Suburban Woods Health & Reha
Inspection history, citations, penalties and survey trends for this long-term care facility in Norristown, Pennsylvania.
- Location
- 2751 Dekalb Pike, Norristown, Pennsylvania 19401
- CMS Provider Number
- 395912
- Inspections on file
- 25
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Suburban Woods Health & Reha during CMS and state inspections, most recent first.
Failure to provide privacy during resident care and communication: a resident with severely impaired cognition was examined by an ENT consultant in the dining room with multiple residents, staff, and other consultants present, and another cognitively intact resident made a personal phone call on speakerphone in the dining room because the only available phone lacked private calling capability and there was no phone line in the resident's room. Residents also reported that nurses administered meds in hallways and the dining room and that dental screenings occurred in hallways.
Incomplete Investigation of Resident Fall: A resident who was alert and oriented, with a hx of compression fracture, weakness, incontinence, and fall risk, had an unwitnessed fall after attempting to get out of bed. The facility’s investigation did not obtain a witness statement from the resident or review environmental conditions at the time of the fall, despite the resident and family reporting that the call bell was used, no one responded, and the resident fell on a wet floor.
Medication Error Rate Exceeded Allowed Threshold: Surveyors observed incorrect med administration for two residents, including an LPN giving aspirin in the wrong formulation and tamsulosin at the wrong time/order details for one resident, and an RN giving Vitamin B-12 by mouth instead of sublingual for another resident. The facility’s med error rate was calculated at 10.71%, above the 5% limit.
A resident with a history of chronic compression fracture and fall risk had an unwitnessed fall and was found on the floor. An x-ray ordered by the on-call MD showed a right femoral neck fracture, but nursing did not promptly notify the physician of the positive result until the resident was later transferred to the hospital.
Surveyors found that multiple residents did not receive medications, including carvedilol, amlodipine, oxycodone, and insulin lispro, within the time frames ordered by physicians and required by facility policy. A resident with diabetes and hypertension had numerous late doses of carvedilol and sliding‑scale insulin, often given well outside the ordered windows, with MAR entries marked only as "charted late" and no documented reason or MD notification. Another resident with diabetes reported insulin being given long after meals, and MAR review showed repeated late pre‑meal insulin doses across morning, midday, and evening med passes, again without explanation or provider notification. A third resident reported consistently late morning and nighttime medications, and records showed antihypertensive and pain medications administered after the scheduled time ranges, with late entries documented but lacking rationale or evidence of physician contact, despite no reported issues with timely meal delivery.
A resident with severe visual impairment and diabetes, requiring staff supervision for ambulation, was left unsupervised after being dropped off by a contracted transportation service following a medical appointment. The resident was not escorted into the building or signed back into nursing care, resulting in the resident walking alone across a busy highway to obtain food, while facility staff were unaware of the resident's whereabouts for an extended period. Facility staff confirmed there were no procedures in place to ensure safe transfer of care after such outings.
Surveyors found that food service areas were not maintained according to professional standards, with trash present around the loading dock, dirty and stained floors in storage and refrigeration areas, peeling paint in the dish room, and heavy buildup of burned food and grease in the convection oven. These conditions were confirmed by the Food Service Director.
A resident who was able to request toileting assistance was told by a staff member to urinate in her brief instead of being assisted to the bathroom, resulting in the resident feeling degraded and embarrassed. The incident was witnessed by the resident's roommate and confirmed through facility investigation as mental abuse, leading to the staff member's termination.
A resident with severe cognitive impairment and dementia, known for daily wandering and refusal to wear a wander guard, was able to exit the facility unsupervised by following a family member out the front door. The resident was later found in the parking lot by the DON, with no injuries identified.
A resident with Huntington's disease refused an outside appointment related to their diagnosis. Although staff attempted to reschedule by leaving a message with the hospital, there was no documentation that a new appointment was arranged, and the DON confirmed that no rescheduling occurred.
Two residents had physician-ordered medications administered without the required documentation of diagnosis or reason for use. Orders for medications such as Metoclopramide, Systane Hydration, and Lidocaine cream were missing ICD-10 codes or any stated indication, as confirmed by the DON.
A resident with multiple medical conditions was given an antibiotic after a Nurse Practitioner reviewed lab results that were only weakly suggestive of infection, despite the resident denying urinary symptoms and pending culture results.
The facility did not ensure that MDS assessments accurately reflected the status of two residents. One resident on hospice care was not properly documented as receiving hospice services in the MDS, and another resident's cognitive status was not assessed due to incomplete interviews by social services, resulting in missing information.
The facility failed to serve meals according to resident preferences, with lunch being delayed up to 2:00 p.m. and breakfast served too early. Residents expressed dissatisfaction with the new meal delivery process, which has led to altered meal times. Staff confirmed the changes and the resulting resident upset.
The facility failed to maintain a safe, clean, and homelike environment on the second-floor nursing unit. Observations included a detached privacy curtain, ripped floor mat, chipped walls, and a slow-draining sink. A resident reported brown spots in the bathroom, a dusty dresser, and clothing on the floor. The hot water temperature was uncomfortable, and a call bell plate had exposed wires. Interviews confirmed the facility's lack of cleanliness, contributing to these deficiencies.
A facility failed to develop comprehensive care plans for a resident with diabetes and a history of alcohol abuse. The care plan did not address the resident's refusal of medication or provide support for maintaining sobriety, despite the resident's need to attend meetings outside the facility. Staff interviews confirmed these deficiencies, highlighting a lack of coordination in care and support for the resident's needs.
The facility failed to provide adequate assistance with ADLs for three residents who were unable to perform these tasks independently. One resident was observed with facial hair and long nails despite requesting grooming, while another had long nails and expressed a desire for them to be trimmed. A third resident requested to have his beard shaved multiple times but was not assisted due to staff time constraints.
The facility failed to provide adequate supervision during transfers, resulting in falls for two residents who required two-person assistance. One resident fell during a hoyer lift transfer attempted by a single aide, while another fell due to insufficient staff assistance. Additionally, the facility environment posed hazards, with industrial detergent lacking instructions and a window without a safety lock, indicating lapses in maintaining a safe environment.
The facility failed to ensure accessible call systems for residents, with reports of delayed responses and staff turning off call bells without providing assistance. Observations confirmed that call bells were often out of reach, highlighting a systemic issue with the facility's call system accessibility and staff responsiveness.
The facility failed to maintain a sanitary environment on the second-floor nursing unit, affecting several residents. Observations revealed a strong urine odor in various areas, confirmed by staff and a resident's family member. Additional maintenance issues included broken blinds, stained windows, walls, and privacy curtains, violating Pennsylvania codes.
Failure to Provide Privacy During Medical Assessments and Phone Use
Penalty
Summary
The facility failed to ensure privacy for residents during both a medical assessment and a telephone conversation. Resident R82, whose annual MDS dated March 4, 2026 showed a BIMS score of 3 indicating severely impaired cognition, was observed on March 16, 2026 sitting in the dining room with approximately 15 residents, two staff members, and two otolaryngology consulting staff present while an ENT evaluation was performed. The otolaryngologist examined the resident's ear and throat in the dining room without privacy, and the Unit Manager later confirmed the concern and contacted the consultant, who then stopped conducting assessments in the dining room. Resident R8, whose annual MDS dated February 20, 2026 showed a BIMS score of 15 indicating intact cognition, was observed making a personal phone call on speakerphone in the dining room with approximately 15 residents, two staff members, and two otolaryngology consulting staff present. Resident R8 stated that the dining room telephone only had a speakerphone function, that there was no cell phone, and that there was no telephone in the resident's room because a previously working phone line had broken and was never replaced. The Unit Manager confirmed that the dining room telephone did not have a ringtone and only had speakerphone capability, and that there was no phone line available in the resident's room. During a Resident Council meeting, residents also reported that licensed nurses administered medications in hallways and the dining room and that dental screenings were performed in hallways.
Incomplete Investigation of Resident Fall
Penalty
Summary
The facility failed to ensure a resident’s fall was fully and thoroughly investigated to rule out neglect. Resident R6 was alert and oriented, admitted with a chronic compression fracture and recent hospitalization for weakness, and was care planned as incontinent of bowel and bladder, needing one person to assist with toileting, and at risk for falls with interventions including keeping the bed in the lowest position and using proper footwear. The resident had an unwitnessed fall and was found lying on the floor in the resident’s room. The facility’s fall prevention policy stated that fall reviews should include the new fall risk assessment, discussion with the resident and/or witnesses about possible causal factors, review of the environment where the fall occurred, and discussion of new interventions to prevent further falls. The investigation was incomplete because a witness statement was not obtained from the alert and oriented resident, and instead the record only included a quote that the resident said, “I was trying to get up,” along with documentation that the resident’s undergarment was wet when found. The investigation also did not include the environmental conditions at the time of the fall as a potential causal factor. The resident’s daughter stated the resident had put the call bell on, no one came, and the resident attempted to get out of bed and fell on a wet floor; the resident confirmed this account. The DON later confirmed the investigation was incomplete and acknowledged that Resident R6 uses the call bell for assistance.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent, and surveyors determined the medication error rate was 10.71%. During observation of medication administration, Employee E5, a Licensed Nurse, administered Aspirin chewable 81 mg to Resident R13 even though the physician order called for Aspirin delayed release 81 mg by mouth once daily. This was identified as administration of the incorrect medication formulation. The same observation also showed Employee E5 administering Tamsulosin 0.4 mg by mouth to Resident R13, while the physician order specified Tamsulosin 0.4 mg, one capsule, by mouth in the evening for elevated PVR. Employee E5 confirmed the findings at the time of observation. Surveyors also observed Employee E6, a Registered Nurse, administer Vitamin B-12 tablet by mouth to Resident R124, and the resident swallowed it. The physician order for Resident R124 directed Cyanocobalamin (Vitamin B-12) 1000 mcg tablet sublingual, making this another incorrect medication administration. The report notes that Resident R13 was signed onto hospice services with a diagnosis of end-stage PVD, and the medication administration observations for both residents contributed to the cited deficiency under Pa Code: 211.12(d)(1)(2)(5) Nursing Services.
Delayed Physician Notification of Fracture Result
Penalty
Summary
The facility failed to promptly notify the physician of a change in a resident's condition when a radiology report confirmed a fracture for Resident R6. Resident R6 was alert and oriented, admitted with a history of chronic compression fracture and recent hospitalization for weakness, and was care planned for bowel and bladder incontinence, one-person assistance with toileting, and fall risk precautions including keeping the bed in the lowest position and using proper footwear. After an unwitnessed fall, the resident was found lying on the floor in the room, and an on-call doctor ordered a 2-view x-ray of the right femur. The x-ray results showed a right femoral neck fracture, but nursing did not inform the physician of the fracture until the resident was transferred to the hospital three days later. The DON stated that nursing failed to inform the physician of the resident's fracture until the transfer.
Repeated Late Medication Administration and Poor Documentation of Insulin and Other Medications
Penalty
Summary
The deficiency involves the facility’s failure to administer medications within the time parameters ordered by physicians and outlined in facility policy for three cognitively intact residents. The facility’s undated "Administration of Medication" policy states that medications are to be given within 60 minutes before or after the designated administration time, with before‑meal medications given approximately 30 minutes before meals and after‑meal medications given no later than 30 minutes after meals. The facility’s meal delivery schedule shows defined breakfast, lunch, and dinner delivery windows, and the Food Director and Nursing Home Administrator both reported no concerns with late delivery of food trucks. There was no documented evidence of actual food delivery times. Despite this, multiple medication administration records (MARs) showed repeated late administrations without documented reasons or physician notification. For one resident with type 2 diabetes and hypertension, the MAR from late December showed numerous late administrations of carvedilol and insulin lispro. Carvedilol, ordered twice daily within specified time windows, was repeatedly given well after the ordered time ranges, including evening doses administered between approximately 8:18 p.m. and 9:21 p.m. when the ordered window was 5:00 p.m. to 7:00 p.m., and a morning dose given at 10:39 a.m. when the ordered window ended at 10:00 a.m. Insulin lispro ordered before meals and at bedtime was also frequently administered late, including morning, midday, afternoon, and bedtime doses given significantly after the scheduled times, some several hours after the ordered administration time. Documentation on the MAR typically noted "charted late" or similar brief comments, but there was no documented evidence of reasons for the delays or of physician notification. This resident reported that medications are often late. A second resident with a hip replacement and type 2 diabetes, cognitively intact, reported that insulin is often given long after meals, sometimes a few hours, despite being ordered to be given prior to meals. Review of this resident’s MAR for early to mid‑January showed repeated late administrations of scheduled pre‑meal insulin lispro doses. Morning, midday, and evening doses ordered within specific time ranges were frequently administered well after those ranges, including midday doses given more than an hour or several hours after the ordered window and morning doses given after the end of the scheduled time frame. Each late dose was documented as "charted late" with minimal comments such as "n/a" or similar, and there was no documented evidence of reasons for the late administration or physician notification. A third resident with a scapula fracture and type 2 diabetes, also cognitively intact, reported that morning medications are received late and that medications are always late, especially at night. Review of this resident’s MAR from late December through January showed late administration of antihypertensive and pain medications. Amlodipine ordered for morning administration within an 8:00 a.m. to 11:00 a.m. window was given after 11:00 a.m. on multiple occasions, and oxycodone ordered twice daily within specified morning and afternoon/evening windows was administered after the end of those windows, including doses given after 7:00 p.m. or later when the ordered window ended at 7:00 p.m. These late administrations were documented as "charted late" or "other" with comments such as "N/A" or "ok," and there was no documented evidence of reasons for the delays or of physician notification. The Director of Nursing confirmed that when medications are late they must be manually entered and documented as late, corroborating the pattern of late entries noted in the MARs.
Failure to Ensure Safe Return and Supervision of Visually Impaired Resident After Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with significant visual impairment and diabetes was not adequately supervised upon return from a medical appointment. The resident, who had a history of right eye exenteration for melanoma and a cataract in the left eye, required staff supervision for ambulation on both level and uneven surfaces, as documented in clinical and therapy assessments. Despite these needs, the resident was routinely transported to medical appointments by a contracted transportation company without evaluation for community mobility, and there were no procedures in place to ensure safe transfer of care back to facility staff upon return. On the day of the incident, the resident left the facility for a medical appointment with physician approval, which specified supervision by staff, family, or another authorized individual. However, after the appointment, the transportation driver dropped the resident off near the facility entrance but did not escort the resident into the building or sign them back into the care of nursing staff. Facility staff were unaware of the resident's whereabouts for an extended period and only realized the resident was missing after questioning and searching the building. The resident was later observed walking alone through the facility parking lot, having crossed a four-lane highway under construction to obtain food at a nearby restaurant. The resident had not received any food or a nutritious snack since leaving the facility that morning. Interviews with facility administration and nursing staff confirmed there were no policies or procedures to ensure residents were safely returned and signed back into the facility after outings with contracted transportation services.
Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service department related to the storage, preparation, and cleanliness of food service areas. Observations included significant trash accumulation around the loading dock near the dumpster, such as empty milk cartons, plastic juice cups, and paper. The dry storage area had a buildup of dust, dirt, and a black substance on the floor under shelves adjacent to the aluminum freezer walls. The walk-in freezer and cooler both had dirty floors with debris and stains under the shelves. In the dish room, the wall behind the high-pressure spray hose and scrap sink was dirty and had peeling paint. Additionally, the convection oven had a heavy buildup of burned-on food splatter and grease drippings on its interior surfaces. These findings were confirmed in an interview with the Food Service Director.
Failure to Protect Resident from Mental Abuse During Toileting Assistance
Penalty
Summary
A resident with a history of bipolar disorder, depression, muscle weakness, and scoliosis, who was continent of urine and able to request assistance, reported that after activating her call light to request help to use the bathroom, a staff member instructed her to urinate in her brief instead of assisting her to the toilet. The resident complied due to inability to hold her urine, and later expressed feelings of degradation and embarrassment about the incident. The event was corroborated by the resident's roommate, who overheard the aide expressing frustration and instructing the resident to go in her pants. Facility documentation and interviews confirmed that the resident was typically able to communicate her needs and receive assistance to the toilet. The facility's investigation substantiated the allegation of mental abuse, as the aide's actions constituted humiliation and deprivation, which are defined as mental abuse in the facility's policy. The aide involved was subsequently terminated following the investigation.
Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for a resident with severe cognitive impairment and a diagnosis of dementia. The resident was identified as being at risk for elopement, with documented daily wandering behavior and a history of removing his wander guard. The interdisciplinary team had previously placed the resident on 15-minute checks due to his refusal to wear the wander guard and continued wandering. On the date of the incident, the resident was last seen ambulating in the hallway and was found to be missing during a routine check. Staff initiated a search after the resident could not be located, and the Director of Nursing eventually found the resident in the parking lot. It was determined that the resident exited the facility through the front door, likely following a family member who was leaving the building. No injuries were identified upon assessment after the resident was returned to the facility.
Failure to Ensure Timely Rescheduling of Outside Professional Services
Penalty
Summary
The facility failed to ensure the timely provision of professional services by outside providers for one resident diagnosed with Huntington's disease. The resident was admitted with this neurological disorder and had an outside appointment scheduled related to their diagnosis. According to nursing documentation, the resident refused to attend the appointment, and staff attempted to reschedule by leaving a message with the hospital to arrange a new date and time. However, there was no documented evidence in the clinical record that the appointment was successfully rescheduled, and the Director of Nursing confirmed that no new appointment had been made.
Incomplete Documentation of Medication Orders
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not documenting the diagnosis or reason for use for several physician-ordered medications. For one resident, orders for Metoclopramide HCl and Systane Hydration did not include an ICD-10 diagnosis or any reason for use, with the diagnosis field marked as 'N/A.' For another resident, an order for Lidocaine HCl cream also lacked a documented diagnosis or reason for use, with the diagnosis field left blank. These omissions were confirmed during an interview with the Director of Nursing, who acknowledged that all medication orders are required to list the diagnosis or reason for use to be considered complete.
Antibiotic Prescribed Without Adequate Indication
Penalty
Summary
A deficiency was identified when a resident with a history of bipolar disorder, depression, muscle weakness, and scoliosis was administered an antibiotic without adequate indication for use. The resident's clinical record showed an abnormal urinalysis and an improving white blood cell count, but the resident denied any urinary symptoms. Despite the lack of clear symptoms, a Nurse Practitioner ordered Bactrim DS for three days after reviewing the laboratory results. The physician's note indicated that the urinalysis was only weakly suggestive of infection and that further culture results were pending at the time the antibiotic was prescribed.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident admitted with Parkinson's Disease and placed on hospice care per physician order, the Significant Change MDS assessment indicated a life expectancy of less than six months in Section J, but Section O did not document that the resident was receiving hospice services. This discrepancy was confirmed by the MDS Coordinator, who acknowledged that Section O should have been completed for hospice. For another resident, a Quarterly MDS assessment had Section C: Cognitive Pattern marked as not assessed, as interviews for mental status were not completed in time by the social services department, resulting in the section being coded as no information.
Delayed Meal Service and Resident Dissatisfaction
Penalty
Summary
The facility failed to serve meals in accordance with resident preferences on both the 1st and 2nd floor nursing units. Interviews with residents revealed that lunch, which was previously served at noon, has been consistently delayed, sometimes being served as late as 2:00 p.m. Observations confirmed that lunch trucks were delivered late, with the last residents on the 1st floor receiving their meals at 1:42 p.m. Additionally, residents reported that breakfast is being served too early, often before they are awake, and dinner is also served later than preferred, with one resident noting dinner was served at almost 7:00 p.m. the previous night. Staff interviews indicated a recent change in the process of delivering meal trays, which has resulted in the altered meal times. A nurse aide confirmed that the 1st floor nursing unit was waiting for additional food trucks and that the new schedule has upset many residents. A resident council meeting further corroborated these issues, with multiple residents expressing dissatisfaction with the timing of breakfast and lunch. The facility's failure to adjust meal service to meet resident needs and preferences constitutes a deficiency in care.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the second-floor nursing unit. Observations revealed several issues, including a privacy curtain partially detached due to missing hooks, a ripped and stained floor mat, and chipped walls. A resident reported a slow-draining bathroom sink, scrapped walls, brown spots on bathroom walls and around the toilet, and a dusty dresser with spilled sugar. The air conditioning unit was dusty with brown spots from old spills. Clothing was found in large bags on the floor, and the bathroom had brown spots and a broken hot water handle, preventing the water from being turned off. The floor was dirty, and there was unrolled toilet paper on the floor. The hot water temperature in the shower room was between 95 F and 99 F, which was not comfortable for residents. Interviews with residents and family members confirmed the facility's lack of cleanliness, with reports of a urine smell and dry stool in a restroom that had to be cleaned by a family member. Maintenance and housekeeping staff confirmed the observations, including exposed wires from a call bell plate that had fallen off the wall. The facility's failure to adhere to its cleaning policy and maintain a sanitary environment contributed to these deficiencies, as evidenced by the observations and interviews conducted during the survey.
Failure to Develop Comprehensive Care Plans for Medication and Sobriety Support
Penalty
Summary
The facility failed to develop comprehensive care plans for a resident, identified as R50, specifically related to medication administration and the management of a history of alcohol abuse. The facility's policy requires a comprehensive, person-centered care plan for each resident, including measurable objectives and timetables to address medical, nursing, mental, and psychosocial needs identified in comprehensive assessments. However, the care plan for Resident R50 did not address the resident's refusal of medication, education for the resident and staff, or any plan for managing hypoglycemia. The resident, who has a diagnosis of diabetes mellitus, routinely refused blood glucose tests and insulin, yet the care plan only included a goal to be free of signs and symptoms of hypoglycemia without addressing the refusal of medication. Additionally, the care plan did not include the resident's history of alcohol abuse or support for maintaining sobriety, despite the resident's expressed need to attend meetings twice a week outside the facility. Interviews with staff and the resident confirmed these deficiencies. The Director of Nursing also confirmed the findings, indicating a lack of coordination in care and support for the resident's needs, including assistance with preparing and traveling to group meetings outside the facility.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide appropriate assistance with Activities of Daily Living (ADL) for three residents who were unable to perform these tasks independently. Resident R19, who was dependent on staff for personal hygiene, transfer, and toileting, was observed with facial hair and long nails, despite expressing a desire to have them trimmed. The Unit Manager confirmed this observation. Resident R29, also dependent on staff for personal hygiene, transfer, toileting, dressing, and bed mobility, was observed with long nails and expressed a desire to have them trimmed, which was confirmed by a Licensed Nurse. Resident R75, who required extensive assistance from one to two staff members for personal hygiene, bathing, and toileting, requested to have his beard shaved multiple times over several days. Despite his requests, the task was not completed due to staff time constraints, as confirmed by a grievance investigation and a statement from a Certified Nursing Assistant. These deficiencies were observed and confirmed by various staff members, indicating a failure to adhere to the facility's policy on personal care, which mandates daily morning care to promote resident comfort and cleanliness.
Inadequate Supervision and Environmental Hazards in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision during resident transfers, leading to falls for two residents. Resident R84, who was cognitively intact and required total dependence on two-person assistance for transfers, fell during a transfer with a hoyer lift. The incident occurred because a nurse aide, Employee E4, attempted the transfer alone, contrary to the resident's care plan and facility policy requiring two-person assistance. The hoyer lift tipped during the transfer, resulting in the resident falling to the floor. Similarly, Resident R30, who had a history of falls and required two-person assistance for transfers, fell while being transferred by only one employee. The resident confirmed the fall during an interview, and facility documentation revealed discrepancies in staff accounts of the transfer process. Employee E20 was terminated for not following the care plan appropriately, as the resident was transferred without the required assistance, leading to the fall. Additionally, the facility environment posed accident hazards due to improper handling and storage of cleaning agents and unsecured windows. The laundry room contained industrial detergent without proper instructions or measuring tools, posing a risk to residents using it. A resident reported skin sensitivity after using the detergent. Furthermore, a window in the dementia unit lacked a safety lock, allowing it to open widely, which was against safety protocols. The Maintenance Director was unaware of this issue, indicating a lapse in maintaining a hazard-free environment.
Inaccessible Call Systems and Poor Staff Response
Penalty
Summary
The facility failed to ensure that the call systems were accessible and functional for 11 residents, as required by their policy. Observations and interviews revealed that residents were unable to reach their call bells, and when they did, the response from staff was inadequate. For instance, Resident R75 reported a delay of one hour in response to their call bell, and often had to use their phone to contact the nursing station. Additionally, during a resident council meeting, several residents reported that staff would turn off call bells without providing assistance, often stating they were not assigned to the resident and failing to return. Specific observations highlighted the inaccessibility of call bells for residents. Resident R49's call bell was found underneath the bed and on the floor, making it unreachable, which was confirmed by staff members. Similarly, Resident R29's call bell was placed on a dresser, out of reach, and a nurse mentioned the need for a clip to attach it to the sheets. These deficiencies were observed and confirmed by facility staff, indicating a systemic issue with the accessibility and responsiveness of the call system in the facility.
Sanitation and Maintenance Deficiencies on Second-Floor Nursing Unit
Penalty
Summary
The facility failed to maintain a functional and sanitary environment on the second-floor nursing unit, affecting six out of ten residents reviewed. The facility's policy requires daily cleaning of occupied resident rooms and mandates housekeeping to report any maintenance issues. However, observations revealed a persistent strong urine odor in various areas of the second-floor nursing unit, including near the dining room and specific resident rooms. These observations were confirmed by both a licensed nurse and the Maintenance and Housekeeping Director. Additionally, a family member of a resident reported frequent urine odors and unsanitary conditions, further corroborating the findings. Further observations on the second-floor nursing unit revealed additional maintenance issues. Resident rooms were found with broken blinds, stained windows, walls, and privacy curtains. These deficiencies were confirmed by the Maintenance Director during the survey. The facility's failure to address these issues is in violation of several Pennsylvania codes, including the Administrator's responsibility, management, and window maintenance regulations.
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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