Sinking Spring Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Sinking Spring, Pennsylvania.
- Location
- 3000 Windmill Road, Sinking Spring, Pennsylvania 19608
- CMS Provider Number
- 395541
- Inspections on file
- 28
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Sinking Spring Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow physician orders and its own medication administration policy for a resident with Hodgkin’s lymphoma and anxiety. An LPN gave only one lorazepam tablet hours before the ordered bedtime dose of three tablets, and on another occasion a different LPN administered only one lorazepam tablet instead of three at bedtime. The same resident also missed a scheduled oxycodone HCL (IR) 10 mg dose for pain because no medication was available, with the last dose on hand given earlier in the day and the next dose not provided until several hours later. The Administrator acknowledged there was no documentation showing that staff followed the physician’s orders in these instances.
A resident with chronic pain, major depressive disorder, and anxiety, who depended on staff for personal hygiene and had a care plan directing staff to postpone care when she refused, had her hair cut and shaved against her wishes. Despite facility policies prohibiting abuse and requiring respect for grooming preferences, the DON instructed staff to cut the resident’s hair using scissors and an electric razor. The resident repeatedly screamed no, stating she wanted to keep her ponytail, but staff proceeded, did not discuss or attempt alternatives, and then took her to the shower. The resident was later observed with unevenly shaved hair and was reported by her roommate to have been crying afterward, with no documentation of medical necessity, alternative options, or acknowledgment of her refusal.
A resident with depression, anxiety, and chronic pain, who was alert, oriented, and dependent on staff for hygiene, had a care plan stating she often refused care, that staff should postpone activities when she refused, and that she should be allowed to choose between a shower or bed bath. Despite this, staff provided a shower instead of the planned bed bath after the resident stated she did not want a shower, and, on the DON’s instruction, staff cut the resident’s hair using scissors and an electric razor while she repeatedly refused and became distressed. The resident was later observed with short, uneven hair, reporting that her ponytail had been shaved off against her wishes, and her roommate reported that she cried afterward.
A resident with chronic pain syndrome, major depressive disorder, and anxiety, who was alert, oriented, and dependent on staff for personal hygiene, had a care plan stating that staff should postpone personal care activities if she refused them. Despite this, staff proceeded to cut the resident’s hair and provide a shower after she refused, and the DON confirmed these actions. There was no documentation that the care was postponed as directed in the care plan.
A review of staffing schedules showed that the facility did not meet the required minimum NA-to-resident ratio during one night shift, failing to provide at least one NA for every 15 residents as required by regulation.
The facility did not meet the required minimum LPN-to-resident ratios on several day and evening shifts, as shown by a review of nursing schedules. On multiple occasions, there were not enough LPNs scheduled to meet the mandated ratios for the number of residents present.
A review of nursing schedules showed that the facility did not provide the required minimum of 3.2 hours of direct nursing care per resident on three days within a 21-day period, with care hours falling below the mandated threshold on each of those days.
Surveyors observed unsanitary conditions in the kitchen, including a black substance on ceiling tiles near exhaust vents, missing ceiling tiles, and a central air vent dripping water onto the floor.
Three residents with significant medical conditions who required staff assistance for hygiene were observed with long, dirty nails and reported that staff had not provided nail care as outlined in their care plans. Despite needing help with activities of daily living, these residents stated that nail care was not offered during showers or as needed.
Surveyors observed peeling wallpaper in the Chapel and damaged walls and linoleum in two resident rooms on one nursing unit. The Administrator confirmed these environmental issues should have been addressed, resulting in a deficiency for failing to maintain a safe, sanitary, and comfortable environment.
A resident's personal funds were not conveyed to their estate nor was a final accounting provided to the appropriate party within 30 days of death, as required. Instead, the facility issued a check to the Social Security Administration, and the Administrator confirmed that the necessary documentation and transfer to the estate did not occur.
Two residents were involved in incidents of ongoing harassment, sexual threats, and physical altercations, with one resident experiencing increased anxiety and depression due to repeated abuse by another. Facility records and interviews confirmed that the abuse had been ongoing and intensified over time, and the facility failed to prevent both physical and mental abuse.
A resident with significant medical conditions reported to staff and a psychologist that another resident had been sexually harassing, threatening, and physically hitting him. Despite facility policy requiring prompt reporting, the incident was not reported to the State Survey Agency.
The facility failed to assess and monitor wounds and implement preventive interventions for two residents. A resident with diabetes and peripheral vascular disease had a new wound that was not assessed or monitored for several days. Another resident, at risk for skin breakdown, had boggy heels documented multiple times without timely preventive interventions. The DON confirmed these deficiencies.
A facility failed to develop a comprehensive care plan for a resident with anxiety and psychotic disorder, as required by the MDS CAA summary. Despite the resident receiving antipsychotic and antidepressant medications, there was no documented evidence of interventions to address psychotropic drug use in the care plan. The Administrator confirmed this deficiency during an interview.
Two residents with muscle disorders and mobility issues did not receive consistent assistance with walking as recommended by therapists. Despite care plans indicating the need for daily ambulation support, there was no documented evidence of such assistance being provided over the last 30 days. Both residents reported not receiving consistent help, and the facility's administration acknowledged the lack of documentation.
The facility failed to properly store food and maintain sanitary conditions in two unit pantries, Station 2 and Arcadia. Observations revealed unlabeled and outdated food items in the refrigerators and freezers, contrary to the facility's policy requiring labeling and discarding after three days. Additionally, unsanitary conditions were noted, such as dried liquid debris and hair inside the refrigerators. This deficiency was cited under CFR 483.60(i) Food Safety Requirement.
The facility failed to maintain dignity during dining assistance for a resident with Alzheimer's and dysphagia, as a nurse aide was observed standing while feeding the resident, contrary to the care plan. Additionally, another resident with physical limitations did not receive timely assistance despite activating the call bell, which was not answered by available staff, violating the facility's policy for prompt response.
The facility failed to maintain a safe, clean, and comfortable environment in three nursing units. Observations included stained sinks, cluttered areas with trash, marred walls, odors, insects, and structural damage such as holes and peeling paint.
The facility failed to serve food at an appetizing temperature, as identified through resident interviews and a test tray audit. Residents reported that their food was often served cold, and a test tray audit confirmed that a smothered pork chop and roast potatoes were served at temperatures below the facility's standard. The Director of Dining Services confirmed the food was cool to taste.
The facility failed to serve two residents their preferred and selected food items, impacting their nutritional care. One resident, with a history of weight loss, did not receive his chosen iced tea and garlic bread, while another resident, with folate deficiency anemia, was served an alternate meal instead of her selected main meal. Both residents expressed that this issue occurred frequently.
The facility did not post current nurse staffing information, as observed during tours when the lobby displayed outdated staffing data. The Nursing Home Administrator confirmed the inaccuracy.
The facility was found to have improperly disposed of trash and refuse. Observations revealed garbage and debris, such as used gloves and plastic items, scattered around the trash compactor. A full garbage bag was stuck between the compactor and the ground, and the dumpster lid was open with trash bags overflowing. A walker was also found next to the dumpster.
The facility did not ensure a safe, clean, and comfortable environment on four nursing units. Issues included a broken toilet seat, dirt and debris under air conditioning units, a non-functioning bathroom light, a dirty wheelchair, and lifting linoleum flooring. These deficiencies compromised the residents' right to a homelike environment.
Two residents, one with hemiplegia and diabetes and another with osteoporosis and depression, were not offered showers as scheduled in an LTC facility. Both residents, who required staff assistance for bathing, reported not being offered showers multiple times over the past month, despite their preference to shower twice a week.
Failure to Follow Physician Orders for Lorazepam and Oxycodone Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for a resident with Hodgkin’s lymphoma and anxiety, contrary to its own medication administration policy. The facility policy dated February 12, 2026, required medications to be administered in accordance with prescriber orders and specified that bedtime medications be given up to one hour prior to the resident’s scheduled bedtime. Clinical record review showed that a physician’s order dated October 27, 2025, directed staff to administer lorazepam 0.5 mg, three tablets at bedtime. However, nursing progress notes and the Individual Patient Narcotic Dispensing Record documented that on December 11, 2025, an LPN administered only one lorazepam tablet at 5:30 p.m., rather than three tablets at the scheduled 8:00 p.m. bedtime. An additional physician’s order dated January 19, 2026, again directed staff to administer lorazepam 0.5 mg, three tablets at bedtime, but the narcotic dispensing record showed that on February 4, 2026, at 8:00 p.m., another LPN administered only one tablet instead of three. A separate order dated January 19, 2026, required oxycodone HCL (IR) 10 mg every four hours for pain. Review of the January 2026 Medication Administration Record revealed that the 8:00 p.m. oxycodone dose on January 29, 2026, was missed because no medication was available, as confirmed by a nursing progress note and the narcotic dispensing record, which showed the last dose on hand was given at 4:00 p.m. and the next dose not administered until midnight on January 30, 2026. In an interview, the Administrator stated there was no documented evidence that staff followed the physician orders as described.
Resident’s Hair Cut and Shaved Against Expressed Refusal, Constituting Abuse
Penalty
Summary
The facility failed to protect a resident from physical and mental abuse when staff cut and shaved the resident’s hair against her expressed wishes. Facility policies on Abuse Prohibition and Treatment: Considerate and Respectful required that residents be free from abuse, mistreatment, and neglect, and that grooming respect resident preferences for hairstyle and length. The resident had chronic pain syndrome, major depressive disorder, and anxiety, and her MDS showed she was alert, oriented, reported feeling down or hopeless several days per week, and was dependent on staff for personal hygiene. Her care plan documented that she often refused care due to personal preference and that staff were to postpone activities if she refused. On the date of the incident, the resident reported that staff told her not to talk to anyone about certain things and that staff shaved her head using an electric razor after she said no. She stated she previously had a ponytail and that staff shaved her hair like she was a prisoner, without trying any other options. She reported that after staff shaved her head, they took her to the shower. Observation showed her hair was visibly short and uneven, with varying lengths from close to the scalp to about a half inch, and she was seen rubbing her hand over her hair and moving her head during the interview. Staff interviews confirmed that the DON instructed staff to cut the resident’s hair and that scissors and an electric razor were used. The DON acknowledged that the resident “freaked out,” said she did not want her ponytail cut, and objected to the hair being cut, and that no other options were discussed or attempted. A nurse aide stated that the resident screamed no until after her hair was cut, then became silent. The resident’s roommate reported that after staff cut the resident’s hair, the resident was in the room crying. There was no documentation that the resident had tangled hair, a medical need, or any other condition requiring her hair to be cut, no evidence that alternatives such as consultation with a hairdresser or a scheduled haircut were offered, and no documentation that staff acknowledged or honored the resident’s refusal.
Removal Plan
- Resident 1 was seen by social services, psychiatry, and the physician.
- The facility will conduct a full abuse investigation.
- The facility will report the allegation to the Department of Health, Pennsylvania Department of Aging, the local Police Department, and the Area Agency on Aging.
- Psychiatry/psychology services will continue to follow Resident 1 routinely.
- All residents will be assessed for injuries or trauma, with follow-up if needed. If any allegations are brought forward, they will be reported to the abuse coordinator, the resident will be removed from the situation, and staff will be placed on leave if identified as the perpetrator.
- The Administrator will re-review the abuse policy.
- The facility will educate all staff on abuse protocols, resident rights, and refusal of care. Staff members will be given a quiz with the education.
- The facility suspended all involved staff members.
- Weekly audits and then monthly audits will be conducted of any potential abuse allegations and the results discussed at the QAPI committee.
Failure to Honor Resident Refusals and Grooming Preferences
Penalty
Summary
The facility failed to honor a resident’s rights to dignity, self-determination, and personal preferences regarding hygiene and grooming. Facility policy required that residents be groomed as they wished, including maintaining preferred hair style and length. The resident involved had chronic pain syndrome, major depressive disorder, and anxiety, and her MDS showed she was alert, oriented, reported feeling down or hopeless several days per week, and was dependent on staff for personal hygiene. Her care plan indicated she often refused care due to personal preference, that staff were to postpone activities if refused, and that it was important for her to choose between a shower or bed bath. Despite this, the nurse aide Kardex directed staff to provide bed baths twice weekly, and documentation showed that staff provided a shower instead of a bed bath on a specific date. During interviews, the resident stated she did not want to go for a shower but staff took her anyway, and that staff cut her hair with an electric razor despite her repeated refusals. She was observed in bed with visibly short, uneven hair, rubbing her hand over her head and moving her head from side to side, and reported that staff had shaved her head, removed her ponytail, and made her feel like a prisoner. A nurse aide reported that the DON instructed her to cut the resident’s hair and that the resident screamed “no” until after the hair was cut, then became silent. Two other nurse aides confirmed the resident had refused a shower but was given one regardless. The DON confirmed she told staff to cut the resident’s hair, acknowledged that the resident objected and “freaked out,” and confirmed that scissors and an electric razor were used and no other options were discussed or attempted. The resident’s roommate reported that after staff cut the resident’s hair, the resident was in the room crying.
Failure to Follow Care Plan for Resident’s Refusal of Personal Care
Penalty
Summary
The facility failed to implement a comprehensive care plan that addressed an individual resident’s assessed needs and documented preferences. Clinical record review showed that the resident had chronic pain syndrome, major depressive disorder, and anxiety, and the Minimum Data Set dated November 6, 2025 indicated the resident was alert and oriented, reported feeling down, depressed, or hopeless several days per week, and was dependent on staff for personal hygiene. The resident’s care plan documented that she often refused care due to personal preference and directed staff to postpone the activity if she refused. However, the resident reported that staff cut her hair and took her for a shower even though she refused, and the Director of Nursing confirmed that staff provided the hair cutting and shower on January 6, 2026 despite the resident’s refusal. There was no documented evidence that staff postponed these activities in accordance with the resident’s care plan.
Failure to Meet Minimum Nurse Aide Staffing Ratio on Night Shift
Penalty
Summary
A review of nursing time schedules for a 21-day period revealed that the facility did not meet the required minimum nurse aide (NA) to resident ratio on one occasion. Specifically, on the night shift from 11:00 p.m. to 7:00 a.m. on December 9, 2025, the facility failed to provide at least one NA for every 15 residents, as mandated by regulation. This deficiency was identified through direct examination of staffing records for the specified period. No additional details regarding the residents' medical history or condition at the time of the deficiency were provided in the report.
Plan Of Correction
1, 2) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios are met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements. 4) Weekly audit of nurse aide ratios will be conducted for 60 days by NHA/designee to ensure nurse aide ratios are met. Tracking and trends to be submitted to the QAPI committee.
Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum LPN-to-resident ratios on five out of twenty-one days reviewed, as evidenced by nursing time schedules. Specifically, on two days, the day shift did not have at least one LPN per 25 residents, and on three separate days, the evening shift did not have at least one LPN per 30 residents. These deficiencies were identified through a review of staffing schedules covering the period from late November to mid-December 2025. No information about specific residents, their medical histories, or their conditions at the time of the deficiency is provided in the report.
Plan Of Correction
1,2) LPN staffing ratios will be reviewed for the last 7 days to evaluate if LPN ratios are met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements. 4) Weekly audit of LPN ratios will be conducted for 60 days by NHA/designee to ensure LPN ratios are met. Tracking and trends to be submitted to the QAPI committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules over a 21-day period revealed that on three specific days, the total nursing care hours fell below the mandated minimum. Specifically, on November 30, 2025, only 3.11 care hours per resident were provided; on December 6, 2025, 3.12 care hours per resident were provided; and on December 13, 2025, 3.09 care hours per resident were provided. This deficiency was identified through a review of the facility's nursing time schedules and affected the overall care provided to residents during those days.
Plan Of Correction
1,2) HPPD will be reviewed for the last 7 days to evaluate if the state minimum PPD of 3.2 is met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements. 4) Weekly audit of HPPD will be conducted for 60 days by NHA/designee to ensure minimal HPPD is met. Tracking and trends to be submitted to the QAPI committee.
Unsanitary Kitchen Conditions Observed
Penalty
Summary
During an environmental tour of the kitchen, surveyors observed unsanitary conditions, including a black substance present on ceiling tiles around the exhaust vents. Additionally, several ceiling tiles were missing, and a central air vent was noted to be dripping water onto the floor. These findings indicate that the facility failed to maintain sanitary conditions in the kitchen as required by professional standards and regulatory requirements. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Required Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for three residents who required staff assistance with activities of daily living, specifically nail care. Clinical record reviews and resident interviews revealed that each resident had care plans directing staff to assist with hygiene and nail care on bath days and as needed. Despite these documented needs, observations on multiple occasions showed that the residents' nails were long and dirty, and the residents reported that staff had not offered to provide nail care during recent showers or at other times. The affected residents had significant medical conditions, including cerebral palsy, seizure disorder, congestive heart failure, kidney failure, and Parkinson's disease, and required varying levels of assistance with self-care. All three residents expressed a preference for short nails and indicated that staff had not fulfilled their care plan requirements regarding nail care. These findings were corroborated by both direct observation and resident statements, demonstrating a pattern of staff inaction in providing necessary hygiene services as outlined in the residents' care plans.
Environmental Maintenance Deficiency Noted on Nursing Unit
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents and staff on one of four nursing units, specifically Station 2. During observations conducted over two days, surveyors noted peeling wallpaper on all four walls in the Chapel, damage to the wall to the left of the door in one resident room, and damage to the wall behind the bathroom sink and toilet, as well as damaged linoleum below the sink in another resident room. The Administrator confirmed in an interview that these environmental issues should have been addressed. These findings indicate that the facility did not uphold required standards for environmental maintenance as outlined in state regulations, resulting in a deficiency related to the physical condition of the environment.
Failure to Convey Resident Funds to Estate After Death
Penalty
Summary
The facility failed to convey a deceased resident's personal funds and provide a final accounting of those funds to the appropriate individual or probate jurisdiction within 30 days of the resident's death. Review of the clinical record and resident fund account showed that the resident was admitted and later expired at the facility, with a remaining account balance of $2,961.70. The account was closed, but there was no documented evidence that a final accounting was provided to the estate as required. Instead, a check was issued to the Social Security Administration rather than to the resident's estate. The Administrator confirmed in an interview that the required final accounting and transfer of funds to the estate did not occur within the specified timeframe.
Failure to Protect Residents from Abuse Resulting in Psychosocial Harm
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in psychosocial harm to one of them. One resident, with a history of hemiplegia, anxiety, and depression, was subjected to ongoing harassment and sexual threats by another resident, who had diagnoses including borderline personality disorder and schizoaffective disorder. Documentation showed that the harassing resident repeatedly demanded food and money, entered the victim's room without permission, took food, made threatening phone calls, and made explicit sexual threats and requests. The victim reported these incidents to staff and a psychologist, describing increased anxiety and depression as a result of the ongoing abuse. The situation escalated when the victim, after enduring repeated harassment and threats, struck the perpetrator with a walker following an argument. Facility records and interviews confirmed that the abuse had been ongoing for several months and had intensified in the weeks leading up to the incident. The facility's failure to intervene and protect both residents from physical and mental abuse constituted a violation of resident rights and resulted in documented psychosocial harm.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by its own policy. According to the policy, the Administrator or designee is responsible for reporting allegations of abuse to the appropriate state and local authority within two hours. Clinical record review showed that a resident with diagnoses including hemiplegia, hemiparesis, anxiety, depression, and heart disease reported to staff and a psychologist that another resident had been sexually harassing him, making threats for food and money, and physically hitting his arm. Despite these reports, the Administrator confirmed that the incident was not reported to the State Survey Agency.
Failure to Assess and Monitor Wounds and Implement Preventive Interventions
Penalty
Summary
The facility failed to adhere to its policy on skin integrity and wound management, resulting in inadequate assessment and monitoring of wounds for two residents. Resident 1, who had multiple diagnoses including diabetes and peripheral vascular disease, developed a new wound on the right third toe. Despite a treatment order, there was no documented evidence of assessment or monitoring of this wound for several days. Additionally, a calloused area on Resident 1's left foot was not assessed or monitored for an extended period, despite being noted to have an odor that resolved after cleansing. Resident 3, who was at risk for skin breakdown due to fragile skin, advanced age, and urinary incontinence, was documented to have boggy heels on multiple occasions. However, interventions to prevent pressure ulcers were not implemented until a physician's order was given much later. The Director of Nursing confirmed the lack of documented evidence for weekly assessments and daily monitoring for Resident 1, as well as the delayed implementation of preventive interventions for Resident 3.
Failure to Develop Comprehensive Care Plan for Psychotropic Drug Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 189, who was admitted with diagnoses including anxiety and psychotic disorder with delusions. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated May 9, 2024, indicated that the resident's use of psychotropic drugs should be addressed in the care plan. However, a review of the medication administration records showed that the resident was receiving both an antipsychotic and an antidepressant at the time of the MDS CAA summary, yet there was no documented evidence of interventions to address the psychotropic drug use in the current care plan. An interview with the Administrator on August 27, 2024, confirmed the absence of documented interventions in the care plan to address the resident's psychotropic drug use, which is a requirement under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Provide Consistent Ambulation Assistance
Penalty
Summary
The facility failed to provide necessary services to improve the activities of daily living, specifically walking, for two residents who required assistance. Resident 128, diagnosed with a disorder of the muscle and a history of repeated falls, was recommended a restorative ambulation program by a therapist. The program aimed for the resident to safely ambulate up to 30 feet using a walker with supervision or stand-by assistance. However, there was no documented evidence that the facility consistently offered assistance with walking on a daily basis for the last 30 days. The resident reported feeling unsteady when walking alone and not receiving consistent assistance from the staff. Similarly, Resident 157, who had a diagnosis of muscle disorder and lumbago with sciatica, was also recommended a restorative ambulation program. The program intended for the resident to ambulate 10-50 feet using a walker with minimal assistance. Again, there was no documented evidence of consistent daily assistance with walking for the last 30 days. The resident confirmed the lack of consistent assistance from the staff. The facility's Administrator and Director of Nursing acknowledged the absence of documented evidence that staff consistently assisted the residents with walking as per their care plans and therapist recommendations.
Improper Food Storage and Sanitation in Unit Pantries
Penalty
Summary
The facility failed to properly store food and maintain sanitary conditions in two of its unit pantries, specifically on Station 2 and Arcadia. The facility's policy, last reviewed on April 3, 2024, requires staff to label food items requiring refrigeration with the resident's name and the date the food was brought in, and to discard the food after three days. However, observations revealed that this policy was not followed. In the Arcadia unit pantry, the refrigerator had a sign indicating it was for resident food only and that foods must be discarded after three days. Despite this, the freezer contained unlabeled raspberry orange sherbet and frozen grape concentrate, and the refrigerator had items such as dished applesauce, milk, and juice that were either past their use-by dates or not labeled with a resident's name or date. Additionally, there was dried liquid debris and hair inside the refrigerator. Similarly, the Station 2 unit pantry had a sign with the same instructions, but the freezer contained a half-eaten whoopie pie without a name or date. The refrigerator held a sandwich dated August 16, 2024, and other items like a bun, juice, string cheese, and various opened bottles and containers that were not labeled with a resident's name or date. These observations indicate a failure to adhere to the facility's food storage policy, resulting in unsanitary conditions and potential food safety issues. The deficiency was cited under CFR 483.60(i) Food Safety Requirement and had been previously cited on September 29, 2023.
Failure to Maintain Dignity in Dining Assistance and Timely Response to Call Bell
Penalty
Summary
The facility failed to provide assistance with dining in a manner that promoted and maintained dignity for a resident diagnosed with Alzheimer's disease, dysphagia, and protein-calorie malnutrition. The resident required total assistance with feeding, as indicated in their care plan, which included feeding slowly and providing verbal cueing. However, observations on two separate occasions revealed that a nurse aide assisted the resident with lunch while standing, which did not align with the care plan's directives for promoting dignity during meals. Additionally, the facility did not ensure timely response to a call bell for another resident with peripheral vascular disease, a muscle disorder, and a history of falling. This resident required staff assistance for repositioning due to physical limitations. Despite the resident activating the call bell and staff being present in the vicinity, the call bell was not answered, and no assistance was provided. The facility's policy required prompt response to call lights, which was not adhered to in this instance.
Environmental Deficiencies in Multiple Nursing Units
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment across three of its five nursing units: Medbridge, Station 2, and Arcadia. On the Medbridge unit, a large brown stain was observed in the bathroom sink of one room, along with a black substance around and inside the drain plug. Additionally, clutter was noted outside another room, including a box containing a new toilet and two large, uncovered garbage cans, one of which was overflowing with trash. On Station 2, several rooms had marred walls and chipped paint, with specific issues such as a pervasive odor of urine and small black crawling insects on a nightstand in one room. Other rooms had gouged walls, bowing ceilings with peeling tape, and unpainted spackle. In one room, tube feed was splattered on the base of the pump, floor, and wall, with black streaks under the sink and used gloves on the floor. The Arcadia unit also had marred walls and chipped paint, with additional damage such as holes in the walls and bathroom doors.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to provide food that was palatable and at an appetizing temperature on one of its nursing units. This deficiency was identified through a review of Dining Council Minutes, resident interviews, and a test tray audit. Residents reported that their food was frequently served cold, which was confirmed during a group interview with three residents. The facility's documentation specified that hot main entrees, starches, and vegetables should be served at temperatures greater than 140 degrees Fahrenheit. However, during a test tray audit, a smothered pork chop was served at 112.6 degrees Fahrenheit and roast potatoes at 108 degrees Fahrenheit, both of which were cool to taste. The Director of Dining Services confirmed the food items were cool to taste.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that residents were served their preferred and selected food items on their meal trays, affecting two residents. Resident 199, who had a diagnosis of adjustment disorder with mixed anxiety and depressed mood, was at nutritional risk due to a history of weight loss. Despite being alert and oriented, the resident frequently did not receive the food and drink items he selected, such as iced tea and garlic bread, as observed on August 26, 2024. The resident expressed that this issue occurred regularly, impacting his enjoyment of meals. Similarly, Resident 202, diagnosed with folate deficiency anemia and also at nutritional risk, did not receive the meal she selected. On August 25, 2024, she was served an alternate meal instead of her chosen main meal, which included country fried steak, green beans, and mashed potatoes. The resident, who was alert and oriented, stated that she often did not receive the meals she preferred or selected. These incidents highlight the facility's failure to honor food preferences as outlined in the residents' care plans.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information as required. During tours of the facility on August 25 and 26, 2024, it was observed that the staffing information displayed in the lobby was outdated, showing the date of August 23, 2024. This discrepancy was confirmed in an interview with the Nursing Home Administrator on August 27, 2024, who acknowledged that the posted staffing information was incorrect.
Improper Disposal of Trash and Refuse
Penalty
Summary
The facility failed to properly dispose of trash and refuse, as observed on August 25, 2024. During the inspection, garbage and debris, including used gloves, plastic food bags, plastic straws, and a gauze roll, were found scattered on the ground around the trash compactor. Additionally, a full garbage bag was stuck between the compactor and the ground. The garbage dumpster was observed with its top lid wide open and filled with trash bags. A walker was also found next to the dumpster.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment across four of its five nursing units, as observed during a survey. On the Medbridge unit, a broken and rusted toilet seat was found in one room, along with dirt and debris under the air conditioning unit in another room, and a non-functioning bathroom light in a third room. The Arcadia unit also had an accumulation of dirt and debris under the air conditioning unit in one room. On Station 2, a resident's wheelchair was observed to have dirt and debris on its bars. Additionally, on Station 3, the linoleum on the bathroom floor was lifting in one room. These observations indicate a failure to uphold the residents' right to a safe, clean, and homelike environment as required by regulations.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide services to enhance the quality of life for two residents by not offering showers as scheduled. Resident 1, diagnosed with hemiplegia and diabetes mellitus, was oriented and required staff assistance for bathing. The resident was supposed to receive a shower twice a week but reported not being offered the opportunity to do so four out of nine scheduled times in the past 30 days. Similarly, Resident 10, who had osteoporosis and depression, was also oriented and required staff assistance for bathing. This resident preferred to take a shower twice a week but was not offered the opportunity six out of nine scheduled times in the past 30 days. Both residents stated they would not refuse the opportunity to shower.
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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