30, 2025, which revealed that the required documentation was not present in the facility's Emergency Preparedness Plan. During the exit interview with the Maintenance Supervisor and Director of Safety/Security, it was confirmed that the necessary documentation addressing these critical components was not available. The lack of these policies and procedures affected the entire facility, as the plan did not meet the regulatory requirements for addressing the needs of the resident population in emergency situations.
Plan Of Correction
Policy in place and will ensure that policy is present in emergency preparedness binder for future surveys.
Failure to Document Emergency Preparedness Collaboration
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Specifically, the plan did not contain documentation of the facility's efforts to contact these officials or evidence of participation in collaborative and cooperative planning efforts. This deficiency was identified through document review and interviews conducted on June 30, 2025. During the exit interview with the Maintenance Supervisor and Director of Safety/Security, it was confirmed that the required documentation was not available. The lack of a documented process and evidence of communication or collaboration with emergency preparedness officials affected the entire facility.
Plan Of Correction
Policy in place and will ensure that policy is present in emergency preparedness binder for future surveys. E 0009
Failure to Conduct and Document Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale emergency exercise or an accepted substitution, as well as the additional required exercise or accepted substitution, within the previous 12 months. This deficiency was identified through document review and interviews conducted on June 30, 2025. The surveyors found that there was no documentation available to demonstrate that these emergency preparedness exercises had been completed as mandated by federal regulations. During the investigation, interviews were conducted with the Maintenance Supervisor and the Director of Safety/Security. Both individuals confirmed that the necessary documentation for the emergency exercises was not available for review. This lack of documentation indicated that the facility did not meet the regulatory requirement to test its emergency plan through the specified exercises. The deficiency affected the entire facility, as the emergency preparedness exercises are designed to ensure that all staff are familiar with and able to implement the emergency plan. The absence of these exercises and the corresponding documentation was confirmed during the exit interview with facility leadership.
Plan Of Correction
Disaster drills have been scheduled for 2025. The Director of Safety & Security will develop the schedule and ensure at least two drills are scheduled annually. Facility emergency preparedness plan was activated in May 2025 due to elopement. Documentation was added to the emergency preparedness binder. A community-based drill is scheduled for September 2025.
Failure to Notify Department and Maintain Required Safety Documentation
Penalty
Summary
The facility failed to notify the Pennsylvania Department of Health prior to initiating external window renovations throughout the building and additional interior renovations to a shut down wing on the ground floor following water damage. This action was taken without obtaining Department-approved plans, as confirmed by the Maintenance Supervisor and Director of Safety/Security during the exit interview. The lack of notification and approval was determined through observation, document review, and staff interviews. Additionally, the facility did not provide portable Life Safety Code Floor Plans that included required information such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. During the survey, it was also found that the facility lacked a carbon monoxide alarm evacuation policy plan and had not conducted associated staff in-service training, as required by the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. These deficiencies affected the entire facility and were confirmed by facility leadership during the exit interview.
Plan Of Correction
Approval for window renovation received from DSI on 5/15/25. Facility will ensure that approval is obtained prior to beginning any future renovations. Facility will ensure that floor plans are readily available for future surveys. Carbon monoxide policy in place. Staff will be educated on carbon monoxide policy.
Failure to Document Annual Emergency Lighting Test
Penalty
Summary
The facility failed to ensure that annual 90-minute testing of battery backup emergency lighting was conducted and documented as required. During a document review, surveyors found that the facility could not provide documentation showing that the required annual testing of emergency lighting had been performed. This deficiency was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security, who acknowledged the absence of the annual testing report. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
90-minute test of battery backup lighting completed and on file. Facility will ensure that proof of testing is available for survey team during all inspections.
Grievance Forms Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that grievance forms were available and accessible to residents on all three nursing units, specifically the second, third, and fourth floors. During a facility tour, it was observed that there were no grievance forms readily accessible to residents without them having to ask for assistance. The facility's policy states that grievances may be filed anonymously through secure drop boxes located on each unit, but these forms were not present or accessible as required. Additionally, a review of the facility's grievance logs over a six-month period revealed only one grievance filed, suggesting limited resident access or awareness of the grievance process. Interviews with staff indicated that the social worker typically interviews anyone with a concern and fills out the grievance form on their behalf, rather than residents having direct access to the forms. This practice does not align with the facility's policy or regulatory requirements, which mandate that residents must be able to file grievances independently and anonymously if desired. The lack of accessible grievance forms and reliance on staff to initiate the process contributed to the deficiency cited by surveyors.
Plan Of Correction
Grievance forms have been placed on all units next to the grievance submission box. Residents will receive education on the grievance process at the resident council meeting. The resident welcome book has been updated to include information regarding grievances and the grievance officer, and will be distributed to all new and current residents. The grievance officer or designee will conduct weekly audits to ensure forms are available for residents and to collect any grievances that may have been submitted. The grievance policy has been updated. Grievances will be reported at quarterly QAPI meetings.
Failure to Honor Resident's Right to Choose Bedtime
Penalty
Summary
A deficiency was identified when staff failed to honor a resident's right to self-determination regarding their bedtime. The resident, who had diagnoses including adjustment disorder with depressed mood, anxiety disorder, gait and mobility abnormalities, muscle weakness, abnormal posture, and a history of falls, required extensive assistance from two or more staff for transfers. On the date in question, the resident reported that two staff members attempted to put them to bed before they were ready. Despite the resident's refusal, a nurse instructed the staff to proceed, and the resident was physically transferred to bed against their wishes. The following day, the resident was found to have bruising on both upper arms, which was brought to the attention of nursing staff by the resident's family. The resident also reported soreness in the right upper extremity. An internal investigation confirmed that the resident's rights were violated when staff transferred the resident to bed without consent, although it could not be determined if the bruising was directly caused by the incident.
Plan Of Correction
F 0561 Staff will be educated regarding residents' rights and self-determination. Residents will be educated at resident council regarding their rights and how to file a grievance if they feel their rights have been violated. The resident welcome book has been updated to include information regarding grievances and the grievance officer and will be distributed to all new and current residents.
Failure to Revise Care Plan for Inappropriate Sexual Behavior
Penalty
Summary
A deficiency was identified when the facility failed to revise a resident's care plan to address inappropriate sexual behavior, despite documented incidents. The facility's policy requires that care plans be revised as changes in a resident's condition dictate and reviewed at least quarterly. However, clinical record review for a resident admitted with depression, anxiety, hyperlipidemia, and acute kidney failure showed multiple nursing notes documenting the resident making sexual comments and inappropriate remarks toward staff, as well as displaying anxiety and frequent call bell use when staff did not respond as desired. Despite these documented behaviors, the resident's current care plan did not include any interventions or plans to address the inappropriate sexual behavior. This omission was confirmed by the Director of Nursing. The lack of care plan revision occurred even though the facility's own policy and federal regulations require care plans to be updated to reflect changes in resident behavior and needs.
Plan Of Correction
All residents with currently documented behaviors and those on psychotropic medication will be audited to ensure care plans are accurate. Staff will be educated on updating care plans to reflect residents' needs. Care plan policy has been updated. The DON or designee will conduct audits weekly for 4 weeks, then perform random audits monthly for 3 months of care plans for residents with behaviors or on psychotropic medication to ensure accuracy. Care plans will also be reviewed and updated with each MDS to reflect the current needs of each resident.
Unsecured Medication Found in Resident Dining Area
Penalty
Summary
A deficiency was identified on the second floor nursing unit where a brown pill capsule was found on top of a pantry area next to resident dining tables. The pantry area was not being utilized at the time, and the items present included plastic bags, napkins, a radio, and the pill capsule. Upon observation, a licensed nurse confirmed that the pill resembled a vitamin capsule but did not match any medications dispensed to residents on that unit. Facility policy requires that medications be administered safely and as prescribed, including verifying resident identity, checking medication labels and expiration dates, and ensuring that the medication cart is closed and locked when out of the nurse's sight. The presence of an unaccounted-for pill in a resident-accessible area indicates a failure to maintain a safe environment free of accident hazards and to provide adequate supervision to prevent such incidents.
Plan Of Correction
Staff will be educated to be aware of not leaving medication or any other hazardous material where residents may be able to access them. Supervisor or designee will audit dining rooms before and after each meal to ensure area is clean and free of hazards. Audits will be conducted 3 times a week for 4 weeks then weekly for 3 months.
Failure to Ensure Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that two of seven nurse aides completed the required 12 hours of annual in-service training as mandated by federal regulations. Review of facility documentation and staff interviews confirmed that Employees E9 and E10, both current nurse aides, did not have evidence of completing the annual in-service training. The facility's policy on education and training, revised March 31, 2025, requires ongoing education to maintain staff competency, but the facility was unable to provide documentation showing that these two employees met the annual training requirement. This finding was confirmed with the facility's director of nursing and administrator.
Plan Of Correction
All new CNAs will be required to attend an additional orientation day to complete required training prior to starting. All CNAs will be required to attend an additional day of training during each calendar year to complete required courses on site. Department head will conduct monthly audits to monitor training. Staff will be educated on changes to training process. Policy has been updated. Trainings will be reported at QAPI meetings.
Deficient Arbitration Agreement Language
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement contained the required regulatory language as per federal regulations S483.70(n) for all 102 residents reviewed. The review of the facility's documentation and interviews with staff revealed that the arbitration agreement offered to residents or their representatives did not comply with several specific requirements outlined in the regulations. These deficiencies were identified during a survey conducted by reviewing the facility's admission agreements and arbitration clauses. The arbitration agreement lacked explicit language stating that signing the agreement was not a condition for admission or continued care at the facility, as required by S483.70(n)(1) and S483.70(n)(4). Additionally, the agreement did not grant residents or their representatives the right to rescind the agreement within 30 days of signing, as mandated by S483.70(n)(3). Furthermore, the agreement contained no provisions ensuring that it did not discourage communication with federal, state, or local officials, which is a requirement under S483.70(n)(5). An interview with the facility administrator confirmed these deficiencies, acknowledging that the arbitration agreement, which was part of the facility's admission agreement, did not include the necessary regulatory language. The administrator stated that all residents or their representatives were offered this arbitration agreement upon admission, but the agreement did not meet the federal requirements, leading to the identified deficiencies.
Failure to Prevent Resident Elopement Due to Lack of Supervision and Assistive Devices
Penalty
Summary
The facility failed to adequately supervise Resident R108, who was at risk for elopement due to severe cognitive impairment and a history of wandering. The facility's policy required the use of a wander-guard tag to prevent elopement, but Resident R108 did not have this device care planned for her safety. Despite being severely cognitively impaired and expressing a desire to leave the facility, the resident was able to exit the fourth floor nursing unit without staff knowledge by using the elevator, which did not alarm or lock due to the absence of a wander-guard. Resident R108 had a history of memory loss, frequent falls, and was admitted to the facility with severe cognitive impairment. The resident expressed a desire to go home and was noted to be wandering and confused, looking for her husband. On multiple occasions, the resident exhibited increased confusion and expressed suicidal ideation, stating a desire to jump out of a window. Despite these indicators, the facility did not implement adequate measures to prevent the resident from leaving the premises. On May 18, 2024, Resident R108 was found missing from the nursing unit and was later discovered outside the facility on a stone ledge near the main entrance. The Director of Nursing confirmed that the resident did not have an alarming device, and the wander-guard system was not activated, allowing the resident to use the elevator and exit the building without detection. This incident highlights a failure in the facility's responsibility to maintain the safety and security of its residents, particularly those at risk for elopement.
Failure to Document PRN Psychotropic Medication Rationale and Duration
Penalty
Summary
The facility failed to ensure compliance with regulations regarding PRN (as needed) orders for psychotropic medications. Specifically, for Resident R21, there was an order for Ativan, a medication used to treat anxiety, to be administered every four hours as needed for agitation/aggression. However, the clinical record lacked documentation from the attending physician or prescribing practitioner that provided the rationale for the use of this psychotropic medication and did not specify the expected duration of the PRN order. This deficiency was confirmed during an interview with the Nursing Home Administrator, Employee E1, who acknowledged the absence of the required documentation in Resident R21's medical record.
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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