Wyncote Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wyncote, Pennsylvania.
- Location
- 208 Fernbrook Avenue, Wyncote, Pennsylvania 19095
- CMS Provider Number
- 396120
- Inspections on file
- 24
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Wyncote Care Center during CMS and state inspections, most recent first.
Two residents reported being physically and verbally abused by a CNA during care. One cognitively intact resident with dementia stated that a male and a female CNA turned the resident violently while providing incontinence care despite the resident’s refusal, that the male CNA hit the resident during the struggle, and that there was swearing by both parties; the resident later identified the female CNA as the caregiver involved that night. Another resident with a history of cerebral infarction and moderate cognitive impairment reported that the same female CNA slapped the resident’s wrist multiple times and grabbed the resident’s glasses. Facility investigations and reports to the State Survey Agency documented that the allegations against the female CNA were substantiated.
The facility failed to complete thorough investigations into abuse allegations involving two cognitively intact residents. In one case, a resident reported being turned violently and hit by two CNAs during nighttime care, but the investigation lacked interviews with other staff or residents on the unit. In another case, a resident with a history of verbal aggression alleged that an RN used unprofessional, racially charged language, which was partially corroborated by the ADON and social worker, yet no statement was obtained from the resident or other residents. The DON acknowledged that additional interviews were not conducted and that investigation documents were fragmented across multiple staff and locations, contrary to facility policy requiring comprehensive, factual documentation and witness statements.
The facility failed to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP), for several residents and departments. A resident with a Foley catheter and MDRO risk received morning care from a CNA who did not wear a required gown, and another resident with a MRSA wound had an order for TBP while the posted sign showed EBP, with the order not updated. A third resident with an open pelvic drain was on EBP, yet a nurse applied a clonidine patch with direct skin contact without EBP PPE and could not explain the reason for EBP. In the laundry area, staff folded clean laundry without clear PPE guidance, and one employee donned a gown incorrectly until redirected by the DON. The DON, also serving as Infection Preventionist, reported there was no formal infection surveillance tracking system, no readily available MRSA or other infection data prior to recent months, no current list of residents on EBP or TBP, and no documented Infection Control Committee minutes, surveillance reporting, annual risk assessment, or infection control goals.
The facility did not implement its antibiotic stewardship program or required surveillance tracking for a prolonged period, despite policies mandating detailed monitoring of antibiotic use and infection outcomes. The DON/Infection Preventionist reported there was no tracking system and relied on memory, with no surveillance forms available. Later-created nosocomial infection logs for several months were incomplete, lacking resident identifiers, infection locations, symptoms, diagnostic testing, antibiotic dose/route/frequency/duration, and evaluations of treatment effectiveness. In multiple cases of upper respiratory infection, there was no evidence of testing for influenza, RSV, or COVID-19. The facility also lacked tracking for community-acquired infections and had no documented antibiotic use protocols or systems, such as pharmacy or lab reports, to monitor antibiotic use and resistance.
The facility failed to ensure that the designated IP had sufficient time and resources to carry out required IPCP responsibilities. The DON functioned as a full-time DON and only part-time IP, while the Infection Control Plan identified the ADON as IP, yet the facility assessment did not define time or resource needs for the role. Infection surveillance data and lists of residents on EBP or TBP were not readily available, and infection tracking logs lacked essential clinical and antibiotic details. There was no evidence of active antibiotic stewardship protocols, monitoring of current disease threats (including influenza, RSV, and COVID-19), or oversight of staff practices such as hand hygiene and PPE use. The ICC did not have documented meetings, input from required members, or review of surveillance data, HAI rates, or annual risk assessments and goals, indicating that core IPCP functions were not being performed.
The facility failed to provide and document required education on influenza vaccination benefits and potential side effects for multiple residents before vaccine administration or refusal. Review of clinical records and consent forms showed that, although the forms included a checkbox indicating that Vaccine Information Sheets (VIS) were received, no VIS documents were available for review. The DON confirmed that no VIS sheets could be produced, resulting in no evidence that residents or their representatives were educated about the influenza vaccine as required.
A resident with hemiplegia, moderate cognitive impairment, and documented frequent urinary and bowel incontinence required supervision or touching assistance for toileting hygiene and had a care plan directing staff to provide needed ADL assistance. During an observation, the resident was found sitting on the bed in street clothes with a strong urine odor in the room, which the DON confirmed. The DON reported that the resident attempts to toilet independently but sometimes does not reach the bathroom in time, demonstrating that staff did not consistently provide the required toileting assistance.
A resident's confidential medical record, including sensitive information such as social security number and date of birth, was mistakenly provided to another resident's representative due to staff not following the facility's medical record request process. The staff member responsible could not be identified, and the incident was determined to be isolated.
A resident with dementia and muscle weakness, who was fully dependent on staff for bed mobility, developed a sacral pressure ulcer. Despite physician orders for pressure prevention devices and frequent repositioning, the resident was not enrolled in a turning and repositioning program, and no care plan was initiated for the facility-acquired pressure ulcer. Documentation gaps were confirmed by the DON and missing wound consult records.
A resident with diabetes, osteoarthritis, and dementia did not receive weekly skin and nail checks as ordered by the physician. Only one skin assessment was documented, and no further assessments or documentation of skin issues were found. The resident was later hospitalized with sepsis, acute renal failure, and a wound requiring surgery. Facility staff were unaware of any skin issues, and there was no evidence that the required weekly assessments were completed.
A resident at Wyncote Care Center fell from bed during a linen change due to improper technique by a nurse aide. The resident, who required substantial assistance for transfers, was turned away from the aide, leading to a fall when her hands slipped off the side rail. The incident resulted in severe right-side pain, and the resident was transported to the hospital for evaluation.
A facility failed to update a care plan for a resident who experienced a decline in self-feeding capabilities. The resident, who had dementia and varied meal completion, was observed being fed by a nurse aide without the adaptive devices specified in their care plan. The care plan had not been revised to reflect the resident's need for one-on-one feeding assistance.
A facility failed to follow proper infection control techniques during a dressing change for a resident with a wound. Despite the policy requiring gloves and gowns for high contact care, a nurse did not wear a gown while performing the procedure. The resident had conditions including hydrocephalus and edema, necessitating Enhanced Barrier Precautions.
The facility was found to be in violation of building construction requirements as it was classified as a two-story, Type V (000), unprotected wood frame construction with a basement, which is fully sprinklered. This classification exceeds the maximum allowable story height for this type of construction, which is limited to one story when sprinklered. The issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the required headroom clearance in the exit access corridor, affecting one smoke compartment. The basement level corridors near the maintenance office had a headroom of six feet at the ramp leading to the laundry, which is below the required six feet-eight inches. This was confirmed during an exit interview with the Administrator and Maintenance Director.
Failure to Protect Two Residents From Physical and Verbal Abuse by Nursing Assistant
Penalty
Summary
The facility failed to ensure residents were free from abuse when two residents reported being physically and verbally mistreated by a nursing assistant during care. One resident with dementia but a BIMS score indicating intact cognition reported that on a late evening, two staff members, described as a male and a heavy-set female nursing assistant, attempted to change the resident despite the resident’s refusal. The resident stated that the staff turned the resident violently, that the male staff member hit the resident after a possible altercation, and that both staff and resident were swearing during the incident. The resident identified the female nursing assistant as the person who had provided care that night and later identified the male nursing assistant through the nursing supervisor. The facility’s investigation documentation indicated that the allegation against the female nursing assistant was substantiated, while the male nursing assistant was determined by the facility not to be involved. A second resident with a history of cerebral infarction and a BIMS score indicating moderate cognitive impairment reported that the same female nursing assistant slapped the resident’s wrist three times and then grabbed the resident’s glasses. The resident’s statement and demonstration of the incident were documented in the facility’s investigation, which concluded there was sufficient concern regarding inappropriate physical interaction. The facility’s report to the State Survey Agency documented that the allegation against the female nursing assistant was substantiated and that the allegation was considered substantiated in the facility’s reported incident. The nursing home administrator confirmed these findings during interview.
Plan Of Correction
1. A thorough investigation of allegations of abuse was conducted for Resident R1 and R2. Interviews and witness statements as applicable with other staff and/or residents completed for alleged abuse for Resident R1 and R2. Employee E3, nurse aide, was terminated based on multiple allegations and refusal to provide statement. Employee E4, nurse aide was found to be not involved with Resident R1 based on facility investigation. 2. Facility will ensure that there will be strictly zero tolerance for any resident abuse and neglect. Any allegations of abuse or neglect will be thoroughly investigated. Appropriate corrective action plans will be taken such as disciplinary action/terminations. 3. All staff will be reeducated on abuse/neglect policy and procedures as part of the facility's mandatory abuse and neglect training. All new hires will also be educated on topics of abuse/neglect policy and procedures as part of facility's orientation. 4. The Administrator/Designee will monitor the frequency and pattern of all abuse allegations and follow up investigations. Any areas of non-compliance will be addressed in QAPI for two quarters or until substantial compliance is met.
Incomplete Abuse Investigations for Two Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to conduct complete and thorough investigations into allegations of abuse for two cognitively intact residents. Facility policy states there is zero tolerance for abuse, neglect, and exploitation and that documentation of abuse investigations must be objective and factual, including who, what, when, where, and witness statements. Despite this, the investigations did not include all relevant interviews or comprehensive documentation as required by the policy and federal regulation. For one resident with dementia but a BIMS score of 15, the resident reported that on a late evening two staff members, identified as a male and a heavy-set female nursing assistant, turned the resident violently while providing incontinence care, that the male staff member hit the resident, and that there was swearing by both the resident and the male staff member. The resident stated the male staff member had a very strong grip and that the female staff member was the aide who cared for the resident that night. The investigation documentation included a nursing supervisor’s note that the resident denied pain or injury and that no bruising was observed, and that the male aide was identified by another aide. However, there was no documented evidence that other staff or residents on the unit were interviewed regarding the alleged incident. For another resident admitted with a left fibula fracture and a BIMS score of 15, who had a care plan for verbal aggression and inappropriate verbal behavior, a grievance was filed alleging that a registered nurse spoke to the resident in an unprofessional manner and cursed at the resident. The investigation file contained statements from the ADON and social worker indicating they heard a commotion and heard the nurse refer to the resident as “boy,” followed by the resident’s upset response, and that there was no observed physical contact. Despite these accounts, there was no documented statement from the resident involved or from other residents on the unit. The DON confirmed that no interviews were conducted with the resident or other residents after the incident and described investigation materials as being scattered among different staff and offices rather than compiled.
Plan Of Correction
1. A thorough investigation of allegations of abuse was conducted for Resident R1 and Resident R3. Interviews and witness statements as applicable with other staff and/or residents completed for alleged abuse for Resident R1 and R3. 2. A review of facility investigation procedures was reevaluated. Facility administration will ensure thorough investigations including but not limiting to collecting witness statements and conducting staff/resident interviews for any alleged abuse cases are completed. 3. The Director of Nursing was educated and in-serviced by the Administrator on ensuring a complete and thorough investigation is complete for all allegations of resident abuse. Statements and interviews to be conducted where applicable and ensure timely reporting of incidents and documentation to the Administrator and the Department of Health. 4. The Administrator/Designee will monitor all reportable incidents pertaining to resident abuse/neglect and any identified non-compliance with reporting procedures will be reported to the QAPI committee.
Failure to Implement Enhanced Barrier Precautions and Infection Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP), for multiple residents and departments. The facility’s EBP policy stated that gowns and gloves were to be used during high-contact resident care activities when contact precautions did not otherwise apply. One resident with a Foley catheter and an order for EBP due to MDRO risk received direct morning care from a nursing aide who did not wear a required gown. Another resident with a history of sepsis and a MRSA wound on the right lower extremity had a physician order for TBP contact precautions, but the sign posted at the room indicated EBP instead of TBP, and the order had not been updated to reflect the current status. A third resident with an open pelvic drain was reported by the DON to be on EBP, yet a nurse administered medication involving direct skin contact (application of a clonidine patch) without using EBP PPE. When questioned, the nurse could not explain why the resident was on EBP, and the DON confirmed the resident’s condition required EBP. In addition to resident care issues, an observation in the laundry area showed the Laundry Director and housekeeping staff folding clean laundry without clear understanding of PPE requirements. The Laundry Director retrieved a reusable apron and gloves from the soiled laundry room and provided them to housekeeping staff, then verified they were clean, but could not clearly state PPE requirements for folding laundry. The housekeeping employee initially attempted to don the gown incorrectly, and the DON had to redirect the employee on proper gown use. The DON, who also serves as the facility’s Infection Preventionist, reported that there was no tracking system for antibiotic surveillance forms and that infections were being reported to the Patient Safety Authority on a case-by-case basis, relying on memory rather than documented surveillance forms. Surveillance tracking for MRSA and other infections prior to January 2026 was not readily available, and there was no current listing of residents requiring EBP or TBP. Review of infection prevention and control program documents revealed there were no Infection Control Committee meeting minutes, no evidence of input from required committee members, no reporting of surveillance data or HAI rates to the committee, and no documented annual infection control risk assessment, goals, or performance measures.
Failure to Implement and Document an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operate an antibiotic stewardship program as required by its own policies for a period of 10 months. The written policies, last revised in December 2016, required that antibiotics be prescribed and administered under the guidance of an antibiotic stewardship program and that antibiotic usage and outcome data be collected on a surveillance tracking form, including resident identifiers, infection details, diagnostic testing, antibiotic specifics, and treatment outcomes. Despite these requirements, the DON, who also serves as the Infection Preventionist, reported that there was no tracking system for antibiotic surveillance forms, that infections were reported only to the Patient Safety Authority on a case-by-case basis, and that infection information was retained from memory rather than documented on surveillance forms. There were no surveillance forms readily available for review covering the period since new ownership began. When the DON subsequently created Nosocomial Infection Tracking Logs for January, February, and March, the documentation remained incomplete and did not meet the policy requirements. The January log listed one infection but omitted the resident name and room number, infection location, symptoms, diagnostic testing, antibiotic dose/route/frequency/duration, and any evaluation of treatment effectiveness. The February log listed three infections but lacked infection locations, symptoms, diagnostic testing, antibiotic details, and treatment evaluations; one resident with an upper respiratory infection had no evidence of testing for influenza, RSV, or COVID-19. The March log listed six infections, with two lacking infection locations, three lacking diagnostic testing, and none including antibiotic dose/route/frequency/duration or treatment effectiveness; two residents with upper respiratory infections had no evidence of testing for influenza, RSV, or COVID-19. Additionally, there were no tracking logs for community-acquired infections and no evidence of antibiotic use protocols to guide prescribing practices or systems to monitor antibiotic use, such as pharmacy or lab antibiotic use and resistance reports.
Failure to Provide Effective Infection Preventionist Oversight and IPCP Implementation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the designated Infection Preventionist (IP) fulfilled the required duties and responsibilities for the Infection Prevention and Control Program (IPCP). The DON, who also served as the IP, reported that she was a full-time DON and only a part-time IP, while an ADON was in training to become the IP. The facility’s 2026 Infection Control Plan identified the ADON as the IP responsible for conducting an annual infection control risk assessment and collaborating with the Infection Control Committee (ICC), but the facility assessment listed only one infection control nurse/preventionist, who was also the DON, and did not specify the amount of time or resources needed for the IP role. There was no documented determination of the resources required for the IPCP or evidence that such resources were provided. Review of IPCP documents showed that infection surveillance data was not readily available and that no data existed prior to January 2026. There was no readily available listing of residents requiring Enhanced Barrier Precautions (EBP) or Transmission-Based Precautions (TBP). The surveyors found no evidence of staff oversight to ensure implementation of infection prevention practices such as hand hygiene and adherence to use of personal protective equipment (PPE). Infection tracking logs lacked key information, including the location of infections, symptoms, diagnostic testing obtained, and details of antibiotic therapy such as dose, route, frequency, duration, and evaluation of treatment effectiveness. Further review revealed no evidence of an antibiotic stewardship system as described in facility policy, including protocols to guide antibiotic prescribing practices, documentation of indication, dose, and duration, review of laboratory reports for antibiotic appropriateness, use of infection assessment tools or algorithms, or systems to monitor antibiotic use and resistance patterns. There were no systems or protocols documented to monitor current disease threats such as influenza, RSV, and COVID-19. Additionally, there were no ICC meeting minutes, no evidence of input from required ICC members, and no documentation of reporting surveillance data, healthcare-associated infection (HAI) rates, or infection control compliance metrics to the ICC. There was also no evidence of an annual infection control risk assessment or development of annual goals and performance measures, demonstrating that the IP did not carry out the required functions of the IPCP.
Lack of Documented Influenza Vaccine Education for Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents or their representatives received education on the benefits and potential side effects of influenza vaccination prior to administration or refusal. Review of the facility’s undated policy titled "Influenza, Prevention and Control of Seasonal" showed that the facility follows current guidelines and recommendations for seasonal influenza and includes strategies for staff vaccination, such as requiring personnel to sign a declaration acknowledging education about vaccination benefits and risks. However, when surveyors reviewed the clinical records and influenza vaccine consent forms for five residents (R1, R2, R3, R4, and R5), there was no documented evidence that these residents had been provided education on influenza vaccines before the vaccine was given or refused. The consent forms contained a checkbox indicating that Vaccine Information Sheets (VIS) had been received, but when surveyors requested copies of the VIS, none were available. In an interview, the DON (Employee E2) confirmed that the consent form included a checkbox stating that VIS had been received, yet no VIS sheets could be produced for review. The DON acknowledged that there was no VIS sheet available, which meant there was no evidence that education regarding influenza vaccines had been provided to the five residents prior to vaccine administration or refusal, constituting a failure to comply with resident rights requirements under 28 Pa. Code 201.18(e)(1).
Failure to Provide Needed Toileting Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide needed assistance with toileting and ADLs for a resident with hemiplegia/hemiparesis and moderate cognitive impairment. The resident’s MDS dated October 2, 2025 documented a BIMS score of 11, indicating moderately impaired cognition, and Section GG showed the resident required supervision or touching assistance for toileting hygiene. The same MDS indicated the resident was frequently incontinent of both bladder and bowel. The care plan, initiated July 18, 2024, identified incontinence of bowel and bladder related to impaired mobility and documented that the resident required assistance with ADLs, with an intervention to provide assistance as required for completion of ADL tasks. On December 29, 2025, at 11:44 AM, surveyors observed the resident in his room, sitting on his bed in street clothes, with a strong odor of urine coming from the room. The DON, who was present during the observation, confirmed the strong urine odor. The DON also stated that the resident tries to go to the bathroom independently but sometimes does not make it in time. These observations and statements showed that, despite the documented need for assistance with toileting and ADLs, the resident was not consistently receiving the necessary help, resulting in episodes of incontinence and a strong urine odor in the room.
Failure to Protect Medical Record Confidentiality
Penalty
Summary
The facility failed to protect the confidentiality of medical records for one resident when staff provided the wrong medical record to another resident's representative. Specifically, the record belonging to one resident was given to the representative of another resident, resulting in a breach of privacy. The facility's medical record request process was not followed, and the staff member responsible for the error could not be identified. The information disclosed included sensitive personal details such as social security number and date of birth, as reported by the recipient of the incorrect records. The incident was identified when the facility was notified that a family member had received the wrong medical records. Review of facility policy confirmed that medical records are to be released only in accordance with federal and state privacy laws, and only to authorized individuals. However, in this case, the required procedures were not adhered to, leading to the unauthorized disclosure of protected health information. The event was determined to be an isolated incident, with no evidence of additional residents affected.
Failure to Implement and Document Pressure Ulcer Prevention and Care
Penalty
Summary
A resident with dementia and muscle weakness was admitted to the facility and had physician orders for the use of pressure prevention devices, frequent turning and repositioning, and offloading of heels while in bed. Despite these orders, documentation revealed that the resident was not enrolled in a turning and repositioning program, and was totally dependent on staff for bed mobility. The care plan identified a risk for skin integrity issues related to incontinence, but there was no evidence of a care plan specifically addressing a facility-acquired pressure ulcer after one was identified. Clinical records showed that an open area was discovered on the resident's sacrum by a CNA and reported to the charge nurse, who assessed and measured the wound. A wound physician later documented significant deterioration of the wound, with necrosis and unmeasurable depth, and recommended offloading and repositioning per protocol. However, there was no documented evidence that a care plan was initiated for the pressure ulcer, and the Director of Nursing confirmed this omission. Additionally, some wound consult documentation was unavailable due to a system changeover.
Failure to Perform Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not performing weekly skin assessments as ordered by the physician for one resident. The facility's policy required comprehensive skin checks to be performed at a frequency consistent with physician orders and for findings to be documented immediately. The resident in question had a history of type 2 diabetes mellitus, bilateral osteoarthritis of the knees, and dementia. A physician's order specified weekly skin and nail checks every Tuesday during the day shift. Documentation showed that a skin check was performed on one occasion, noting abdominal fold irritation and redness, but there were no further skin assessments or documentation of skin issues after that date. Subsequently, the resident was transferred to the hospital due to a change in mental status and abnormal vital signs. Hospital records indicated the resident was diagnosed with sepsis and acute renal failure, and further examination revealed swelling and a wound on the right lower extremity, which required surgical intervention. Interviews with facility staff, including the DON and the nurse assigned to the resident on the day of transfer, revealed they were unaware of any skin issues or wounds, and the facility could not provide evidence that weekly skin assessments had been performed as ordered.
Resident Fall Due to Improper Linen Change Technique
Penalty
Summary
Wyncote Care Center was found to be non-compliant with the requirement to maintain a resident environment free of accident hazards, as evidenced by an incident involving a resident falling from bed during care. The facility's policy on fall management emphasizes the need to identify and mitigate hazards and risks, yet the incident occurred when a nurse aide was changing the resident's bed linens. The resident, who had diagnoses of lack of coordination, unsteadiness on feet, obesity, and muscle weakness, required substantial assistance for transfers and moderate assistance for bed mobility. During the linen change, the resident was turned away from the aide, and while the aide was changing the sheets, the resident rolled over the sheets and fell to the floor, resulting in severe right-side pain. The facility's investigation revealed that the bed was in a high position, and the resident was holding onto a side rail when her hands slipped, leading to the fall. The nurse aide involved stated that she was performing a complete bed change and had turned the resident towards the door with the side rails up. The Director of Nursing confirmed that the appropriate technique for changing linens with a resident in bed was not followed, which contributed to the accident. The resident was transported to the hospital for evaluation and returned with complaints of discomfort in the right shoulder.
Plan Of Correction
1. R1 was re-assessed by rehab and care planned updated for 2 person assist. Resident is currently on restorative care services. 2. ADON/DON to audit incident reports within the last 60 days. Residents affected will be re-assessed and care plans will be updated according to outcome. Interdisciplinary team will be consulted in order to develop comprehensive care plan updates. Completion Date: 5/30/2025 3. DON/ED provided all care staff with in-service & educated on policy's & procedures specific to bed mobility. Completion date: 4/25/2025 4. ADON/DON have ongoing audits of incident reports, and present any trends or decline to the ED/IDT during daily clinical meeting, weekly UR meeting, and weekly risk management meetings to ensure an ongoing review of potential risks & identifying/implementing interventions proactively. Completion Date: 5/30/2025
Failure to Update Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as R34, regarding feeding assistance. The resident had a comprehensive care plan indicating a potential for altered nutrition status due to dementia, varied meal completion, and a decline in self-feeding, necessitating the use of adaptive feeding devices. Despite interventions dated earlier in the year to provide a Kennedy cup and inner lip plate during meals, observations revealed that the resident was not provided with these adaptive devices during a lunch meal service. Instead, the resident was being fed by a nurse aide. An interview with the nurse aide confirmed that the resident had experienced a decline in self-feeding capabilities and now required one-on-one feeding assistance. However, the care plan had not been updated to reflect this change in the resident's condition and needs.
Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques during a dressing change for a resident. The facility's policy on Transmission Based Precautions, revised in May 2024, mandates the use of gloves and gowns during high contact resident care activities, such as wound care, for residents on Enhanced Barrier Precautions (EBP). However, during an observation on December 18, 2024, it was noted that two licensed nurses, Employee E3 and Employee E4, did not fully comply with these precautions. While both donned gloves, Employee E4 did not wear a gown while performing a dressing change on the resident's wound. The resident involved, identified as Resident R32, was admitted with diagnoses including hydrocephalus, edema, and lack of coordination. The resident had a physician's order for daily wound care on the left buttock, which included cleansing with normal saline, applying anasept gel and calcium alginate, and covering with border gauze. Despite the facility's policy and the resident's condition requiring EBP, the observation revealed a lapse in following the required infection control measures, as confirmed by an interview with Employee E4.
Building Construction Type Violation
Penalty
Summary
The facility was found to be in violation of building construction requirements as it was classified as a two-story, Type V (000), unprotected wood frame construction with a basement, which is fully sprinklered. This classification exceeds the maximum allowable story height for this type of construction, which is limited to one story when sprinklered. The deficiency was identified during an observation and document review conducted on December 17, 2024, at 8:15 a.m. The issue was confirmed during an exit interview with the Administrator and Maintenance Director later that morning.
Failure to Maintain Minimum Headroom Clearance in Exit Corridor
Penalty
Summary
The facility failed to maintain the minimum headroom clearance in the exit access corridor, which affected one out of five smoke compartments. During an observation and document review conducted on December 17, 2024, at 8:15 a.m., it was found that the headroom clearance within the corridors of the basement level, near the maintenance office and similar staff areas, measured at six feet at the ramp leading to the laundry. This measurement was less than the minimum height requirement of six feet-eight inches. An exit interview with the Administrator and Maintenance Director confirmed that the ceiling height was below the required minimum.
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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