York Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 7101 Old York Road, Philadelphia, Pennsylvania 19126
- CMS Provider Number
- 395687
- Inspections on file
- 46
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at York Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that staff did not administer medications according to physician-ordered times and facility policy for multiple residents. One resident receiving treatments for SOB, DVT, seasonal allergies, cough, UTI, and COPD had several medications, including apixaban, inhalers, nasal spray, antibiotics, and nebulizer treatments, repeatedly given hours later than scheduled over multiple days. Another resident reported late administration of diabetes and cardiac medications, and audit reports confirmed that morning doses of metoprolol ER, metformin, Provera, diltiazem ER, hydrochlorothiazide, and losartan were consistently delayed by several hours. A third resident’s amiodarone, aspirin, and magnesium oxide, all ordered for morning administration, were also given in the afternoon. These documented delays showed that medications were not provided in accordance with professional standards of practice and physician orders.
A resident with a right artificial knee joint and cervical radiculopathy did not receive medications and wound treatments in accordance with MD orders and facility policy. Multiple pain medications, including Naproxen, a Lidocaine patch, Diclofenac gel, and Celecoxib, were administered significantly later than their scheduled times, and these late administrations were confirmed by a regional nurse. In addition, ordered right knee wound care, including removal of a Mepilex dressing and cleansing and redressing of the incision with NSS and bordered gauze, lacked documentation of completion on the ordered day.
A resident with dementia and a history of wandering exited the facility undetected due to inadequate supervision and gaps in the wander guard alarm system. Staff failed to notice the resident's absence for several hours, and the elopement protocol was not activated until much later. The resident was found by law enforcement over a mile away and was hospitalized for hypothermia.
A resident with a history of behavioral problems physically assaulted another resident during a supervised smoke break, resulting in a chipped tooth and actual harm. Staff and care plan reviews revealed that only minimal interventions were in place to address the aggressor's behavior, and the facility did not implement adequate measures to prevent abuse or protect residents from harm.
Three residents reported issues with food quality, including lack of flavor, food not being hot, and meals not being prepared correctly. Test tray observations with the Foodservice Director confirmed that both hot and cold food items were served outside of required temperature ranges, resulting in food that was not palatable.
The facility failed to provide palatable and properly heated meals to residents, with reports of unappetizing food, incorrect meal temperatures, and dietary restrictions not being respected. Observations showed systemic issues in food service, including malfunctioning equipment and delayed meal delivery, leading to food being served at unacceptable temperatures.
The facility failed to maintain an effective pest control program, with multiple observations of flies and mice in various areas, including resident rooms and common areas. A resident reported frequent fly sightings, and pest control logs documented mice activity. Despite increased pest control treatments, the presence of pests persisted, indicating an ineffective program.
A facility failed to update a resident's advance directive upon their transition to hospice care, leaving the directive as full code despite the resident's new care status. The Unit Manager confirmed that the necessary discussion regarding the resident's end-of-life care preferences did not occur, resulting in a discrepancy in the resident's medical records.
The facility failed to maintain a clean and homelike environment in two nursing units. Observations included dirty privacy curtains, unsecured closet doors, water-damaged ceiling tiles, and cluttered shower rooms with trash cans and mechanical lifts. These deficiencies indicate a lack of adherence to regulations requiring a safe, clean, and comfortable environment for residents.
The facility failed to conduct a timely criminal history background check for the DON, who was hired without the required check being completed within the first 30 days, as per facility policy. The check was only completed months later, leading to a deficiency in compliance.
A facility failed to develop a comprehensive care plan for a resident who was identified as a smoker. Despite being cognitively intact and having a smoking assessment completed, the resident's care plan did not include smoking interventions. This deficiency was confirmed by the DON, who acknowledged the oversight in care planning.
The facility failed to maintain personal hygiene for two residents dependent on staff for assistance. One resident, fully dependent on staff, had long, dirty nails despite a care plan intervention to keep them short. Another resident, requiring setup assistance, also had long, dirty nails and had been waiting for a nurse to cut them. Staff interviews indicated that the second resident sometimes refuses care and prefers certain caregivers.
A resident's room was found to have a long electrical extension cord with multiple outlets plugged into a wall outlet, extending across the room to power a television. The resident claimed they had permission to use the cord, but the Maintenance Director confirmed that such cords are not allowed due to being hazardous.
A resident experienced significant weight loss, and the facility failed to implement timely interventions. The dietician attributed the weight loss to a scale malfunction without testing the scale, and the physician did not address the issue in documentation or provide new orders. The resident's care plan goals and interventions were not effectively implemented, leading to a deficiency in maintaining nutritional status.
The facility failed to provide appropriate respiratory care for three residents, with discrepancies between physician orders and actual oxygen administration. One resident with acute respiratory failure was given 4 liters of oxygen instead of the ordered 2 liters. Another resident dependent on supplemental oxygen received 3 liters instead of 2, and a third resident with COPD was observed using 4 liters instead of the ordered 3 liters, with a dusty concentrator.
A facility failed to verify the certification status of a nurse aide, Employee E8, who worked with a revoked certification. The revocation was discovered during an audit, revealing that the facility did not check the quarterly annotation list that would have indicated the revocation. Employee E8 was aware of the revocation but continued to work until the issue was identified.
The facility failed to develop comprehensive care plans for two residents with PTSD, as required by their trauma-informed care policy. The care plans lacked specific goals and interventions for managing PTSD, despite the facility's policy mandating individualized care for trauma survivors. The Director of Nursing acknowledged the care plans were incomplete, highlighting a deficiency in addressing the specific needs of residents with PTSD.
The facility failed to maintain food safety standards in the Food Service Department. Observations revealed empty chemical containers at the loading dock, compromised frozen food in the walk-in freezer, and unsanitary conditions in the cooler and storage areas. The convection oven also had a buildup of burned-on food. These issues were confirmed by the Food Service Director.
A resident with dementia was given acetaminophen for pain, but the administration was not documented in the electronic record by the LPN and RN, violating the facility's documentation policy.
The facility failed to follow its infection control policy by not using required PPE during wound care for two residents with open wounds. Staff were observed providing care without gowns, contrary to the facility's guidelines for enhanced barrier precautions.
A facility failed to complete a discharge summary within the required 30 days after a resident's death. The resident was admitted in 2021 and passed away in 2024, but the discharge summary was not completed until several months later. This was confirmed by the Nursing Home Administrator.
The facility failed to meet the required nurse aide-to-resident ratios during specified periods, falling short of the mandated staffing levels for day, evening, and night shifts. For example, on one day, the evening shift required 149.32 hours but only 144.0 hours were worked, and the night shift required 109.5 hours but only 96.0 hours were worked. Similar shortfalls were observed on other days, indicating a pattern of non-compliance with staffing regulations.
The facility failed to meet the required LPN staffing levels during specific shifts over several weeks. The regulation requires a minimum of one LPN per 25 residents during the day and one LPN per 40 residents overnight. However, the facility did not meet these requirements on nine out of twenty-one days reviewed, with actual LPN hours consistently falling short of the required hours. These deficiencies were discussed with the facility's administration.
The facility did not provide the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period on multiple days. Staffing sheets revealed that on sixteen out of twenty-one sampled days, the hours of care ranged from 2.08 to 3.09 hours, falling short of the regulatory requirement. Facility administration confirmed the deficiency during an interview.
The facility did not maintain its fire alarm system properly, as the fire alarm panel at the main entrance displayed Trouble Code #1, indicating a malfunction. This issue was confirmed by the Administrator and Maintenance Director during an exit interview.
The facility failed to maintain the emergency generator, as observed when the annunciator panel displayed a "Not in Auto" trouble code, indicating it was not set to automatically engage. This deficiency was confirmed during an interview with the Administrator and Maintenance Director, highlighting a significant oversight in maintenance protocols.
The facility was found to have deficiencies in fire safety and kitchen maintenance. There was a lack of a second acceptable means of egress from each floor, and the facility failed to maintain the kitchen hood exhaust suppression system as per NFPA standards. Documentation of a semi-annual kitchen exhaust hood/duct cleaning prior to August 2, 2024, was missing, as confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to conduct and document required fire drills for the 1st quarter of 2024 across all shifts. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director.
The facility failed to maintain fire resistance on one of three floors. Observations revealed unsealed penetrations around data lines and malfunctioning double doors by the Staff Development Office, which did not close or latch properly and had broken hardware. These issues were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain clear means of egress as required by NFPA 101 standards. An observation revealed that the ground floor exit next to the Admissions Office was blocked by boxes, carts, and a large indoor plant, affecting one of the three floors. This was confirmed during an interview with the Administrator and Maintenance Director.
The facility failed to maintain proper illumination in the exit stairways, affecting one of three floors. An observation revealed that the lights in the first floor South main stair tower were not illuminating. This was confirmed during an exit interview with the Administrator and the Maintenance Director.
The facility failed to maintain operable battery back-up lighting on one of three floors. Observations revealed that emergency back-up lights on the second floor South, next to resident rooms 230 and 238, were not functioning correctly. The lights next to room 230 did not illuminate when tested, and those next to room 238 did not turn off after testing. These issues were confirmed by the Administrator and Maintenance Director.
The facility did not maintain the necessary safety features for doors to hazardous areas, impacting one of three levels. An observation revealed that the Infectious Waste Room on the ground floor was missing door hardware and a self-closer. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain the automatic sprinkler system, with missing escutcheon plates and spare parts on the first and ground floors, and damaged ceiling tiles near a sprinkler head on the second floor, potentially affecting system activation.
The facility was found to have an unsealed penetration in a smoke barrier wall on the first floor South, above the smoke doors by room 142. This was observed during a survey and confirmed in an interview with the Administrator and Maintenance Director.
The facility did not properly maintain its HVAC systems, affecting one of three floors. Observations revealed portable air conditioning units ducted into the ceiling in both the South Elevator Mechanical Room and the North Kitchen Dietary Office on the ground floor. These issues were confirmed during an exit interview with the Administrator and the Maintenance Director.
The facility failed to maintain electrical wiring protection on one floor. An observation revealed that an electrical panel in the Mechanical Room had a missing latch, preventing the cover from closing. This was confirmed in an interview with the Administrator and Maintenance Director.
The facility failed to maintain proper oxygen storage requirements due to missing precautionary signage in two Med Rooms on the first and second floors. The required signage, indicating the presence of oxidizing gases and prohibiting smoking, was absent, as confirmed by the Administrator and Maintenance Director.
York Nursing And Rehabilitation Center's emergency preparedness communication plan lacked a means to provide information about the facility's needs and ability to assist to authorities, affecting the entire facility. This deficiency was confirmed during a survey and acknowledged by the facility's leadership.
The facility failed to conduct the required annual full-scale exercise for its emergency plan, as revealed during a document review. The absence of documentation was confirmed in an interview with the Administrator and Maintenance Director, indicating non-compliance with emergency preparedness regulations.
The facility failed to comply with building construction requirements for both the Center and South Buildings. The Center Building, classified as a three-story, Type V (000) unprotected wood frame construction, exceeded the maximum allowable height by two stories. Similarly, the South Building, classified as a three-story, Type II (000) unprotected non-combustible construction, exceeded the height limit by one story. These issues were confirmed during exit interviews with facility administrators.
The facility failed to provide two acceptable exits from each floor of the Center Building, affecting the entire building component. All three floors lacked a second acceptable means of exiting, with existing routes consisting exclusively of horizontal exits into adjacent healthcare buildings, not meeting NFPA 101 standards.
York Nursing and Rehabilitation Center failed to maintain required air temperatures in two resident rooms due to a malfunctioning central heater and inadequate insulation around a window air conditioning unit. One room had a temperature of 69°F, which was later corrected to 72°F, while another room had a colder area near the window at 68°F, affecting a resident's comfort. The facility's policy requires maintaining temperatures between 71-81°F.
The facility consistently failed to meet required nurse aide staffing ratios over a seven-day period, with significant shortfalls in hours provided across day, evening, and night shifts. For example, on one day, the facility required 157.50 hours of nurse aide care during the day shift but only provided 80.00 hours. This pattern of inadequate staffing was observed through a review of staff schedules and punch reports.
The facility did not meet the required LPN staffing levels during day shifts on two occasions in a week. On one day, 8.00 LPNs were provided when 8.40 were needed, and on another day, 8.00 LPNs were provided when 8.36 were required. This deficiency was identified through a review of staffing records and discussed with the Nursing Home Administrator and the DON.
The facility failed to provide the required 3.2 hours of direct nursing care per resident per day on six out of seven days reviewed. The deficiency was identified through a review of nursing time schedules and punch reports, revealing consistent shortfalls in staffing levels. For example, on one day, with a census of 210 residents, only 527.25 hours of care were provided, equating to 2.51 hours per resident.
A resident with multiple medical conditions was unable to receive visits from a long-time friend due to accusations of financial misconduct. The friend was banned from the facility pending an investigation, which was not properly conducted. The resident was visibly upset by the situation, and staff interviews revealed inconsistencies in communication regarding the friend's visitation status.
The facility failed to accurately document the Pennsylvania Preadmission Screening Review (PASRR) for a resident. The resident's PASRR form lacked documentation of several mental health diagnoses, including Schizophrenia, Dementia with Behavioral Disturbances, Anxiety Disorder, and substance use disorder (alcohol). This was confirmed by a Social Services employee.
A resident with hypertension and lymphedema did not receive their prescribed Amlodipine due to unavailability and lack of awareness among nursing staff about the medication's presence in the Pyxis machine. This deficiency was identified through a review of facility policy, clinical records, and staff interviews.
The facility failed to ensure that devices to promote the healing of pressure ulcers were implemented for a resident. Despite a policy requiring daily pressure relief measures and a physical therapy evaluation recommending specific devices, an observation revealed that the necessary devices were not available for the resident, who was at risk for developing pressure ulcers.
Failure to Administer Medications According to Physician-Ordered Times
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders and its own medication administration policy, which requires verification of the right medication, dose, time, and method before administration. For one resident, R1, review of the Medication Administration Record (MAR) showed multiple medications were given outside the prescribed times on several consecutive days. On April 9, 2026, fluticasone-salmeterol inhaler, apixaban, fluticasone nasal spray, Mucinex, Macrobid, and albuterol nebulizer treatments were all administered later than their scheduled times, in some cases by more than an hour. The same pattern continued on April 10, 2026, when apixaban, fluticasone-salmeterol, Mucinex, Macrobid, fluticasone nasal spray, and albuterol nebulizer were again administered significantly later than ordered. On April 11, 2026 (a.m.), R1’s apixaban, fluticasone-salmeterol inhaler, Mucinex, Macrobid, and fluticasone nasal spray were all administered approximately two hours after the scheduled 9:00 a.m. time. These medications were ordered for conditions including shortness of breath (SOB), deep vein thrombosis (DVT), seasonal allergies, cough, urinary tract infection (UTI), and chronic obstructive pulmonary disease (COPD). The documented administration times on the MAR did not align with the physician-ordered schedules, demonstrating that medications were not given within the required time frames. Another resident, R12, reported that medications were not administered timely on three separate days and expressed concern because these medications were for diabetes and heart issues. Audit reports confirmed that on April 15, 16, and 17, 2026, R12’s scheduled morning medications—including metoprolol succinate ER, metformin, Provera, diltiazem ER, hydrochlorothiazide, and losartan—were administered several hours later than their ordered times. Additionally, review of R13’s medication administration audit report showed that amiodarone, aspirin, and magnesium oxide, all scheduled for 9:00 a.m. on April 16, 2026, were not administered until early afternoon. These findings were confirmed with the facility’s Nursing Administrator and Assistant DON, establishing that medications for multiple residents were not administered according to physician-ordered times and professional standards of practice.
Failure to Administer and Document Medications and Wound Treatments as Ordered
Penalty
Summary
The facility failed to administer medications and treatments according to physician orders, resident preferences, and facility policy for one resident. The resident was admitted with diagnoses including presence of a right artificial knee joint and cervical radiculopathy. Facility policy on administering medications required that medications be given safely, timely, and as prescribed, with the right medication, dose, time, and method, and that all administrations, holds, refusals, or time changes be documented in the electronic health record, with notification to the responsible party and attending physician as applicable. Review of the medication audit for this resident showed that Naproxen 500 mg, ordered twice daily with meals for arthritis pain and scheduled for 8:00 a.m., was administered at 9:23 a.m. Lidocaine 4% patch ordered once daily to the right lower extremity for pain and scheduled for 9:00 a.m. was documented as administered at 3:36 p.m. Diclofenac 1% topical gel ordered four times daily to the right leg for pain, with a scheduled 9:00 a.m. dose, was documented as given at 3:34 p.m., and the 12:00 p.m. dose was also documented as administered at 3:34 p.m. Celecoxib 200 mg ordered once daily for pain and scheduled for 9:00 a.m. was administered at 3:35 p.m. The Regional Nurse confirmed that these medications were administered late. The facility also failed to provide and document ordered wound care treatments for the same resident’s right knee following total knee replacement. The treatment administration record for January showed a physician order to remove the Mepilex dressing on the right knee on a specified date and leave the area open to air one time only for one day; there was no documented evidence that this treatment was completed on that date. Another order directed staff to cleanse the right knee incision with normal saline, pat dry, and cover with a bordered gauze dressing daily and as needed for soiling, with saline solution listed as to be applied topically every four hours as needed for wound care; there was no documented evidence that this treatment was completed on the specified date. These findings were cited under 28 Pa. Code 211.10(c) resident care policies and 28 Pa. Code 211.12(d)(1) nursing services.
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of dementia and wandering exited the facility without adequate supervision. The resident had been assessed as an elopement risk, with interventions in place such as a wander guard device and inclusion in the facility's elopement risk program. Despite these measures, the resident was able to leave the second-floor nursing unit, access the elevator, and exit through the ground floor loading dock door without triggering any alarms or being stopped by staff. The wander guard system did not have sensors on the elevators or stairwells, and staff were unaware of this gap in coverage. Multiple staff members observed the resident ambulating the unit and attempting to access doors and elevators, but there was no order for frequent checks, and staff did not consistently monitor the resident's whereabouts. The resident was last seen around dinner time, and after refusing dinner, was assumed by staff to be elsewhere on the unit. The resident was observed on security footage exiting the building in the early evening, but the absence was not discovered until several hours later. The facility's elopement protocol, including a code yellow and a building search, was not initiated until approximately four hours after the resident had left the premises. The resident was found by local law enforcement approximately 1.5 miles away from the facility in sub-freezing temperatures and was admitted to the hospital with hypothermia. The resident was unable to identify themselves and required fingerprinting for identification. The delay in recognizing the resident's absence and the lack of effective monitoring and alarm coverage directly contributed to the resident's elopement and subsequent harm.
Removal Plan
- Code Yellow-Responding to Elopement was called by the nursing supervisor.
- Elopement protocol initiated and whole building and outside perimeter was searched.
- All other residents were verified as being present through a whole house bed check, and the police/911 and physician were called.
- Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified that Resident R223 was missing.
- Ground level door audits and wander guard system audit was completed by NHA to ensure proper function.
- Police notified NHA that Resident R223 was located at the local hospital.
- NHA and nurse aide verified Resident R223's identity at the local hospital.
- It was determined that Resident R223 was picked up by Emergency Medical Services (EMS) about 1.2 miles from the facility and taken to the local hospital.
- An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held with department heads.
- Whole house wander guard audit was completed to verify placement and function for residents assessed as needing one.
- Whole house elopement assessments completed with no new residents identified as being at risk for elopement.
- Elopement binder reviewed and audited to ensure book is up to date and current with completion of new assessments.
- Every 1-hour loading dock door checks initiated and are ongoing.
- Facility contacted wander guard service provider to obtain quotes to add wander guard sensors to elevators, stairwells, and service hallways.
- It was determined that the resident exited out of the loading dock doors.
- Frequency of loading dock door check increased to every 30-minutes.
- Education on Code Yellow-Responding to Elopement initiated with in-house nursing staff.
- Elopement policy reviewed.
- Education initiated with all facility staff on signs and symptoms of elopement and supervision of residents with dementia and history of exit seeking behaviors, how to identify residents and where wander guard sensors are located within the facility.
- This education will be added to new hire orientation.
- 85% of facility staff will be educated.
- Facility is completing loading dock and front entrance door audits every 30 minutes daily for 30 days.
- Facility will review findings of audits during QAPI meeting.
- Resident R223 at hospital and will be re-assessed upon re-admission.
Failure to Protect Resident from Physical Abuse During Supervised Activity
Penalty
Summary
The facility failed to implement adequate interventions to protect a resident (Resident R3) from physical abuse, resulting in actual harm. During a supervised smoke break, another resident (Resident R4), who had a documented history of behavioral problems including verbal aggression and use of profanity during smoke breaks, became verbally aggressive when informed that staff would no longer provide cigarettes. When Resident R3 attempted to intervene, Resident R4 struck Resident R3 in the face with a wheelchair leg rest, causing a chipped tooth, and continued to physically assault Resident R3 for approximately 15 seconds. Staff interviews confirmed that Resident R4 had previously displayed aggressive behaviors, and that Resident R3 had also made threats toward others in the past. Review of care plans revealed that Resident R4's behavioral issues were only addressed with a single intervention of administering medications as ordered, with no additional strategies to manage or monitor aggressive behaviors. Resident R3's care plan did not include interventions to address potential risks from other residents. The facility's failure to implement and update appropriate interventions and monitoring for residents with known behavioral issues directly led to the incident of physical abuse and injury.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and served at safe and appetizing temperatures for three of ten residents reviewed. Resident interviews revealed complaints about food lacking flavor, food being served warm instead of hot, and meals not being prepared correctly. During a test tray observation with the Foodservice Director, hot food items such as chicken and another entrée were found to be served at 118°F, and steamed broccoli at 106.7°F, all below the facility's policy requirement of at least 135°F for hot foods. Additionally, cold pears were served at 46.2°F, exceeding the maximum allowed temperature of 41°F for cold foods. The Foodservice Director confirmed that these temperatures were outside the acceptable range and that the food was not palatable as a result.
Deficiency in Food Service and Palatability
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at appropriate temperatures for several residents. Multiple residents reported dissatisfaction with the meals, citing issues such as receiving food items they could not eat due to dietary restrictions, meals being unappetizing, and food being served at incorrect temperatures. For instance, one resident mentioned receiving pork despite being unable to consume it, while another noted that meals were consistently late and unappealing. Additionally, residents expressed concerns about the lack of variety and the poor presentation of meals, with some resorting to ordering food from outside the facility. Observations and interviews revealed systemic issues in the food service process. The kitchen staff were observed placing cold pellets on trays, and the pellet heater was reportedly not functioning. Plates were not adequately warmed, and food items were served at temperatures below the acceptable range for palatability. During a test tray observation, it was noted that the meal delivery process was delayed, with food temperatures falling outside the acceptable range, as confirmed by the Food Service Director. These deficiencies indicate a failure to meet the regulatory requirements for food service in the facility.
Plan Of Correction
Step 1 R130, R44, R17, R82, R146, R126, R86, R165, R136, R147, R112, R121, R60, R111, R56 and R32 preferences reviewed and updated. Work order initiated to repair pellet heaters. Alternative process for warming plates initiated. Step 2 Audit completed to ensure that all equipment designed to help maintain proper food temps are functioning properly. Food satisfaction survey completed with residents who are AAOX3 to ensure that food preferences are met. Step 3 Kitchen staff educated on proper use of pellet heaters to ensure plates are warmed as per facility protocol. Nursing staff educated on ensuring trays are delivered immediately upon arrival of units. Step 4 Admin/Designee will conduct weekly audits x 4, monthly x2. All results will be presented at QA for further review.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and reports of pest activity. On January 28, 2025, flies were observed on the first floor South nursing unit and during a lunch meal service on the second floor near Room 212. A resident reported frequent sightings of flies in their room. Additionally, flies were seen during a resident council meeting in the activity room on the first floor. The pest control logbook documented incidents of mice in rooms 132 and 134, and a report of 'nets' in the S Services location. A review of pest control invoices revealed that the kitchen and baseboards were inspected and treated, with recommendations for improved sanitation practices due to heavy drain/fruit fly activity and water leaks in the cooking area. An interview with an administrative employee confirmed the ongoing issue with flies and 'nets' in the facility, leading to an increase in pest control treatments from once a week to twice a week. Despite these efforts, the presence of pests indicates that the facility's pest control program was not effectively maintained.
Plan Of Correction
Step 1 The facility has partnered with all state pest management services. The facility immediately reviewed the pest control program and is now following the recommendation of all state pest control. The facility increased the frequency of pest control services from once a week to twice a week. Facility power-washed food tray charts and wheelchairs. The leak behind the cooking area was fixed and the kitchen was deep-cleaned throughout. Step 2 The maintenance director, HSKP Manager, and NHA completed environmental rounds throughout the facility to identify areas with pest control issues. All issues identified were added to the pest control log and will be treated by All state pest management services. Step 3 Facility staff were educated on the pest control protocol and the requirement to immediately report any pest observation using the pest control log on each unit. Step 4 NHA/designee will audit weekly x4 and monthly x2. Findings will be reviewed during QAPI.
Failure to Update Advance Directive for Hospice Resident
Penalty
Summary
The facility failed to ensure that a resident's right to request or refuse medical treatments was accurately reflected in the resident's record. This deficiency was identified for a resident who was admitted to the facility with a diagnosis of dementia and later placed on hospice care. Despite the change in care status, the resident's advance directive remained as full code, indicating a lack of proper documentation and discussion regarding the resident's end-of-life care preferences. An interview with the Unit Manager confirmed that the Physician Orders for Life-Sustaining Treatment (POLST) should have been discussed with the resident and/or their responsible party when the resident was placed on hospice care. However, this discussion did not occur, leading to a discrepancy between the resident's care plan and their documented advance directives. This oversight highlights a failure in the facility's process to ensure that residents' treatment preferences are accurately documented and respected.
Plan Of Correction
Step 1 Advance Directive for resident R96 reviewed with Responsible party: POLST updated to reflect updated Code status. Step 2 All Hospice residents POLST to be audited to ensure that a resident's right to request or refuse medical treatments were accurately reflected in the resident's record. Step 3 Social Services/nursing management will be educated to ensure that a resident's right to request or refuse medical treatments were accurately reflected in the resident's record. Step 4 Admin/Designee will conduct weekly audits x 4, monthly x2. Findings will be reviewed during QAPI meeting.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two of its nursing units, as evidenced by several observations made by surveyors. In room 139 bed C, privacy curtains were found to be dirty with brown spots and black streaks. In room 140B, a loose closet door with unsecured hinge screws and cracks in the wall around the heater were noted. Additionally, the shower room on the 1st South nursing unit had 12 ceiling tiles with water damage, including one with a large hole. Room 152 had a broken dresser, a detached baseboard, a loose heater P-Tac unit cover box, holes in the wall near the baseboard, and broken tray tables. Further observations in the 1 North shower room revealed clutter, including three large trash cans in the first shower stall, a large trash can and three tray tables in the second stall, and a mechanical lift stored in the middle of the shower area. There was no privacy curtain between the second and third shower stalls, and the fourth stall contained three mechanical lifts. A regular resident's chair was also placed near the sink, contributing to the cluttered environment. These findings indicate a failure to provide a safe, clean, and comfortable environment as required by regulations.
Plan Of Correction
Step 1 The privacy curtain in room 139C was replaced. Furniture in room 140B was repaired, crack in the wall in room 140 was repaired. Ceiling tiles in 1 south nursing unit replaced. The dresser in room 152 was repaired. The baseboard was repaired and the PTAC cover was repaired, hole in the wall. The bedside tray table replaced room 152B. Clutter in 1 north shower room was immediately removed and the privacy curtain was installed between the second and the third stall. Step 2 A Facility-wide audit will be completed to ensure that furniture, walls, privacy curtains, baseboard, bedside tray tables, and PTAC covers are in good condition and that all shower rooms are clutter-free. Step 3 Facility staff will be educated on the requirements to ensure that residents have a safe, clean, comfortable, and homelike environment. Step 4 NHA/Designee will complete random audit weekly x4 monthly x2. Findings will be reviewed during QAPI meeting.
Failure to Conduct Timely Background Check for New Hire
Penalty
Summary
The facility failed to perform a criminal history background check prior to hiring for one of the personnel files reviewed. Specifically, the Director of Nursing, referred to as Employee 2, was hired on November 11, 2024, but did not have a Pennsylvania State Police background check completed until January 29, 2025. This is in violation of the facility's policy, which mandates that a criminal history check be conducted as a condition of employment within the first 30 days of hire. During an interview, the Nursing Home Administrator, Employee E1, stated that the Human Services Director, Employee E9, had conducted a criminal background check at the time of hiring; however, it was not saved, and a more recent copy was unavailable. This oversight led to a deficiency in compliance with the facility's policy and state regulations, as the required background check was not completed in a timely manner.
Plan Of Correction
Step 1 The background check for the DON was completed on 1/29/25 and the result was added to the personnel file. Step 2 HR director will complete an audit of all active employees to ensure that background checks are completed as required. Step 3 HR personnel were educated on the requirement to complete background checks before onboarding. Step 4 HR director/ designee will audit all new hires weekly x4 than monthly to ensure that criminal background checks were completed before onboarding. Findings will be reviewed in QAPI meeting.
Failure to Develop Comprehensive Care Plan for Smoking Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as a smoker, which is a requirement under §483.21(b)(1). The resident, who was admitted to the facility with diagnoses including dementia, mild cognitive impairment, adjustment disorder, and memory deficit, was assessed as cognitively intact with a BIMS score of 15. Despite the completion of a smoking assessment shortly after admission, the facility did not create a person-centered care plan addressing smoking interventions for the resident. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a comprehensive care plan for safe smoking interventions. The facility's policy mandates the initiation of a baseline care plan upon admission and a comprehensive care plan upon completion of the Care Area Assessment, but this process was not followed for the resident in question. The lack of a care plan addressing smoking was observed during a routine smoking session, highlighting the facility's failure to meet regulatory requirements for comprehensive care planning.
Plan Of Correction
Step 1 Resident R192 person centered comprehensive smoking care plan reviewed and updated to reflect residents smoking status and safe smoking interventions. Step 2 Care plan audit completed for all residents who are smokers to ensure that it reflects residents smoking status with safe smoking interventions included. Step 3 Social services, activities and nursing team educated on ensuring residents identified as smokers have comprehensive smoking care plan that reflects residents smoking status and safe smoking interventions. Step 4 Admin/Designee will conduct weekly audits x 4, monthly x2. Findings will be reviewed during QAPI meeting.
Failure to Maintain Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to maintain adequate personal hygiene and grooming for residents who are dependent on staff assistance for activities of daily living. Resident R114, who is totally dependent on staff for assistance, was observed with long and dirty fingernails despite his preference for short nails. His comprehensive care plan specifically included an intervention to keep his fingernails short due to his potential for skin integrity impairment related to decreased mobility and incontinence. Observations over several days confirmed that his nails remained untrimmed, and the unit manager acknowledged that it was the responsibility of the nursing assistant to ensure they were cut. Similarly, Resident R60, who requires setup or clean-up assistance with personal hygiene, was found with very long and dirty fingernails. Although he is independent in some activities, he cannot cut his nails himself and had been waiting for a nurse to assist him. Despite having intact cognition, he expressed that he had not received the necessary assistance until a specific nurse eventually cut his nails. Interviews with staff revealed that Resident R60 sometimes refuses care and prefers certain caregivers, which may have contributed to the delay in receiving the necessary grooming assistance.
Plan Of Correction
Step 1 Resident R114, E22, R60, E23, E24 nails were trimmed and cleaned. Step 2 All residents audited, nails cleaned and trimmed to ensure adequate personal hygiene and grooming for all residents who are dependent on staff for ADL. Step 3 Nursing staff educated on adequate personal hygiene and grooming for residents who are dependent on staff for assistance with ADL. Step 4 Managers/ designee will conduct audits weekly x4, monthly x 2 as per facility protocol. Findings will be reviewed during QAPI meeting.
Improper Use of Electrical Extension Cord in Resident's Room
Penalty
Summary
The facility failed to ensure a resident environment free of accident hazards for one resident. During an observation, it was noted that a long electrical extension cord with five outlets was plugged into a wall outlet behind the resident's bed, extending across the room to power a television on a dresser. The resident stated they had purchased the extension cord for their television and video player with the facility's permission. However, the Maintenance Director confirmed that the facility does not allow the use of electrical extension cords in residents' rooms as they are considered hazardous.
Plan Of Correction
Step 1 The extension cord was removed from resident R35's room. Step 2 The maintenance Director/designee completed a facility-wide audit to ensure that extension cords are not in use. Step 3 Facility staff educated on the requirement to ensure that extension cords are not in use and that the resident environment remains as free of accident hazards as possible. Step 4 The maintenance director/designee will audit resident rooms weekly x 4, and monthly x 2. Findings will be reviewed during QAPI meeting.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident R67, who experienced significant weight loss. The facility's policy required communication between nursing staff and the dietician to prevent, monitor, and intervene in cases of undesirable weight loss. However, despite the resident's weight loss of 20.29% over a short period, there was no documented evidence that the facility obtained weekly weights as ordered by the physician. The dietician, Employee E5, acknowledged awareness of the weight loss but attributed it to a scale malfunction without testing the scale or implementing protocols for addressing the weight loss. Additionally, the medical doctor, Employee E20, was aware of the resident's significant weight loss but did not address it in his documentation or provide new orders related to the weight loss. The resident's care plan included goals to maintain adequate nutritional status and interventions to monitor and report signs of nutritional issues, but these were not effectively implemented. The lack of timely and appropriate interventions contributed to the deficiency in maintaining the resident's nutritional status.
Plan Of Correction
Step 1 Resident R67 weight obtained. Step 2 All residents requiring weekly weights related to weight loss audited to ensure weights obtained according to physician orders. Step 3 Nursing staff educated on ensuring weekly weights are obtained as ordered by the physician. Step 4 Managers/designee will conduct audits weekly x4, monthly x2 to per facility protocol. Findings will be reviewed during QAPI meeting.
Inadequate Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for three residents, as evidenced by discrepancies between physician orders and the actual administration of oxygen. One resident, diagnosed with acute respiratory failure with hypoxia and a malignant neoplasm of the upper lobe of the left lung, was observed receiving oxygen at 4 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Director of Nursing at the time of observation. Another resident, dependent on supplemental oxygen, was ordered to receive oxygen at 2 liters per minute but was observed receiving 3 liters per minute. Additionally, a third resident with chronic obstructive pulmonary disease was ordered to receive 3 liters of continuous supplemental oxygen but was observed using 4 liters, and the oxygen concentrator was found to be covered in dust. These findings were confirmed by the respective staff members present during the observations.
Plan Of Correction
Step 1 Resident R31, R88, R163 oxygen settings updated as per Physician orders. Step 2 All residents with Physician orders for oxygen audited to ensure oxygen concentrators are set appropriately. All oxygen concentrators audited to ensure they are free from dust/debris. Step 3 Nursing staff educated to ensure appropriate respiratory care and services provided as per physician orders. Housekeeping staff educated on the requirement to ensure oxygen concentrators are free of dust/debris. Step 4 Managers/ designee will conduct audits weekly x4, monthly x 2 to per facility protocol. Findings will be reviewed during QAPI meeting.
Failure to Verify Nurse Aide Certification Status
Penalty
Summary
The facility failed to verify the nurse aide certification status of Employee E8, which led to the individual working with a revoked certification. Employee E8 was initially hired with a valid nurse aide certificate, and the facility last verified this certification in July 2023. However, the certification was revoked in July 2024 due to a substantiated finding from a different facility, which the facility did not become aware of until October 2024 during a routine audit. The Human Services Director, Employee E9, discovered the revocation while auditing staff licenses. Upon confronting Employee E8, it was confirmed that the certification was indeed revoked, and Employee E8 was aware of this. Despite this, Employee E8 continued to work until the discovery was made. The facility's failure to check the quarterly annotation list, which would have indicated the revocation, contributed to this oversight. Interviews with the Nursing Home Administrator and the HR Director revealed that the facility was not aware of the quarterly annotation list that could have alerted them to the revocation. The facility only became aware of the revocation after conducting an audit and subsequently suspended and terminated Employee E8. The lack of awareness and failure to regularly verify the certification status of their staff led to this deficiency.
Plan Of Correction
Step 1 Protocol to immediately check the annotation list was initiated on 10/24/24. Moving forward the facility will review the annotation list quarterly to ensure that no current staff members are listed. Step 2 HR director will complete an audit of all current employee files to ensure that no current employees are not listed in the most recent annotation list. Step 3 HR personnel educated on the requirement to check the annotation list quarterly to ensure that no current employees are listed in the annotation list. Step 4 HR director/ designee will audit new hires weekly x4 than monthly to ensure that new hires are not listed on the annotation list.
Inadequate PTSD Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents diagnosed with post-traumatic stress disorder (PTSD). The facility's policy on trauma-informed care mandates that residents who are trauma survivors receive culturally competent care, including the development of individualized care plans that address their specific needs and triggers. However, upon review, it was found that the care plans for both residents lacked specific goals, implementations, or outcomes directly related to their PTSD diagnosis. For Resident R139, the care plan mentioned PTSD in relation to other health concerns but did not include any specific interventions or goals for managing PTSD. Similarly, Resident R157's care plan did not document any treatment or services related to their PTSD diagnosis. The deficiency was confirmed through interviews with facility staff, including the Director of Nursing, who acknowledged that the care plans were incomplete regarding the specific needs of residents with PTSD. The facility's failure to adhere to its own policy and federal regulations resulted in inadequate care planning for residents with PTSD, potentially impacting their mental and psychosocial well-being. The report highlights the need for the facility to ensure that all residents with mental health conditions receive appropriate and individualized care planning to address their specific needs.
Plan Of Correction
Resident R139 R157 PTSD trauma informed comprehensive care plans updated to include person centered interventions. Step 2 All residents with PTSD diagnosis was designated a comprehensive person-centered care plan. Step 3 Social Services department educated on comprehensive person-centered care-plan related to PTSD. Step 4 Managers/ designee will conduct audits weekly x4, monthly x 2 to per facility protocol. Findings will be reviewed during QAPI meeting.
Food Safety Deficiencies in Food Service Department
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the Food Service Department, several deficiencies were observed. At the receiving dock, numerous empty plastic chemical containers were found outside the loading dock door, which could pose a contamination risk. In the walk-in freezer, a bag of frozen French fries with a hole and an open box of frozen peanut butter cookie dough were exposed to circulating air, compromising their safety. Additionally, the walk-in cooler had a yellow substance spilled on the floor, with cracks in the steel plating that had sharp, rusty edges and food substances lodged in them, creating a tripping hazard. Further observations revealed unsanitary conditions in other areas of the food service department. A thick black substance was found on the floor next to the prep sink, and in the dry storage area, multiple boxes of napkins, cups, and other disposable paperware were stacked less than the required 18 inches from the ceiling or other fixtures. The convection oven had a heavy buildup of burned-on food substances on its doors, base, and walls. These findings were confirmed by an interview with the Food Service Director, indicating a lack of adherence to food safety standards.
Plan Of Correction
Step 1 Bag of French fries and box of peanut butter cookie dough secured to prevent exposure to circulating air. Storage area rearranged to ensure that all items are stacked less than 18 inches from the ceiling and other fixtures as required. The oven was cleaned throughout. Step 2 Walk in freezer, food storage areas and food prepping equipment audited to ensure that all items were stored, secured and or maintained in accordance with food safety requirements. Step 3 Dietary staff were educated on the requirement to ensure that food procurement, storage and preparation are done in accordance with state and federal food safety requirements. Step 4 Admin/Designee will conduct audit weekly audits x 4, monthly x2. Findings will be reviewed during QAPI meeting.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as R603, who was admitted with a diagnosis of unspecified dementia with agitation. On January 20, 2025, it was documented in the nursing progress notes that 500 mg of acetaminophen was administered to the resident for pain relief, with a positive effect noted. However, the Licensed Practical Nurse (LPN) and the Registered Nurse (RN) involved did not document the administration of acetaminophen in the resident's electronic administration record, which is a requirement according to the facility's policy titled 'Charting and Documentation.' Interviews with the LPN and RN confirmed that the medication was given, but the failure to document this in the electronic administration record was evident. This lack of documentation is a violation of the facility's policy and the regulatory requirement to maintain complete and accurate medical records, as it did not reflect the care provided to the resident. The deficiency was identified during a review of clinical records, staff interviews, and facility policy, highlighting a lapse in the documentation process for resident care.
Plan Of Correction
Step 1 R603 Resident discharged from facility Step 2 Current residents that have used prn pain medications over the last 30 days will be reviewed to ensure medication administration was documented, non-pharm interventions were documented, and a pain assessment was conducted prior to medication administration. Step 3 All nursing staff educated on ensuring observations, medications administered, services performed, etc., will be documented in the resident's clinical records. Step 4 Managers/ designee will conduct audits weekly x4, monthly x 2 to ensure medication administration policy is followed as per facility protocol. All results will be presented at QA for further review.
Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding the use of appropriate personal protective equipment (PPE) during wound care for two residents. The facility's policy mandates the use of enhanced barrier precautions, including gowns and gloves, for residents with conditions such as open wounds or infections that could lead to the transmission of multi-drug-resistant organisms (MDRO). However, during observations, it was noted that the required PPE was not utilized by the staff members providing care. Resident R4, who was admitted with conditions including anemia, stroke, and hemiplegia, was observed receiving wound care without the nurse wearing the necessary gown, only gloves were used. This was despite the resident having an open lesion, which according to the facility's policy, necessitates the use of enhanced barrier precautions. Similarly, Resident R171, who has paraplegia and was being treated for a stage 3 pressure ulcer and a trauma wound, was also observed receiving wound care without the required gown being worn by the attending nurses. Interviews with the staff involved confirmed the oversight, with one nurse acknowledging the requirement for gowns and gloves for both residents. Another nurse incorrectly stated that the wounds did not qualify for enhanced barrier precautions, contradicting the facility's policy. This discrepancy highlights a failure in the implementation of the infection control program, as the staff did not follow the established guidelines for PPE usage during high-contact activities involving residents with open wounds.
Plan Of Correction
Step 1 Resident R4, R171 audited to ensure proper EBP signage (alerting staff of resident needs), bins and PPE available. Step 2 All Residents identified with wounds treatment pass were audited to ensure proper PPE was utilized. Step 3 Wound team educated on EBP protocols and proper PPE to be utilized with wound care. Step 4 Unit Managers/ designee will conduct audits weekly x4, monthly x 2 to per facility protocol. All results will be presented at QA for further review.
Failure to Timely Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary within the required 30 days following the death of a resident. Specifically, the clinical record of a resident who was admitted on June 28, 2021, and died on November 13, 2024, was reviewed. It was found that the discharge summary was not completed until January 31, 2025, which exceeded the 30-day requirement. This deficiency was confirmed during an interview with the facility's Nursing Home Administrator on January 31, 2025.
Plan Of Correction
Step 1 Discharge Summary for resident R200 was completed. Step 2 The facility completed an audit of discharge records for the last 30 days to ensure that a discharge summary was completed. Step 3 Medical record staff and physician educated on the requirement to ensure that a discharge summary is completed within 30 days of discharge. Step 4 Medical record Director/designee will audit discharged records weekly x 4 monthly x 2 to ensure that a discharge summary was completed. Findings will be reviewed during QAPI.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by the regulation effective July 1, 2024. The regulation stipulates a minimum of one nurse aide per 10 residents during the day, one per 11 residents in the evening, and one per 15 residents overnight. However, during the specified periods of August 9, 2024, to August 14, 2024, December 21, 2024, to December 27, 2024, and January 24, 2025, to January 30, 2025, the facility consistently fell short of these staffing requirements. For instance, on August 9, 2024, the evening shift required a minimum of 149.32 hours, but only 144.0 hours were worked, and the night shift required 109.5 hours, but only 96.0 hours were worked. The deficiency was further evidenced by similar shortfalls on other days within the specified periods. On December 22, 2024, the day shift required 151.50 hours, but only 96.0 hours were worked. On January 24, 2025, the day shift required 166.40 hours, but only 120.0 hours were worked, and the night shift required 110.93 hours, but only 80.0 hours were worked. These findings were discussed with the facility's administration on January 31, 2025, indicating a pattern of non-compliance with the staffing regulations over multiple weeks.
Plan Of Correction
Step 1 The facility is currently staffed at or above state minimum requirements. Step 2 The facility will partner with agencies to ensure that nurse aid requirements are met and to better manage last-minute callouts and unexpected events related to staffing. Step 3 The staff coordinator and other administrative staff involved in coordinating staffing educated on federal and state CNA staffing requirements. Step 4 The NHA or designee will audit staffing levels weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.
LPN Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during specific shifts over several weeks. The regulation mandates a minimum of one LPN per 25 residents during the day and one LPN per 40 residents overnight. However, the facility did not meet these requirements on nine out of twenty-one days reviewed. Specifically, during the day shift, the facility consistently fell short of the minimum required LPN hours, with actual hours ranging from 66.0 to 66.0, while the required hours varied from 67.32 to 70.40. Additionally, on one night shift, the facility provided 41.25 hours of LPN coverage, falling short of the required 42.69 hours. These deficiencies were discussed with the facility's administration on January 31, 2025.
Plan Of Correction
Step 1 The facility is currently staffed at or above state minimum requirements. Step 2 The facility will partner with agencies to ensure that LPN minimum requirements are met, allowing for better management of last-minute callouts and unexpected staffing events. Step 3 The staff coordinator and other administrative staff involved in coordinating staffing educated on federal and state CNA staffing requirements. Step 4 The NHA or designee will audit staffing levels weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified through a review of the facility's nursing staffing sheets for specific weeks in August 2024, December 2024, and January 2025. On sixteen out of twenty-one sampled days, the facility's staffing hours fell below the required threshold, with recorded hours ranging from 2.08 to 3.09 hours per resident. The facility administration confirmed during an interview on January 31, 2025, that they did not meet the nursing hour requirements on these days.
Plan Of Correction
The facility is currently staffed at or above state minimum requirements. Step 2 The facility will partner with agencies to ensure the state minimum requirement of 3.2 hours of direct resident care is met, allowing for better management of last-minute callouts and unexpected staffing events. Step 3 The staff coordinator and other administrative staff involved in coordinating staffing educated on federal and state CNA staffing requirements. Step 4 The NHA or designee will audit staffing levels weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system in proper operating condition, as evidenced by an observation on January 30, 2025. During this observation, the fire alarm panel located at the ground floor main entrance displayed Trouble Code #1, indicating a malfunction or issue with the system. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director, who acknowledged the presence of the trouble code on the fire alarm panel.
Plan Of Correction
Step 1 Trouble on the fire alarm panel at the ground floor main entrance cleared. Step 2 The maintenance team was educated to ensure that the fire alarm system including the fire panel is monitored, tested, and maintained in accordance with the NFPA 70 requirement. Step 3 The maintenance director/ designee will audit the fire panel weekly to ensure safe operation. Findings will be reviewed during QAPI meeting.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the emergency generator as required, which affected the entire facility. During an observation on January 30, 2025, at 9:55 a.m., it was noted that the emergency generator annunciator panel located at the ground floor main entrance displayed a warning lamp illuminated with a "Not in Auto" trouble code. This indicates that the generator was not set to automatically engage in the event of a power failure, which is a critical requirement for ensuring the safety and functionality of the facility's essential electrical systems. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m. The failure to maintain the generator in a state of readiness as per the NFPA 101 and NFPA 110 standards, which require the generator to be capable of supplying service within 10 seconds, represents a significant oversight in the facility's maintenance protocols. This oversight could potentially compromise the facility's ability to provide continuous care and safety to its residents in the event of a power outage.
Plan Of Correction
Step 1 The emergency generator was reset to auto. Step 2 The maintenance team educated on the requirement to ensure that the emergency generator is set to auto to ensure that service can be automatically provided within 10 seconds as required. Step 3 The maintenance director will audit the generator setting weekly and ensure that the annunciator panel is set on auto. Findings will be reviewed during QAPI meeting.
Fire Safety and Kitchen Maintenance Deficiencies
Penalty
Summary
The facility was found to have deficiencies related to fire safety and kitchen maintenance. During an exit interview with the Administrator and the Maintenance Director, it was confirmed that there was a lack of a second acceptable means of egress from each floor, which is a requirement for safety compliance. Additionally, the facility failed to maintain the kitchen hood exhaust suppression system as required by the National Fire Protection Association (NFPA) standards. Specifically, the facility could not provide documentation of a semi-annual kitchen exhaust hood/duct cleaning prior to August 2, 2024. This lack of documentation was confirmed during the exit interview, indicating a failure to adhere to necessary fire safety protocols.
Plan Of Correction
Step 1 The facility has partnered with AVDC for the cleaning of the Main Kitchen Hood Exhaust Systems every 6 months. Documentation of a semi-annual kitchen exhaust hood/duct cleaning will be added to the life safety binder. Step 2 The maintenance director and Food and Nutrition Services Director were educated on the requirement to ensure a semi-annual kitchen hood/duct cleaning is completed and maintain proof of documentation. Step 3 NHA/designee will audit documentation and ensure this requirement is met semiannually.
Failure to Conduct and Document Fire Drills
Penalty
Summary
The facility failed to conduct and properly document required fire drills, affecting three of twelve quarters. During a document review on January 30, 2025, it was revealed that the facility did not provide documentation of fire drills for the 1st quarter of 2024 across all three shifts. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day.
Plan Of Correction
Step 1 Moving forward, the facility will ensure that fire drills are completed quarterly on each shift. Step 2 The maintenance director was educated on the requirement to conduct quarterly fire drills on each shift. Step 3 The maintenance director/designee will audit fire drill documentation monthly x 4 to ensure that fire drills are completed as required. Findings will be reported in QAPI meeting.
Fire Barrier Deficiencies on First Floor
Penalty
Summary
The facility failed to maintain the fire resistance of fire barriers, affecting one of three floors. During an observation on January 30, 2025, between 9:05 a.m. and 9:15 a.m., deficiencies were noted on the first floor regarding common fire wall separations. Specifically, there was an unsealed penetration around data lines above the double doors by the Staff Development Office. Additionally, the double doors by the Staff Development Office failed to close and positively latch when tested, and there was broken hardware on the door. These findings were confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m.
Plan Of Correction
Step 1 The maintenance team used 3M fire barrier sealant CP25B+ to seal penetration around data lines above the double door by the staff development office. Hardware on double doors repaired. Doors now positively latch and are closing appropriately. Step 2 The maintenance director/designee completed an audit of all doors to ensure safe operation. Smoke barriers were inspected throughout the building to ensure that there were no other unsealed penetrations. Repairs were completed for any deficiencies found. Step 3 The maintenance team was educated on the requirement to ensure the safe operation of all doors in the facility and to ensure that smoke barrier walls have no unsealed penetration. Step 4 The maintenance director/designee will complete a random audit of doors monthly x 4 to ensure safe operation. Findings will be reviewed during QAPI meeting.
Obstructed Means of Egress
Penalty
Summary
The facility failed to maintain the means of egress free of obstructions, as required by NFPA 101 standards. During an observation on January 30, 2025, at 9:55 a.m., it was noted that the ground floor exit next to the Admissions Office was blocked by boxes, carts, and a large indoor plant. This obstruction affected one of the three floors in the facility. The issue was confirmed during an exit interview with the Administrator and the Maintenance Director later that morning at 11:30 a.m.
Plan Of Correction
Step 1 Means of egress next to the admissions offices cleared. Step 2 The maintenance team checks all exits to ensure that all means of egress are free of obstruction. Step 3 Facility staff educated on the requirement to ensure that all exits are free of obstruction. Step 4 The maintenance director/ designee will audit all means of egress monthly x4 to ensure that they are free of obstruction. Findings will be reviewed during QAPI.
Failure to Maintain Illumination in Exit Stairways
Penalty
Summary
The facility failed to maintain proper illumination of the exit stairways, specifically affecting one of the three floors. During an observation on January 30, 2025, at 9:20 a.m., it was noted that the lights in the first floor South main stair tower were not illuminating as required. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director later that morning at 11:30 a.m., where it was acknowledged that the exit stair tower lights did not illuminate.
Plan Of Correction
Step 1 Lights on the first-floor South main stair tower repaired. Step 2 The maintenance team completed a facility-wide audit of all stairways to ensure that all exit stairways had adequate illumination. Step 3 The maintenance team was educated on the requirement to maintain the illumination of the exit stairways. Step 4 The maintenance director or designee will audit monthly x4 to ensure that the illumination of the exit stairways is properly maintained. Findings will be reviewed in QAPI.
Emergency Back-Up Lighting Deficiency
Penalty
Summary
The facility failed to maintain battery back-up lighting in operable condition, affecting one of three floors. During an observation on January 30, 2025, from 10:50 a.m. to 10:55 a.m., deficiencies were noted in the emergency back-up lighting system on the second floor South. Specifically, at 10:50 a.m., the emergency back-up lights next to resident room 230 failed to illuminate when tested. Additionally, at 10:55 a.m., the emergency back-up lights next to resident room 238 failed to turn off after being tested. These deficiencies were confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m.
Plan Of Correction
Step 1 Back-up lighting on the second floor South next to resident room 230 was repaired. Back-up lighting on the second floor South next to resident room 238 was repaired. Step 2 A facility-wide audit of all emergency battery backup lights was completed to ensure that they operate as required. Step 3 The maintenance team was educated on the requirement to ensure that Emergency lighting of at least 1-1/2-hour duration is provided automatically. Step 4 The maintenance director/ designee will complete a random audit of backup lighting monthly x 4 to ensure safe operation. Findings will be reviewed during QAPI meeting.
Deficiency in Hazardous Area Door Maintenance
Penalty
Summary
The facility failed to maintain the required safety features for doors leading to hazardous areas, specifically affecting one of the three levels. During an observation on January 30, 2025, at 10:15 a.m., it was noted that the Infectious Waste Room within the ground floor Environmental Room was missing essential door hardware and a self-closing mechanism. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director later that morning at 11:30 a.m.
Plan Of Correction
Step 1 Hardware and self-closer installed on the ground floor Infectious Waste Room. Step 2 A facility-wide audit was completed to ensure that all doors leading to a hazardous area had self-closer and the appropriate hardware installed. Step 3 The maintenance team was educated on the requirement to have the appropriate hardware and self-closer on doors leading to hazardous areas. Step 4 The maintenance director/ designee will audit the infectious waste room to ensure that appropriate hardware and self-closers are installed as required. Findings will be reviewed during QAPI.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system and its components, affecting two of three floors. On January 30, 2025, observations revealed several deficiencies: on the first floor South, near the Supervisor's Office and resident room 142, sprinklers were missing escutcheon plates. Additionally, the ground floor South Sprinkler Room lacked a mounted utility box containing six spare sprinkler heads and a wrench. These issues were confirmed during an exit interview with the Administrator and the Maintenance Director. Further observations on the same day at 11:05 a.m. identified additional deficiencies on the second floor North. In the stairwell, multiple missing and damaged ceiling tiles were found near a sprinkler head, which could negatively affect the activation of the sprinkler system. This issue was also confirmed during the exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
Step 1 The escutcheon plate by the supervisor's office on 1 South was replaced. The escutcheon plate by room 142 was replaced. Utility box containing six spare sprinkler heads and wrench mounted in the ground floor South Sprinkler Room. Step 2 The maintenance team was educated on the requirement to have a utility box mounted in the sprinkler room and to ensure that the Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25. Step 3 The maintenance director/ designee will audit the sprinkler room monthly x 4 to ensure that all requirements are met. Findings will be reviewed during QAPI meeting. Step 1 Ceiling tiles near the sprinkler head on the Second floor North, Stairwell replaced. Step 2 A Facility-wide audit was completed to ensure that all ceiling tiles were in good condition. Step 3 The maintenance team was educated on the requirement to ensure that ceiling tiles around sprinkler heads are in good condition and do not negatively affect the activation of the sprinkler system. Step 4 The maintenance director will complete a random audit monthly x4. Findings will be reviewed during QAPI meeting.
Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on January 30, 2025, at 9:30 a.m., it was noted that on the first floor South, above the smoke doors by room 142, there was an unsealed penetration around a data wire. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m.
Plan Of Correction
Step 1 The maintenance team used 3M fire barrier sealant CP25B+ to seal penetration around data lines above the smoke doors by room 142. Step 2 Smoke barrier walls were inspected throughout the building to ensure that there was no other unsealed penetration. Repairs completed for any deficiencies found. Step 3 The maintenance team was educated on the requirement to ensure that there is no unsealed penetration around the data line on smoke barrier walls. Step 4 The maintenance director/ designee will complete a random audit of smoke barrier walls monthly x 4. Findings will be reviewed during the QAPI meeting.
Improper HVAC Maintenance
Penalty
Summary
The facility failed to properly maintain its HVAC systems, affecting one of three floors. On January 30, 2025, at 9:55 a.m., an observation revealed that a portable air conditioning unit was ducted into the ceiling in the ground floor South Elevator Mechanical Room. Additionally, at 9:40 a.m. on the same day, another portable air conditioning unit was found ducted into the ceiling in the North Kitchen Dietary Office on the ground floor. These findings were confirmed during an exit interview with the Administrator and the Maintenance Director on January 30, 2025, at 11:30 a.m.
Plan Of Correction
Step 1 The portable air conditioning unit was removed from the ground floor South Elevator Mechanical Room. Step 2 A facility-wide audit was completed to ensure that no other portable air conditioning units were venting directly into the ceiling. Step 3 The maintenance team was educated on the requirement to ensure that portable air conditioner units are not vented directly into the ceiling. Step 4 The maintenance director/ designee will complete a random audit monthly x 4 to ensure that no portable AC units are vented directly into the ceiling. Findings will be reviewed during QAPI. Step 1 The portable air conditioning unit was removed from the dietary office. Step 2 A facility-wide audit was completed to ensure that no other portable air conditioning units were venting directly into the ceiling. Step 3 The maintenance team was educated on the requirement to ensure that portable air conditioner units are not vented directly into the ceiling. Step 4 The maintenance director/ designee will complete a random audit monthly x 4 to ensure that no portable AC units are vented directly into the ceiling. Findings will be reviewed during QAPI.
Electrical Panel Latch Deficiency
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, specifically affecting one of the three floors. During an observation on January 30, 2025, at 10:30 a.m., it was noted that the electrical panel labeled MR1 in the Mechanical Room on the ground floor had a missing latch. This missing latch prevented the cover of the electrical panel from closing properly. The deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director at 11:30 a.m. on the same day.
Plan Of Correction
Step 1 Latch placed on the electrical panel labeled MR1 in the ground floor Mechanical Room. Step 2 A facility-wide audit of all electrical panels was completed to ensure that all panels have covers that positively close. Step 3 The maintenance team was educated on the requirement for electrical panels to have covers that are positively closed. Step 4 The maintenance director/ designee will complete the audit monthly x 4 and findings will be reviewed during QAPI meeting.
Oxygen Storage Signage Deficiency
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements, as evidenced by missing precautionary signage in two locations. During observations conducted on January 30, 2025, between 11:00 a.m. and 11:15 a.m., it was noted that the North Nurses Station Med Rooms on both the second and first floors lacked the required precautionary signage on their entry doors. The signage should have included the wording: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING." This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m. The absence of the necessary signage indicates a failure to comply with the National Fire Protection Association (NFPA) standards for gas equipment storage, specifically regarding the storage of oxidizing gases. This oversight affects two of the three floors in the facility, potentially compromising safety protocols related to oxygen storage.
Plan Of Correction
Step 1 Caution signage was installed in 1 North and 2 North nursing station med room. Step 2 A facility-wide audit was completed to ensure that oxygen storage areas have the appropriate caution signage. Step 3 The maintenance team was educated on the requirement to monitor the oxygen storage area and ensure they have appropriate caution signage. Step 4 The maintenance director/designee will audit oxygen storage areas monthly x4. Findings will be reviewed during QAPI meeting.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
York Nursing And Rehabilitation Center was found to have a deficiency in its emergency preparedness communication plan during a survey conducted on January 30, 2025. The survey revealed that the facility's plan did not include a means of providing information about the facility's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or a designee. This deficiency affects the entire facility and was confirmed during an exit interview with the Administrator and the Maintenance Director. The deficiency was identified through a document review conducted at 8:30 a.m. on the day of the survey. The absence of this critical information in the emergency preparedness communication plan indicates a gap in the facility's ability to effectively communicate its needs and capabilities during an emergency. The lack of documentation was acknowledged by the facility's leadership during the exit interview, confirming the surveyors' findings.
Plan Of Correction
Step 1 The facility reviewed and revised the Emergency Preparedness Manual to include a Policy detailing the means of providing information about the facility's needs and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Step 2 NHA educated on the requirement to include the facility's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee in its emergency communication plan. Step 3 NHA/ Designee will review the emergency preparedness manual annually to ensure that the emergency communication plan complies with federal and state laws.
Failure to Conduct Required Emergency Plan Exercise
Penalty
Summary
The facility failed to conduct the required annual full-scale exercise or an accepted substitution for testing its emergency plan. This deficiency was identified during a document review conducted on January 30, 2025, at 8:30 a.m. The review revealed that the facility did not perform a full-scale exercise within the previous 12 months, which is a requirement under the emergency preparedness regulations. The absence of documentation confirming the completion of the annual full-scale exercise was confirmed during an exit interview with the Administrator and the Maintenance Director on the same day at 11:30 a.m. This lack of documentation indicates that the facility did not meet the regulatory requirements for emergency preparedness testing. The deficiency affects the entire facility, as the emergency plan's effectiveness could not be adequately tested and evaluated without the required exercise. The failure to conduct the exercise or provide an acceptable substitution means that the facility did not comply with the mandated emergency preparedness protocols.
Plan Of Correction
E0039 Step 1 A full-scale disaster drill was completed on 1/10/2025. Evidence and signed documents of the drill were added to the emergency preparedness binder. Step 2 NHA educated on the requirement to complete full-scale disaster drills annually and to maintain documentation of the drill in the emergency preparedness binder. Step 3 NHA/ Designee will review the emergency preparedness manual annually to ensure a full-scale disaster drill was completed within the last 12 months.
Non-Compliance with Building Construction Requirements
Penalty
Summary
The facility failed to maintain building construction requirements as evidenced by the classification of the Center Building as a three-story, Type V (000), unprotected wood frame construction, which is fully sprinklered. This classification exceeded the maximum allowable story height for an unprotected wood frame construction by two stories. The issue was confirmed during an exit interview with the Administrator and the Maintenance Director, who acknowledged the building's non-compliance with the construction type and height regulations. Similarly, the South Building was classified as a three-story, Type II (000), unprotected non-combustible construction, which is also fully sprinklered. This classification exceeded the maximum allowable story height for an unprotected non-combustible construction by one story. The Assistant Administrator and Maintenance Director confirmed this non-compliance during an exit interview. Both instances indicate a failure to adhere to the NFPA 101 building construction type and height requirements, affecting the entire building components.
Facility Lacks Second Acceptable Exit from Center Building
Penalty
Summary
The facility failed to provide two acceptable exits from each floor of the Center Building, affecting the entire building component. During a document review on January 30, 2025, it was observed that all three floors of the Center Building lacked a second acceptable means of exiting. The existing exit routes consisted exclusively of horizontal exits into adjacent healthcare buildings, which does not meet the requirement for two distinct egress paths from each story and smoke compartment as per NFPA 101 standards.
Non-Compliance with Heating Requirements in Resident Rooms
Penalty
Summary
York Nursing and Rehabilitation Center was found to be non-compliant with the requirement to maintain essential equipment in safe operating condition, specifically regarding air temperatures in resident rooms. The facility's policy mandates maintaining ambient temperatures between 71-81°F. However, during a survey, it was discovered that the central heater in the first south hallway was malfunctioning, affecting the heating in Rooms 119 and 239. In Room 119, the temperature was recorded at 69°F due to inadequate insulation around a window air conditioning unit, which allowed cold air to enter. The maintenance technician addressed this by removing the unit and improving window insulation, raising the temperature to 72°F. In Room 239, the overall temperature was 72°F, but the area near the window, where a resident was residing, was colder at 68°F. The resident reported feeling cold by the window, and it was noted that despite insulation, the large window allowed a draft. The resident had recently been moved to this room for more space. Both the Maintenance Director and the Administrator confirmed that the rooms were out of compliance with heating temperature requirements during the survey tour.
Plan Of Correction
Step 1 The AC window unit in room 119 was removed, and the window was insulated. The maintenance team checked the PTAC unit and confirmed that it was operational but turned off. The PTAC unit was turned on and was working adequately. The air temperature was rechecked and was within normal limits. The resident in bed 239C was moved to another room with adequate heat. The maintenance team re-insulated the window and sealed all drafts. A quote was obtained to replace the PTAC unit and the facility will install a new PTAC unit as soon as possible. The air temperatures for beds A, B, and D were rechecked and were within normal limits. Step 2 The facility completed an audit of the entire building. All window AC units were removed and windows insulated as needed. The facility audited all PTAC units and other HVAC equipment to ensure proper operation. Air temp audit completed in residents' rooms, hallways, dining, and lounge areas. No other areas were identified with air temperature issues. Step 3 Facility maintenance staff educated on air temperature policy and the requirement to check room temps daily and report any abnormal temps immediately to NHA. Step 4 The facility maintenance team will check air temps daily. NHA or designee will audit temp logs weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required staffing ratios for nurse aides across all shifts over a seven-day period. Specifically, the facility did not maintain the mandated minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. This deficiency was identified through a review of nursing staff schedules, punch reports, and staff interviews. On each day from November 28 to December 4, 2024, the facility's staffing levels fell short of the required hours of nurse aide care based on the facility census data. For instance, on November 28, 2024, the facility had a census of 207 residents, necessitating 141.14 hours of nurse aide care during the evening shift, but only 128.00 hours were provided. Similarly, on December 1, 2024, with a census of 210 residents, the facility required 157.50 hours of nurse aide care during the day shift, yet only 80.00 hours were provided. These discrepancies were consistent throughout the week, with significant shortfalls in nurse aide hours across various shifts, indicating a systemic issue in maintaining adequate staffing levels.
Plan Of Correction
Step 1 The facility is currently staffed at or above state minimum requirements. Step 2 The facility will partner with agencies to ensure that nurse aid requirements are met and to better manage last-minute callouts and unexpected events related to staffing. Step 3 The staff coordinator and other administrative staff involved in coordinating staffing educated on federal and state CNA staffing requirements. Step 4 The NHA or designee will audit staffing levels weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.
LPN Staffing Deficiency on Day Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during the day shifts on two occasions within the week of November 28 to December 4, 2024. Specifically, on December 1, 2024, the facility provided only 8.00 LPNs when 8.40 were required based on the resident census. Similarly, on December 2, 2024, the facility provided 8.00 LPNs while 8.36 were needed. This deficiency was identified through a review of the facility's weekly staffing records and was discussed with the Nursing Home Administrator and the Director of Nursing on December 11, 2024.
Plan Of Correction
Step 1 The facility is currently staffed at or above state minimum requirements. Step 2 The facility will partner with agencies to ensure that LPN minimum requirements are met, allowing for better management of last-minute callouts and unexpected staffing events. Step 3 The staff coordinator and other administrative staff involved in coordinating staffing educated on federal and state LPN staffing requirements. Step 4 The NHA or designee will audit staffing levels weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. On six out of seven days reviewed, the facility did not provide the required hours of care. Specifically, on November 29, 2024, with a census of 209 residents, only 567.25 hours of direct nursing care were provided, equating to 2.71 hours per resident. Similar shortfalls were noted on subsequent days, with the facility consistently providing less than the mandated 3.2 hours of care per resident. The deficiency was further evidenced by specific data from each day reviewed. For instance, on December 1, 2024, with a census of 210 residents, only 527.25 hours of care were provided, resulting in 2.51 hours per resident. On December 4, 2024, with a census of 208 residents, the facility provided 537.75 hours of care, equating to 2.59 hours per resident. These findings were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to comply with the required staffing levels.
Plan Of Correction
Step 1 The facility is currently staffed at or above state minimum requirements. Step 2 The facility will partner with agencies to ensure the state minimum requirement of 3.2 hours of direct resident care is met, allowing for better management of last-minute callouts and unexpected staffing events. Step 3 The staff coordinator and other administrative staff involved in coordinating staffing educated on federal and state direct resident care hours requirements. Step 4 The NHA or designee will audit staffing levels weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.
Facility Fails to Honor Resident's Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing, as evidenced by the case of a resident who was unable to receive visits from a long-time friend and emergency contact. The resident, who has multiple medical conditions including anemia, hypertension, diabetes, and moderate cognitive impairment, was informed that their friend was banned from visiting due to accusations of financial misconduct. The friend was accused during a meeting with facility staff of stealing money from the resident and another resident, which led to the friend being told they were not allowed in the building pending an investigation. Interviews with facility staff revealed inconsistencies in the communication regarding the friend's visitation status. The receptionist stated that she was instructed to deny entry to the friend pending an investigation, while the Nursing Home Administrator and other staff members denied issuing such an instruction. The resident expressed distress over the situation, indicating a significant emotional impact due to the inability to receive visits from their friend. The facility's failure to conduct a proper investigation into the allegations further compounded the issue, as confirmed by the Nursing Home Administrator's refusal to provide details of any investigation.
Inaccurate PASRR Documentation for Resident
Penalty
Summary
The facility failed to conduct an accurate Pennsylvania Preadmission Screening Review (PASRR) for one of four residents. The facility's policy required that all residents receive a screening and review in accordance with State and Federal Regulations. However, the PASRR form for Resident R94 was not accurately documented or completed. The resident had a diagnosis of mild or major neurocognitive disorder, but the screening form lacked accurate documentation about the mental health diagnoses, including Schizophrenia, Dementia with Behavioral Disturbances, Anxiety Disorder, and substance use disorder (alcohol). This deficiency was confirmed during an interview with the Social Services employee, who acknowledged the incomplete documentation on the PASRR form for Resident R94.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received medication in accordance with physician orders. The resident, who had diagnoses of hypertension and lymphedema, had a physician's order for Amlodipine Besylate Tablet 10 mg to be administered once daily. However, the medication was not available for administration on the specified date, and the nurse could not locate the blister pack for the medication during the morning medication administration. The nurse revealed that the medication had been ordered but had not yet arrived, and there was no documented evidence that the medication was administered as prescribed. Further investigation revealed that the facility had a supply of Amlodipine in their Pyxis machine, but the nurse was unaware of its availability. The Assistant Director of Nursing confirmed the presence of Amlodipine in the Pyxis machine, indicating a lapse in communication and awareness among the nursing staff. This deficiency was identified through a review of the facility's policy, clinical records, and staff interviews, highlighting a failure to administer medication in a safe and timely manner as prescribed by the physician.
Failure to Implement Pressure Ulcer Care Devices
Penalty
Summary
The facility failed to ensure that devices to promote the healing of pressure ulcers were implemented for Resident R93. The facility's policy on wound prevention, dated April 1, 2022, required daily pressure relief measures, including the use of pressure redistribution mattresses, mobility as tolerated, positioning and repositioning devices, and wheelchair cushions as needed. However, a clinical record review revealed that Resident R93, who was cognitively impaired and diagnosed with Huntington's disease, was at risk for developing pressure ulcers. A physical therapy evaluation dated April 10, 2024, indicated that Resident R93 needed to wear an orthotic knee wedge with a towel for the right lower extremity and heel relief positioning boots bilaterally to promote wound healing and prevent further pressure ulcer development. During an observation on April 17, 2024, in the presence of a licensed practical nurse (LPN), it was noted that the orthotic knee wedge cushion with a towel and the heel relief positioning boots were not available for Resident R93. This observation confirmed that the necessary devices to relieve pressure and promote wound healing were not being used for Resident R93, contrary to the facility's policy and the physical therapy evaluation recommendations. This failure to implement the required devices for pressure ulcer care was a deficiency in the facility's nursing services and resident care policies.
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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