Parkhouse Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Royersford, Pennsylvania.
- Location
- 1600 Black Rock Road, Royersford, Pennsylvania 19468
- CMS Provider Number
- 395454
- Inspections on file
- 32
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Parkhouse Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with dementia, left shoulder pain, and a significant left-hand contracture had an OT plan with short- and long-term goals to achieve normal finger alignment using a left hand roll. Initial OT sessions showed the resident tolerated several hours of splint use with intact skin, but on subsequent days no left-hand treatment was provided, and documentation later noted cognitive decline, difficulty with ADLs, and refusal of the left hand splint and hygiene. OT goals for the left hand were discharged, and there was no further evidence of left-hand treatment before discharge, while leadership confirmed that therapy sessions on key days did not address the hand, resulting in a failure to provide the ordered specialized rehabilitative services.
A resident with intact cognition and a history of schizoaffective disorder, bipolar type, was observed sitting on the bedside without any call bell available to summon staff. Surveyors found no call bell cord plugged into the wall and no call bell present in the room, despite facility records from recent nonclinical rounds indicating that a call bell had previously been in place. A staff member and the Nursing Home Administrator confirmed that the resident did not have access to a call bell at the time of the survey.
Surveyors found that one unit had a sticky floor in front of the nursing station and in the hallway, visible spills in the lounge and a room doorway, and scattered debris including paper scraps, a sugar packet, a plastic lid, a straw, and a plastic glove on floors. A dried, brown substance was observed on the floor and in the bathroom of a room, including on the toilet, and dried food substances were present on the floors of multiple rooms. In addition, a room thermostat lacked a cover, leaving exposed wires visible. These conditions resulted in a deficiency under resident rights for not maintaining a safe, clean, comfortable, and homelike environment.
A resident who uses a wheelchair and requires supervision or touching assistance for showering and transfers did not receive scheduled showers on two consecutive days. The resident reported that staff told him/her there were not enough staff on the unit to provide the shower and requested that staff be informed of the desire to shower. Facility policy requires person-centered ADL care, including bathing, but during an interview the NHA and DON, while stating that some residents refuse showers or are care planned for bed baths, did not confirm that this resident preferred or was care planned for bed baths only.
A resident with multiple comorbidities, including metabolic encephalopathy, HTN, hyperlipidemia, paroxysmal A-fib, and a neurocognitive disorder, was mistakenly given Humalog insulin instead of a tuberculin solution. Facility policy required verification of the right medication, dose, time, and route before administration and consultation with a physician if a medication or dose seemed inappropriate. The nurse administered Humalog despite no physician order for insulin, and subsequent documentation and a medication error report confirmed that the wrong medication had been given. The DON later verified that the resident received Humalog in error instead of the ordered tuberculin solution.
Surveyors identified unsanitary and unsafe environmental conditions on the North Building 7th and 8th floors, including a bathroom on N8 with used briefs on the trash can, paper towels, used gloves, and empty body wash and shampoo bottles left in the sinks. The N8 trash chute closet had an overflowing trash bin with papers, used gloves, paper towels, and food on the floor, and used gloves were found on the stairwell landing between N7 and N8. Additional observations of trash chute rooms on the North Building floors showed food, used gloves, papers, and paper towels on the floor on N8.
Surveyors identified that the facility did not ensure a safe, clean, and homelike environment for residents. One resident room had a wall with bubbled and peeling paint, cracked drywall, and pieces of drywall on the windowsill. On another floor, fraying fall mats were observed in several resident rooms, indicating inadequate maintenance of resident care areas and safety equipment.
Surveyors identified unsanitary conditions in the 8th floor pantry, including rust and brown stains on cabinet interiors and exteriors, stained countertops, and red and brown stains inside the refrigerator and freezer. A coffee carafe with dried coffee, a water-stained ice bucket and ice scoop on the counter, rust on the coffee and ice machines, and calcium build-up on the ice machine, sink fixtures, and inside the sink were also observed. During an interview, the NHA reported that both dietary and housekeeping staff were responsible for cleaning the pantry. The deficiency was cited under Food and Nutrition Services 483.60(i)(1)(2) for failure to maintain sanitary food storage conditions.
A nursing unit failed to maintain a clean and homelike environment, with multiple residents affected by unclean and sticky floors, unmade or soiled beds, refuse such as food, gloves, and empty containers left in rooms, and broken or missing furnishings. Staff confirmed the presence of unsanitary items, including feces, and the facility's policy for cleanliness and comfort was not followed.
Multiple residents were not provided necessary assistance with activities of daily living, as evidenced by observations of soiled clothing, unkempt appearance, wet bed linens, and missed meals. Documentation and resident grievances further revealed infrequent showers, delayed care, and unmet needs for snacks, water, and toileting. The facility administrator confirmed these failures following review.
A deficiency was identified when a unit serving residents with Alzheimer's and other dementias did not provide an ongoing program of activities to support their physical, mental, and psychosocial well-being. Observations showed only a single activity—folding towels—was offered, with the activities calendar containing many blank or vague entries and staff confirming the lack of structured programming.
Staff did not ensure that residents, including those with dementia, had access to drinking water, with observations showing empty or missing cups and beverages in multiple rooms. Nurse aides relied on residents to request water and were unaware that some may not be able to do so due to cognitive impairment. The deficiency was confirmed by the administrator.
The facility did not timely assess or document pressure ulcers and failed to follow wound care orders for three residents. One resident with quadriplegia developed a Stage 3 sacral ulcer that was not identified or treated until it had progressed, with no prior documentation of a blister. Another resident's Stage 3 ulcer was not comprehensively assessed for six days after admission, and a third resident's Stage 4 ulcer treatment was delayed by four days due to late order entry. These actions resulted in noncompliance with wound care policies and regulations.
Three residents with conditions including severe protein-calorie malnutrition experienced significant weight loss that was not promptly identified or addressed, and timely re-weights were not obtained as required by facility policy. Staff interviews confirmed that proper monitoring and intervention did not occur, resulting in inaccurate assessments and a failure to ensure adequate nutrition and hydration.
During a kitchen inspection, surveyors observed opened and undated bags of frozen burgers and chicken patties in the freezer, contrary to facility policy requiring all food items to be labeled and dated. A staff member confirmed that labeling and dating were expected but not followed for these items.
A resident's quarterly MDS assessment inaccurately documented significant weight loss, despite weight records and a reweigh by the RD showing otherwise. A licensed employee confirmed the inaccuracy in the assessment.
A facility failed to meet professional standards for medication administration when an LPN left a resident's medications mixed in an Ensure drink without ensuring full consumption. The resident, with severe cognitive impairment, was not assessed for safe self-medication, leading to incomplete administration of prescribed medications.
A facility failed to change the feeding bag for a resident with a feeding tube every 24 hours as required by their policy. The resident, who had multiple medical conditions, was on a specific feeding regimen. Observations showed the feed bag was not changed within the required timeframe, which was confirmed as a deficient practice by the Nursing Home Administrator.
Two residents experienced medication administration errors, resulting in a 17.24% error rate. A nurse crushed and mixed medications into a drink for one resident, which was not fully consumed, and improperly crushed Morphine ER for another resident, contrary to guidelines.
Failure to Provide Ongoing Specialized OT for Hand Contracture
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that specialized rehabilitative services were provided as required for one resident. The resident was admitted with diagnoses including unspecified dementia with mood disturbance and left shoulder pain, and was observed on April 16, 2026, to have a significant left-hand contracture. Occupational therapy (OT) had evaluated the resident on August 22, 2025, and established short-term and long-term goals for achieving normal anatomical alignment of the left fingers for specified durations to facilitate joint mobility and prevent contractures. Treatment encounter notes showed that on August 28, 2025, the resident tolerated wearing a left hand roll for 3.5 hours with intact skin, and on September 3, 2025, tolerated 4 hours with no skin breakdown or redness, though pain was noted as “hurts.” Subsequent OT notes revealed that on September 4 and 5, 2025, the resident did not receive treatment for the left hand. On September 8, 2025, OT documented that the resident was showing a decline in cognition and sequencing for ADLs, was unable to use utensils appropriately, and was refusing the left hand splint and left hand hygiene. The OT discharge summary dated September 12, 2025, indicated that the short-term and long-term goals for the left hand were discharged. Review of the clinical record showed no evidence of further attempts at left hand treatment prior to the resident’s discharge. The Rehabilitation Director confirmed that therapy provided on September 4 and 5 did not address the left hand, and the Nursing Home Administrator confirmed these findings, supporting the determination that required rehabilitative services for the resident’s left hand contracture were not provided as planned.
Failure to Ensure Resident Access to Call Bell in Room
Penalty
Summary
Surveyors determined that the facility failed to ensure a working call system was available for a resident, as required for resident bathrooms and bathing areas. During a complaint survey on the seventh floor, an observation at approximately 11:09 a.m. showed Resident 13 sitting on the bedside without a call bell available to alert staff for assistance. Further inspection of the room revealed there was no call bell cord plugged into the wall and no call bell present anywhere in the room. Review of Resident 13’s clinical record showed the resident was admitted on a documented date, had a BIMS score of 15 indicating intact cognition, and carried diagnoses including schizoaffective disorder, bipolar type. Facility records from nonclinical rounds indicated that a call bell had been present in the resident’s room three days earlier. An interview with a staff member (Employee 5) confirmed the absence of a call bell for this resident, and the Nursing Home Administrator later confirmed these findings, constituting noncompliance with 28 Pa. Code 201.14(a) and 201.18(b)(1).
Failure to Maintain Clean, Safe, and Homelike Environment on One Unit
Penalty
Summary
Surveyors identified a failure to provide a safe, clean, comfortable, and homelike environment on the North building 8th floor (N8). During observations conducted between 10:00 and 10:30 a.m., the floor in front of the nursing station and in the hallway was found to be sticky, and visible spills were present in the lounge area and in the doorway of a resident room. Multiple scraps of paper were scattered on the floor in the lounge and hallways, and additional debris, including a sugar packet, a plastic lid, and a straw, were observed on the floors of resident rooms. A plastic glove was seen on the hallway floor. A dried, brown substance was present on the floor and in the bathroom of a resident room, including on the toilet, and dried food substances were observed on the floors of multiple other resident rooms. In one room, a thermostat was noted to be missing its cover, leaving exposed wires visible. These conditions were reported to the Nursing Home Administrator and the Director of Nursing at 12:30 p.m. the same day. The deficiency was cited under 42 CFR 483.10 (Resident rights) and 28 Pa. Code 201.18(e)(1), and was noted as previously cited on 1/30/26 and 7/28/25.
Failure to Provide Scheduled Assisted Showers for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with activities of daily living (ADLs), specifically bathing, to one resident. Facility policy on ADLs, last reviewed in December 2024, states that care and services for hygiene, including bathing, dressing, grooming, and oral care, will be person-centered and honor each resident’s preferences, choices, values, and beliefs. Review of the resident’s admission MDS dated February 20, 2026, showed the resident uses a wheelchair and requires supervision or touching assistance with showering/bathing and with tub/shower transfers. During an interview on March 3, 2026, the resident reported not receiving scheduled showers on March 2 and March 3, 2026, and stated staff told him/her there were not enough staff scheduled on the unit to provide the care. The resident expressed a desire to have a shower and requested that staff be made aware. In a subsequent interview on March 4, 2026, when this information was presented to the Nursing Home Administrator (NHA) and Director of Nursing (DON), they stated that residents often refuse showers, prefer bed baths, and some are care planned for bed baths only; however, they did not confirm that this resident preferred or was care planned for bed baths only. The deficiency was cited under Quality of Care 483.24(b)(1) and related Pennsylvania nursing services and clinical records regulations.
Medication Error: Insulin Administered Instead of Tuberculin Solution
Penalty
Summary
The facility failed to administer medications safely and as prescribed for one resident when a nurse gave Humalog, a fast-acting insulin, instead of tuberculin solution. Facility policy on administering medications, revised April 17, 2024, requires that medications be administered in a safe and timely manner as prescribed, that staff verify the right medication, dose, time, and method before administration, and that the nurse contact the physician or medical director if a dosage is believed to be inappropriate or a medication has potential adverse consequences. For this resident, the nurse did not follow these verification steps and administered Humalog insulin despite there being no physician order for Humalog in the resident’s record. The resident involved had multiple medical diagnoses, including metabolic encephalopathy, hypertension, hyperlipidemia, paroxysmal atrial fibrillation, and neurocognitive disorder with Lewy bodies, and had been admitted on December 31, 2025. Progress notes documented that in the early morning of January 1, 2026, a nurse notified the RN supervisor that the resident had received insulin, and new orders were received to monitor blood sugars. A medication error report documented that the resident was given Humalog instead of tuberculin solution, and review of the physician’s orders confirmed there was no order for Humalog. In an interview, the DON confirmed that the resident received Humalog insulin in error instead of tuberculin solution on that date.
Unsanitary Environmental Conditions on North Building 7th and 8th Floors
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment on two of eight units, specifically the North Building 7th and 8th floors. On the North Building 8th floor (N8), surveyors observed a bathroom with used briefs placed on the trash can, paper towels, used gloves, and empty bottles of body wash and shampoo left in the sinks. The N8 trash chute closet contained an overflowing trash bin with papers, used gloves, paper towels, and food scattered on the floor. In the North Building stairwell, used gloves were observed on the landing between the 7th (N7) and 8th (N8) floors. Additional observations of trash chute rooms on all North Building floors showed food, used gloves, papers, and paper towels on the floor on N8. When these findings were presented to the Nursing Home Administrator and DON, they acknowledged the information and stated they would investigate. No specific residents, medical histories, or clinical conditions were described in relation to these environmental sanitation deficiencies.
Environmental Deficiencies in Resident Rooms and Fall Mats
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents as required under Resident Rights 483.10(i)(1)-(7). During observations of 27 rooms on the 8th floor, one room was found to have a wall with bubbled and peeling paint, along with cracked drywall and pieces of drywall sitting on the windowsill. Additional observations on the 6th floor identified fraying fall mats in multiple rooms, specifically rooms 601, 615, 616, 625, and 627. These environmental deficiencies were identified during surveyor observations, and when the findings were presented to the Nursing Home Administrator and DON, the NHA stated she would investigate the matter.
Unsanitary 8th Floor Pantry and Food Storage Conditions
Penalty
Summary
The facility failed to ensure that food was stored in a clean, sanitary environment in the pantry on the 8th floor. Surveyor observations of this pantry showed rust and brown stains on the outside and inside of the cabinets, as well as brown stains on the countertop. Additional observations revealed red and brown stains inside the refrigerator and freezer, a coffee carafe with dried coffee at the bottom, and a water-stained ice bucket and ice scoop on the counter. Further review identified rust on the coffee and ice machines, along with calcium build-up on the ice machine, sink fixtures, and inside the sink. During an interview, the NHA stated that both dietary and housekeeping staff were responsible for cleaning the pantry and indicated that she would investigate the matter. The deficiency was cited under Food and Nutrition Services 483.60(i)(1)(2) for failure to maintain sanitary conditions for food storage and related equipment on one of three floors observed.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, and homelike environment on one of its nursing units, affecting 12 out of 17 residents. Observations included unclean and sticky floors in common areas and resident rooms, unmade beds, and the presence of refuse such as empty cups, food, and soiled gloves in various locations. Specific rooms were found with winter holiday decorations and excessive tape on the walls, missing outlet cover plates, broken furniture, and personal items in disarray. In several instances, soiled items such as gloves, incontinence brief pieces, and what appeared to be feces were found on floors, beds, and linens. Some residents were observed lying in beds without linens or with soiled linens, and in one case, a resident was in a bed not assigned to them. Staff interviews confirmed the presence of these unsanitary conditions, with a nurse aide identifying a brown object under a bed as feces. The facility's own policy requires maintaining a clean, comfortable, and homelike environment, including regular housekeeping and maintenance services, but these standards were not met. The Nursing Home Administrator acknowledged the failure to provide the required environment for the affected residents.
Failure to Provide Adequate ADL Assistance to Multiple Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for 11 of 17 residents, as evidenced by multiple observations, document reviews, and interviews. Residents were observed with soiled clothing, untrimmed fingernails with debris, greasy and unbrushed hair, and in some cases, without bed linens. Several residents were found in wet clothing and bed linens, and documentation did not reflect timely toileting or incontinence care. One resident was not provided lunch until prompted by staff, and another was found in a bed not assigned to them, surrounded by pieces of an incontinence brief. Grievance records and Resident Council minutes further documented concerns about lack of assistance with showers, delayed care from nurse aides, and unmet needs for snacks, water, and catheter care. Facility records indicated that some residents had not received showers as frequently as expected, and grievances confirmed delays in care and lack of staff responsiveness. Resident Council minutes from several months highlighted ongoing issues with staff not providing care, not passing snacks or water, long call light response times, and not completing rounds. The Nursing Home Administrator confirmed the failure to provide necessary ADL assistance for the affected residents.
Failure to Provide Ongoing Activities Program for Residents with Memory Impairments
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of residents on one of four nursing units, specifically 8 North, which is a secure unit for residents with memory impairments such as Alzheimer's disease and non-Alzheimer's dementia. Review of the facility's assessment indicated a commitment to providing therapeutic recreation for this population. However, observations on the unit revealed that the only activity provided was folding towels in the morning, with no further recreational or structured activities observed throughout the day. The posted activities calendar for the month contained multiple blank days and vague entries such as 'TBA' (to be announced), with limited scheduled activities and many days lacking any planned events. Interviews with staff confirmed the lack of structured activities, with one activities employee stating that the calendar had been hastily prepared and acknowledging the absence of a comprehensive program. Further, there was no evidence of nursing staff engaging with residents in a non-clinical manner during the observed period. The Nursing Home Administrator confirmed that the facility did not provide an ongoing program of activities to meet the needs of residents on the affected unit, as required by facility policy and state regulations.
Failure to Provide Drinking Water Consistent with Resident Needs
Penalty
Summary
The facility failed to provide drinking water consistent with resident needs and preferences on the 8 North nursing unit. Observations revealed that multiple residents, including those with memory impairment and dementia, did not have access to drinking cups or beverages in their rooms. Some residents had only empty or outdated cups, and in several cases, no cups or beverages were present at all. Staff interviews confirmed that nurse aides relied on residents to request water, and did not routinely provide fresh water, particularly for those unable to verbalize their needs due to cognitive impairment. Additionally, staff were unaware that individuals with dementia may not recognize thirst or be able to request fluids. Further observations later in the day confirmed that water was still not made available to residents. The facility's policy required that residents be offered sufficient fluid intake to maintain hydration, but this was not followed. The deficiency was acknowledged by the Nursing Home Administrator, who confirmed the lack of available drinking water consistent with resident needs and preferences on the unit.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to timely and comprehensively assess and document pressure ulcers, as well as to follow physician wound treatment orders for multiple residents. For one resident with quadriplegia, epilepsy, protein-calorie malnutrition, and psychiatric disorders, the care plan required frequent repositioning and skin monitoring due to high risk for skin breakdown. Despite weekly skin checks indicating no new issues, a nurse later discovered a significant sacral wound, which was ultimately identified as a Stage 3 pressure ulcer. There was no clinical documentation of a preceding blister or prior sacral wound, and treatment by the wound consultant was delayed due to the resident's unavailability. The pressure ulcer was not identified until it had progressed to Stage 3, and no treatments were in place for a blister prior to this discovery. Another resident was admitted with a history of acute respiratory failure and was found to have a Stage 3 pressure ulcer on the left buttock. Although the wound was identified upon admission, a comprehensive assessment of the wound's size and condition was not completed until six days later. The Director of Nursing confirmed this delay in assessment, indicating a lapse in timely wound evaluation and documentation as required by facility policy. A third resident was admitted with a Stage 4 sacral pressure ulcer, and a wound care order was issued by the wound physician. However, the order was not implemented until four days after it was written, due to a delay in entering the order into the electronic medical record. The responsible nurse acknowledged the delay was due to not entering the order promptly. These failures resulted in noncompliance with facility policies and state regulations regarding timely assessment, documentation, and implementation of wound care for residents at risk for or experiencing pressure ulcers.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that residents' weights were properly monitored and that significant weight changes were promptly addressed for three out of fifteen residents reviewed. According to the facility's policy, any weight change greater or less than 5 pounds within 30 days should be retaken for confirmation, and the dietitian is responsible for reviewing monthly weights and addressing negative trends. For one resident with diagnoses including depression and severe protein-calorie malnutrition, a 7.3% weight loss was recorded over a month, but there was no evidence that this significant weight loss was identified or that any intervention was implemented. Similarly, another resident experienced a rapid weight drop, but a timely re-weight was not obtained, resulting in an inaccurate MDS assessment. A third resident, also with severe protein-calorie malnutrition, lost 8.39% of body weight in a month, with no documentation of the weight loss being identified or addressed. Staff interviews confirmed that re-weights should have been obtained sooner and that the facility did not follow its own policy for monitoring and responding to significant weight changes. The lack of timely identification and intervention for significant weight loss in these residents, some of whom had critical conditions such as severe protein-calorie malnutrition, represents a failure to provide adequate food and fluids to maintain residents' health as required by facility policy and regulatory standards.
Failure to Properly Label and Date Frozen Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in the freezer area. During an observation in the freezer, a bag of frozen burgers and frozen chicken patties were found opened and undated. Facility policy requires that leftover food be stored in covered containers or wrapped securely, with each item clearly labeled and dated before refrigeration. An interview with a staff member confirmed that all items should be labeled and dated, but this was not done for the items observed.
Inaccurate MDS Assessment of Resident Weight
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident. Clinical record review showed that the resident's quarterly MDS assessment indicated a significant weight loss. However, a review of the resident's weight summary revealed fluctuating weights, with a reweigh by the registered dietitian showing a current body weight that did not support the significant weight loss documented in the MDS. An interview with a licensed employee confirmed that the MDS inaccurately reflected a significant weight loss for the resident.
Failure in Medication Administration Standards
Penalty
Summary
The facility failed to ensure that staff met professional standards for medication administration for a resident with severe cognitive impairment. During an observation, a licensed nurse, supervised by another nurse, crushed and mixed several medications into an Ensure drink for the resident. The nurse then left the room after marking the medications as administered in the electronic medical record, without confirming that the resident consumed the entire drink. Later, it was observed that the Ensure drink, containing the medications, was discarded with some liquid remaining, indicating that the medications were not fully administered. The supervising nurse confirmed this observation. An interview with the nurse revealed that the resident had a history of not taking medications, and the staff left the drink for the resident to finish on their own. However, there was no documentation in the resident's clinical record indicating an assessment for safe self-medication administration.
Failure to Change Feeding Bag for Resident with Enteral Nutrition
Penalty
Summary
The facility failed to ensure proper care for a resident with a feeding tube, specifically Resident 269, by not adhering to the established procedure for enteral nutrition via pump. The facility's policy required that the tubing connected to a feeding bag be changed every 24 hours when using canned formula. However, observations revealed that the feed bag for Resident 269 had not been changed within the required timeframe, as it was dated two days prior to the observation. Resident 269 had several medical conditions, including hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage, diabetes mellitus type II with nephropathy, and gastroesophageal reflux disease without esophagitis. The resident's clinical record indicated a specific feeding regimen using Nutren 1.0 with fiber via a feeding pump. Despite these detailed orders, the facility did not comply with the necessary protocol to prevent complications from enteral feeding, as confirmed by the Nursing Home Administrator during an interview.
Medication Administration Errors
Penalty
Summary
The facility failed to correctly administer medications to two residents, resulting in a medication error rate of 17.24%. The facility's policy requires medications to be administered safely and as prescribed. However, during an observation, a licensed nurse, Employee E3, supervised by Employee E4, crushed and mixed several medications, including Aspirin, Amlodipine, Olanzapine, and Oxycodone, into an Ensure drink for a resident. The nurse then left the room without ensuring the resident consumed the entire mixture. Later, it was observed that the drink, with some medication still in it, was discarded, indicating incomplete administration. In another instance, Employee E3 crushed Morphine ER, which should not be crushed according to the manufacturer's guidelines, and administered it to another resident. The nurse admitted that the resident does not take medications whole and acknowledged that the physician should have been notified to change the medication form. These actions led to the residents not being free from medication errors, violating the facility's policies and state 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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