Wesley Enhanced Living Pennypack Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 8401 Roosevelt Boulevard, Philadelphia, Pennsylvania 19152
- CMS Provider Number
- 395413
- Inspections on file
- 26
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Wesley Enhanced Living Pennypack Park during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and multiple pressure ulcers did not have required wound care documentation completed on several occasions. The facility's records lacked details of wound treatments for multiple wound sites, contrary to its own wound care policy and professional standards.
A resident with severe obesity, dementia, and muscle weakness, who required two staff for mechanical lift transfers, was transferred by a single CNA in violation of policy and care plan. During the transfer, the resident fell, sustaining multiple skin tears and bruising, and experienced severe pain requiring hospital evaluation. Investigation found no equipment defect and confirmed only one staff member was present during the transfer.
A resident who was dependent on staff for transfers was moved using a mechanical lift by a single nurse aide, despite facility policy and physician orders requiring two staff for such transfers. During the transfer, the resident fell, sustaining multiple skin tears, bruising, and severe pain, which required hospitalization. Investigation confirmed the lift equipment was not defective and the incident was due to inadequate staffing during the transfer.
A nurse aide did not receive a required annual performance review, and a resident was injured during a transfer when the aide used a mechanical lift alone, against facility policy requiring two staff for such transfers. The DON confirmed there was no process for completing employee performance evaluations.
A facility failed to re-admit a resident after hospitalization, despite the resident being medically stable and off restraints. The resident, with a history of aggressive behavior and multiple medical conditions, was initially sent to the hospital due to increased aggression. The facility's DON and NHA refused re-admission, citing inadequate documentation, and did not collaborate with the hospital to address the resident's needs, leading to a deficiency.
A facility failed to create a person-centered care plan for a resident with complex medical and psychological needs, including anxiety and hallucinations. The resident exhibited challenging behaviors such as aggression and medication refusal, yet no comprehensive plan was in place to manage these issues. The Unit Manager confirmed the absence of such a plan, highlighting a deficiency in regulatory compliance.
A resident with a history of UTI and delirium was admitted with acute encephalopathy and exhibited aggressive behaviors. Despite repeated recommendations from a psychiatric nurse practitioner to conduct lab tests, including a urine analysis, the facility failed to follow through. The resident's condition worsened, leading to hospitalization for an acute kidney injury and a UTI.
A resident with diabetes exhibited aggressive behaviors and refused meals and medications. Despite recommendations from an endocrinologist and a psychiatric nurse practitioner to consult endocrinology and monitor blood sugar levels, the facility failed to schedule an appointment or contact the endocrinologist. The DON confirmed the endocrinologist was not contacted regarding the resident's diabetes management.
The facility failed to maintain an effective pest control program, leading to the presence of pests such as mice and roaches. Observations noted an air gap in the kitchen doors and a mouse in the second floor kitchenette. Pest control reports from June to October 2024 indicated repeated treatments but highlighted issues like food debris and water on kitchen floors, suggesting inadequate pest control measures.
A facility failed to update a resident's care plan regarding their activities of daily living. The resident, with diagnoses of muscle weakness, dementia, and mobility issues, had a physician's order for physio-therapy. Despite this, the care plan was not revised to reflect the resident's current status, as confirmed by the DON.
A resident with a history of alcohol abuse eloped from the facility unsupervised, returning with alcohol. Despite being cognitively intact, the resident left without using her usual mobility aids, which went unnoticed by staff. The facility's elopement prevention policy was not effectively implemented, leading to a lapse in supervision.
A facility failed to follow physician orders for a resident's indwelling urinary catheter. The resident, with a history of UTI, cognitive communication deficit, and depression, had an order for a 16FR/10ML Foley catheter. However, the catheter in use lacked size markings, preventing verification of compliance with the order. This was confirmed by an RN.
A resident experienced significant weight loss and developed pressure sores, yet the facility failed to conduct a comprehensive nutritional assessment as required by its policies. Despite a low albumin level indicating malnutrition and the resident's need for assistance with eating, there was no documentation of nutritional interventions or consideration of food preferences and adaptive utensils.
A resident with multiple health conditions was found to be receiving oxygen at 4.5 liters per minute, contrary to the physician's order of 2 liters per minute for pulse oxygen levels below 92%. The oxygen tubing was also not dated, and there were no orders for the frequency of tubing changes, as confirmed by staff interviews.
A facility failed to document the clinical rationale for continuing an antipsychotic medication and did not attempt a gradual dose reduction (GDR) for a resident. The resident, admitted with dementia and muscle weakness, was prescribed Quetiapine Fumarate for psychosis. The facility's policy requires a GDR unless clinically contraindicated, but no evidence of a GDR attempt or rationale documentation was found. The DON confirmed these findings.
A resident's medications were found unattended on a bedside table, left by a nurse without explanation. The resident, with multiple health conditions, confirmed the medications were his. A nurse verified the medications were left unattended, indicating a failure in secure storage and administration protocols.
A resident experienced prolonged mouth pain due to decaying teeth, as the facility failed to provide timely dental services despite a policy ensuring routine and emergency care. A dental examination confirmed the need for extractions and dentures, but staff delayed arranging these services, acknowledging awareness of the required follow-up care.
A facility failed to ensure accurate physician orders for a resident's oxygen therapy. The resident was observed without the prescribed oxygen device, and both the resident and their MDS indicated no need for oxygen therapy. A nurse confirmed the inaccuracy of the orders.
A facility failed to maintain an effective infection control program when an RN examined a resident's urinary Foley catheter without wearing PPE, despite the resident being suggested for Transmission Based Precautions. The facility's policy requires PPE to prevent exposure to body fluids, which was not adhered to in this instance.
The facility did not provide education on the benefits and potential side effects of the influenza vaccine to residents before administering it for the 2024-2025 flu season. This was confirmed through clinical record reviews and staff interviews, indicating a lapse in compliance with Pennsylvania Code requirements.
Essential equipment in the dietary services department was not fully operational, with dish machines in the main kitchen and nursing unit kitchenettes failing to meet the manufacturer's specifications for sanitizing temperatures. The main kitchen's dish machine required a booster heater repair, while the second floor B wing, first floor A wing, and C wing kitchenettes had dish machines with insufficient rinse temperatures.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure complete documentation of wound care treatments for one resident with multiple pressure ulcers. According to the facility's own wound care policy, specific information must be recorded in the medical record after each wound treatment, including the type of care given, date and time, resident positioning, the name and title of the caregiver, assessment data, resident tolerance, and any problems or refusals. However, review of the clinical record for a resident diagnosed with hemiplegia, hemiparesis, and stage 4 sacral pressure ulcer revealed missing documentation for wound treatments on several dates for multiple wound sites, including the right buttock, right heel, sacrum, left ischial, and lateral ankle. The absence of required documentation was noted on multiple occasions, with no records of wound care being completed for the specified areas on the identified dates. The facility's failure to document these treatments is not in accordance with accepted professional standards and the facility's own policy, as required by regulation. The findings were based on a review of clinical records and facility-provided documentation.
Failure to Provide Sufficient Staff During Mechanical Lift Transfer Resulting in Resident Harm
Penalty
Summary
Facility staff failed to follow established protocols requiring two nursing assistants to perform a mechanical lift transfer for a resident with morbid obesity, dementia, and muscle weakness. The resident was assessed as dependent for bed mobility and transfers, with care plans and physician orders specifying the need for extensive assistance of two staff members during transfers using a stand-up lift. Despite these requirements, a nurse aide conducted a transfer alone, contrary to facility policy and the resident's care plan. During the transfer, the resident fell from the mechanical lift. The nurse aide initially reported that the sling broke during the transfer, but subsequent inspection by staff and interviews revealed no evidence of damage or defect to the sling. The incident resulted in the resident sustaining multiple skin tears to the left forearm, hand, and wrist, as well as bruising to the head and face. The resident experienced severe pain, with pain levels reported as high as 10 out of 10, and required transfer to the hospital for further evaluation and treatment. Documentation and interviews confirmed that only one staff member was present during the transfer, in violation of facility policy, the resident's care plan, and physician orders. There was no evidence that the equipment was defective, and the failure to have sufficient staff directly led to the resident's fall and subsequent injuries.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with morbid obesity, dementia, and muscle weakness, who was dependent on staff for all transfers, was transferred using a mechanical stand-up lift by a single nurse aide, contrary to facility policy, care plan, and physician orders that required the assistance of two staff members. The nurse aide performed the transfer alone, and during the process, the resident fell from the lift. The incident resulted in the resident sustaining multiple skin tears to the left forearm and hand, bruising to the head and face, and experiencing severe pain, which ultimately required hospitalization for evaluation and treatment. Facility documentation and staff interviews confirmed that the mechanical lift and sling were not defective or broken, and the failure was attributed to the lack of a second staff member during the transfer. The resident's care plan and physician orders clearly specified the need for two-person assistance with all mechanical lift transfers, and the facility's policy reinforced this requirement. Despite these directives, the nurse aide proceeded with the transfer alone, leading to the resident's fall and subsequent injuries. The investigation further revealed that the environment was not maintained free from accident hazards, as required by regulation, due to the improper use of the mechanical lift and lack of adequate supervision. The resident reported significant pain following the incident, and clinical observations documented active bleeding and multiple wounds. The facility's failure to ensure adherence to safe transfer techniques and supervision directly resulted in actual harm to the resident.
Failure to Complete Annual Performance Review and Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to complete a performance review for a nurse aide at least once every 12 months, as required by policy. Review of personnel files showed no documented evidence that the nurse aide had a performance evaluation for the years 2024 and 2025. The Director of Nursing confirmed that there was no process in place for completing performance evaluations for employees, including the nurse aide in question. Additionally, an incident occurred in which a resident fell while being transferred from a wheelchair to a bed using a mechanical lift. The nurse aide performed the transfer alone, contrary to facility policy requiring two staff members for all Hoyer lift transfers. The resident sustained an injury as a result of the fall. Inspection of the mechanical lift sling revealed no issues, and the Director of Nursing confirmed that the injury occurred due to the nurse aide transferring the resident independently.
Facility Fails to Re-Admit Resident Post-Hospitalization
Penalty
Summary
The facility failed to re-admit a resident after a change in condition, which was identified as a deficiency. The resident, who had a history of morbid obesity, transient cerebral ischemic attack, hypertension, cognitive communication deficits, diabetes, and a urinary tract infection, exhibited aggressive behaviors such as kicking, scratching, yelling, and refusing meals and medications. On March 3, 2025, the resident was sent to the hospital due to increased aggression and was later diagnosed with an acute kidney injury and treated for a urinary tract infection. Despite the hospital's report that the resident no longer required Haldol or physical restraints, the facility refused to re-admit the resident. The hospital social worker documented that the resident had been off restraints for over 60 hours and was medically stable for discharge. However, the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) expressed concerns about the resident's stability and refused re-admission, citing inadequate documentation of the resident's condition. The facility did not provide documentation to support their decision not to re-admit the resident, nor did they collaborate with the hospital to address the resident's needs. Interviews with the DON and NHA confirmed the lack of documentation and collaboration, which contributed to the deficiency. The facility's actions were not in compliance with the regulatory requirements for permitting residents to return after hospitalization.
Plan Of Correction
The facility does and shall ensure to permit residents to return to the facility after hospitalization/therapeutic leave. The facility does and shall ensure to follow the bed hold policy permitting residents to return to the facility after hospitalization/therapeutic leave. The facility does and shall ensure to document conversations with the hospital and family regarding transfer back to the facility. Monitoring/random review will be conducted by admission director or designee and social services 1 time weekly for 3 months with findings reported to the CQI Committee for a period deemed appropriate by the CQI Committee.
Failure to Develop Person-Centered Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who exhibited various challenging behaviors and refused medications. The resident, who had multiple diagnoses including morbid obesity, transient cerebral ischemic attack, hypertension, cognitive communication deficits, diabetes, and a urinary tract infection, was also being treated for anxiety, visual hallucinations, and disorientation. Despite these complex medical and psychological needs, the facility did not create a comprehensive care plan to address the resident's behaviors and medication refusals. The resident displayed a range of behaviors from January to March 2025, including kicking, scratching, yelling, screaming uncontrollably, refusing meals and medications, and exhibiting increased anxiety. The resident also attempted to climb out of bed, removed clothing, and was combative with staff. These behaviors were documented in nursing notes, which detailed incidents of the resident being anxious, confused, lethargic, and aggressive, often requiring staff intervention and, at times, hospitalization. Despite these documented behaviors, the facility did not have a plan of care in place to manage the resident's behaviors effectively. The Unit Manager confirmed the absence of a person-centered care plan to address and manage the resident's behaviors, which was a significant oversight given the resident's complex needs and the frequency of behavioral incidents. This lack of a comprehensive care plan was a deficiency in meeting the regulatory requirements for developing and implementing person-centered care plans.
Plan Of Correction
The facility does and shall develop and implement comprehensive person-centered care plans for each resident, that includes measurable objectives and timeframes also consistent with the residents' rights to meet resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The facility does and shall ensure that comprehensive care plan is culturally competent. All residents' comprehensive care plans will be reviewed to ensure they are comprehensive and include any interventions deemed necessary. All nursing staff have/will be educated on proper comprehensive care planning and the importance of ongoing care plan updates to ensure the most effective and contemporary care. Monitoring/random review of comprehensive care plans will be conducted 1 time weekly for 3 months with findings reported to the CQI Committee for a period deemed appropriate by the CQI Committee. Monitoring/random review of comprehensive care will be conducted 1 time weekly for 3 months with findings reported to the CQI Committee for a period deemed appropriate by the CQI Committee.
Failure to Follow Lab Test Orders for Resident with UTI and Behavioral Issues
Penalty
Summary
The facility failed to ensure that physician orders and recommendations for laboratory tests were followed for a resident who was admitted with acute encephalopathy and a urinary tract infection. The resident, who had a history of UTI with delirium, exhibited various behaviors such as increased anxiety, hallucinations, and aggression. Despite the psychiatric nurse practitioner's repeated recommendations to obtain a urine analysis and other lab tests to rule out infectious or metabolic causes of the resident's altered mental status, these tests were not conducted. The resident's clinical records showed ongoing behavioral issues, including aggression towards staff and other residents, refusal of meals and medications, and attempts to leave the facility. The psychiatric nurse practitioner made multiple visits and consistently recommended lab tests to assess the resident's condition, but these recommendations were not addressed by the facility. The resident's condition did not improve, and he was eventually transferred to the hospital, where he was diagnosed with an acute kidney injury and treated for a urinary tract infection. Interviews with the Unit Manager confirmed that the urine analysis ordered by the physician and recommended by the nurse practitioner on several occasions was not completed. This oversight in following medical orders and recommendations contributed to the resident's continued behavioral issues and eventual hospitalization.
Plan Of Correction
The Facility does and shall ensure that routine and emergency Lab services were provided for all residents to meet their health needs. All residents will be reviewed for Lab orders to meet health needs. Education has been done. All nursing staff have/will be educated regarding timely lab services for all residents. Monitoring and random check will be conducted by supervisors/Unit Managers once a day for 2 weeks and 1 time a week for 6 weeks. Findings and on-going monitoring will be reported to the CQI Committee for a period deemed appropriated by the CQI Committee. Monitor: Unit Managers/shift Supervisor/DON
Failure to Address Endocrinology Consultation for Resident
Penalty
Summary
The facility failed to ensure that a recommendation for a resident to be seen by an endocrinologist was addressed. The resident, who had a history of diabetes, was seen by the facility endocrinologist, who recommended a follow-up in 2-4 weeks and advised the facility to contact them sooner if there were any concerns or changes in the resident's health status related to diabetes. Despite this, there was no evidence in the clinical record that the nursing staff scheduled an appointment or contacted the endocrinologist, even after a psychiatric nurse practitioner noted that the resident's behaviors might be linked to low blood sugar levels and advised consulting endocrinology. The resident exhibited various behaviors, including aggression towards staff and other residents, refusal of meals, and medication non-compliance, which were documented in multidisciplinary notes. The psychiatric nurse practitioner highlighted that the resident's condition worsened when blood sugar levels were low and recommended frequent blood sugar checks and a urinalysis to rule out other medical causes. However, these recommendations were not acted upon, and the Director of Nursing confirmed that the endocrinologist was not contacted regarding the resident's diabetes management concerns.
Plan Of Correction
The Facility does and shall ensure that endocrinologist services were provided for all residents to meet their spatialized health needs. All nursing staff have/will be educated regarding timely dental services for all residents. Monitoring and random checks will be conducted by supervisors/Unit Managers once a day for 2 weeks and 1 time a week for 6 weeks. Findings and ongoing monitoring will be reported to the CQI Committee for a period deemed appropriate by the CQI Committee. Monitor: Unit Managers/shift Supervisor/DON
Inadequate Pest Control Measures in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests within the building. Observations revealed that the main kitchen had a set of double doors leading to a concrete dock, which did not seal completely, creating an air gap that allowed easy access for pests and rodents. Additionally, a large metal dumpster was located just below the dock, where garbage and refuse were stored, potentially attracting pests. On the second floor B wing nursing unit kitchenette, a mouse was observed running across the floor into a hole beneath the wooden cabinets, which showed signs of water damage. This kitchenette was equipped with a dish machine and sink used for residents dining in the area. The pest control operator's reports from June to October 2024 indicated repeated treatments for common household pests, including mice and roaches, within the building. The reports highlighted issues such as food debris and excess water on the kitchen floors, and the need for cleaning floor drains to ensure proper drainage. Despite these treatments, the presence of pests persisted, indicating that the facility's pest control measures were inadequate. The facility's management and licensee were found to be responsible for these deficiencies under the relevant Pennsylvania Code sections.
Failure to Revise Care Plan for Resident's ADLs
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident R32, regarding their activities of daily living. Resident R32 was admitted to the facility with diagnoses including muscle weakness, dementia, and abnormalities of gait and mobility. A physician's order dated March 13, 2024, indicated a need for a physio-therapy evaluation and treatment. However, the care plan, which was initiated on January 16, 2024, and had a target date of September 8, 2024, was not updated to reflect the resident's current status or improvements in activities of daily living. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan had not been revised to reflect the resident's current condition.
Resident Elopement and Alcohol Possession
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident R80, who was able to leave the facility without staff knowledge. The facility's policy on elopement, effective since December 12, 2016, was not effectively implemented in this case. Resident R80, who was cognitively intact with a BIMS score of 15, left the facility unsupervised and returned with alcohol, despite having a history of alcohol abuse. The resident was not using her usual mobility aids, which might have alerted staff to her unsupervised departure. The incident occurred when a CNA discovered Resident R80 missing during a routine check. Despite a search by staff and security, the resident was not found until she returned to her room. Upon her return, staff noticed the smell of alcohol on her breath and discovered bottles of alcohol in her possession. The resident claimed to have attended a party and purchased alcohol, which was confirmed by the presence of a shopping bag containing alcohol bottles. The front desk staff did not notice anything unusual when the resident left, as she had not previously shown any signs of elopement risk. Interviews with staff confirmed the sequence of events, and it was noted that the resident frequently left the facility with family members, which may have contributed to the oversight. The facility's failure to recognize and address the potential for elopement, despite the resident's history of alcohol abuse and her verbal indications of wanting to leave, highlights a lapse in supervision and adherence to the facility's elopement prevention policy.
Failure to Follow Physician Orders for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that physician orders were followed for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including a urinary tract infection, cognitive communication deficit, and depression, had a physician order dated August 23, 2024, for a 16FR/10ML Foley catheter due to urinary retention. On October 24, 2024, it was observed that the Foley catheter in use for the resident did not have the size marked, preventing verification that the correct catheter size was used as per the physician's order. This finding was confirmed by a registered nurse at the facility.
Failure to Monitor and Assess Nutritional Status
Penalty
Summary
The facility failed to adequately assess and monitor the nutritional status of a resident, identified as Resident R27, which led to a deficiency in maintaining acceptable nutritional parameters. The facility's policy required that any weight change of less than five pounds should prompt the nursing staff to notify the dietitian, who would then conduct a nutritional assessment and provide necessary interventions. However, despite a significant weight loss of seven pounds in one month and a total of twenty-one pounds over six months, there was no documentation indicating that a comprehensive nutritional assessment was conducted for Resident R27. Additionally, the resident's clinical records showed a low albumin level, indicative of malnutrition, and the development of an arterial wound and a new sacral pressure sore, yet no nutritional assessment was documented following these changes in the resident's condition. Observations during a breakfast meal revealed that Resident R27 required assistance with eating and was consuming warm cooked cereal with milk. There was no evidence that the resident's food preferences, nutritional supplementation, or the use of adapted utensils were considered to enhance food consumption and eating abilities. Interviews with the registered nurse, nursing aide, and registered dietitian confirmed the absence of a documented nutritional assessment for the month of October, despite the resident's ongoing weight loss and the development of pressure sores. This lack of assessment and intervention highlights the facility's failure to adhere to its own policies and ensure the nutritional well-being of Resident R27.
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen as ordered by the physician for a resident, identified as Resident R22. Resident R22 was admitted with multiple diagnoses, including Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis, obesity, Essential Hypertension, and an unspecified fracture of the left lower leg. A physician's order dated September 26, 2024, specified that oxygen should be administered at 2 liters per minute via nasal cannula when the resident's pulse oxygen level was below 92% on room air. However, during an observation on October 21, 2024, it was found that Resident R22 was receiving oxygen at 4.5 liters per minute, contrary to the physician's order. Additionally, the oxygen tubing was not dated, and there were no orders specifying the frequency of tubing changes. Interviews with the Unit Manager and Director of Nursing confirmed these findings.
Failure to Document Rationale for Antipsychotic Use and Attempt GDR
Penalty
Summary
The facility failed to provide documentation of a clinical rationale for the continued administration of an antipsychotic medication and did not attempt a gradual dose reduction (GDR) for a psychoactive drug for one resident. According to the facility's policy on Medication Monitoring and Management, a GDR should be attempted in two separate quarters within the first year of antipsychotic therapy, unless clinically contraindicated. After the first year, a GDR must be attempted annually. The policy also states that a GDR is clinically contraindicated if target symptoms return or worsen after the most recent attempt, and the physician must document the clinical rationale for not attempting further dose reductions. Resident R32 was admitted with diagnoses including dementia and muscle weakness. The resident had a physician order for Quetiapine Fumarate, an antipsychotic medication, for psychosis in the absence of dementia. However, the clinical record lacked evidence of a physician review for a GDR or documentation of the rationale for continuing the medication. The Director of Nursing confirmed these findings during an interview, indicating a failure to adhere to the facility's policy and regulatory requirements.
Failure to Securely Store and Administer Medications
Penalty
Summary
The facility failed to ensure the safe storage of drugs and biologicals for one resident, identified as Resident R36. The resident was admitted with multiple diagnoses, including Atherosclerosis Heart Disease, Type 2 Diabetes Mellitus, and Essential Hypertension, among others. The physician's orders for Resident R36 included several medications such as Aspirin, Lasix, Metoprolol Tartrate, Plavix, and Metformin HCl ER, with specific administration times. However, during an observation, it was found that these medications were left unattended on the resident's bedside table in a medication cup. The resident confirmed that the medications were his and that they were left by a nurse without any explanation of what they were. A licensed nurse, identified as Employee E9, confirmed that the medications were indeed left unattended on the bedside table. This incident indicates a failure in the facility's protocol to ensure that medications are securely stored and properly administered, as required by professional principles and regulations.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident R56, who was cognitively intact and experiencing mouth pain and discomfort due to decaying teeth. The facility's policy, dated December 2016, stated that routine and emergency dental services should be provided to all residents, with a dentist contracted to visit monthly and as needed. However, despite a dental examination on August 28, 2024, confirming the need for dental care, including extractions and fitting for dentures, the resident reported waiting several months for the nursing staff to arrange these services. Interviews with the resident and staff, including a registered nurse and a social worker, confirmed the delay in providing timely dental services. The staff acknowledged awareness of the dental evaluation and the recommended follow-up care but failed to act promptly. This inaction resulted in the resident continuing to experience pain and discomfort, highlighting a deficiency in the facility's adherence to its dental services policy and the responsibilities of the social worker in assisting with dental appointments and transportation arrangements.
Inaccurate Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of physician orders for a resident, identified as Resident R32. A review of the physician order dated March 13, 2024, indicated that Resident R32 was to have their oxygen tubing changed weekly and their pulse oximetry checked every shift, with oxygen administered as needed if their pulse oximetry reading fell below 92% on room air. However, during an observation on October 24, 2024, it was noted that Resident R32 did not have an oxygen device in place as ordered. An interview with Resident R32 revealed that they had not been receiving or needing oxygen therapy for a long time. The Minimum Data Set (MDS) for Resident R32, dated September 3, 2024, also indicated that the resident was not receiving oxygen therapy. Employee E9, a Registered Nurse, confirmed that the physician orders related to oxygen for Resident R32 were not accurate.
Infection Control Deficiency: Failure to Use PPE
Penalty
Summary
The facility failed to maintain an effective infection control program related to Transmission Based Precautions for one resident. The facility's policy, effective October 2018, requires the use of Transmission Based Precautions when measures more stringent than Standard Precautions are necessary to prevent infection spread. This includes wearing Personal Protective Equipment (PPE) to prevent exposure to body fluids. On October 24, 2024, a Registered Nurse (RN), identified as Employee E9, examined the urinary Foley catheter of a resident who was suggested for Transmission Based Precautions without wearing PPE. Employee E9 confirmed the failure to wear PPE during the examination.
Failure to Educate Residents on Flu Vaccine
Penalty
Summary
The facility failed to provide education related to influenza vaccines to six residents before administering the vaccine for the 2024-2025 flu season. Clinical record reviews and staff interviews revealed that residents were offered and received the flu vaccine without documented evidence of being informed about the benefits and potential side effects. The Director of Nursing confirmed that the residents did not receive the necessary education prior to vaccination, which is a requirement under the relevant Pennsylvania Code sections.
Deficient Dish Machine Temperatures in Dietary Services
Penalty
Summary
Essential mechanical equipment used for the food and nutrition services department in the facility was found to be not fully operational and safe. Observations in the main dietary kitchen revealed a dish machine that did not meet the manufacturer's recommendations for safe operation, which required hot water for cleaning and sanitizing dishes, utensils, bowls, cups, and everyday china. The director of Dietary Services, Employee E3, confirmed that the booster heater needed mechanical equipment, specifically a pressure reducing valve, and repair to maintain the dish machine safely and in accordance with the manufacturer's specified final rinse temperature of 180 degrees Fahrenheit. Further observations in the nursing unit kitchenettes revealed similar deficiencies. The dish machine in the second floor B wing nursing unit kitchenette was not maintained according to the manufacturer's specifications, with a final water rinse temperature of only 86 degrees Fahrenheit, far below the required 180 degrees Fahrenheit. Additionally, dish machines in the first floor A wing and C wing nursing unit kitchenettes were also not maintained properly, with final rinse temperatures of 157 and 165 degrees Fahrenheit, respectively, instead of the required 180 degrees Fahrenheit. These deficiencies were confirmed with the director of dietary services, Employee E3.
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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