Pennsylvania Department of Health
LONGWOOD AT OAKMONT
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 77 surveys for this facility. Please select a date to view the survey results.

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LONGWOOD AT OAKMONT - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance survey completed on February 18, 2026, it was determined that Longwood at Oakmont was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Plan of Correction - To be completed: 04/08/2026

The Director of Nursing (DON) or designee conducted a comprehensive audit of all oxygen tubing, BiPAP equipment, and nebulizers currently in use within the facility to ensure each item was properly dated and stored in accordance with infection control guidelines. Any equipment found to be undated or improperly stored was immediately removed and replaced at the time of identification.
All residents utilizing oxygen tubing, nebulizers, or BiPAP equipment had the potential to be affected by the alleged deficient practice. There were no identified negative outcomes related to this concern.
The DON or designee will provide education to licensed nursing staff and respiratory therapy staff regarding proper procedures for dating and storing respiratory equipment. Training will include correct labeling of oxygen tubing and nebulizer equipment, appropriate storage of BiPAP masks, and review of infection control guidelines related to recommended replacement intervals.
The DON or designee will conduct weekly audits of respiratory equipment for four (4) weeks to ensure compliance with proper dating and storage requirements.
Audit results will be reported to the QAPI Committee for review. Any identified trends or areas of noncompliance will result in additional corrective action and follow-up education as indicated.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of twelve months (October 2025, November 2025, and December 2025).

Findings include:

Review of the admission record indicated Resident R44 was originally admitted on 11/5/25, with diagnoses that included diabetes, benign prostatic hyperplasia (BPH - a common enlargement of the prostate gland in aging men that squeezes the urethra), and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids)

Review of Resident R44's clinical record revealed that the resident was transferred to the hospital on 11/22/25.

Review of facility provided documentation failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for Resident R44's hospitalization on 11/22/25.

Review of the admission record indicated Resident R46 was originally admitted on 11/27/23, with diagnoses that included Covid 19, atrial fibrillation (irregular heart rhythm), and BPH.

Review of Resident R46's clinical record revealed that the resident was discharged home on 12/28/25.

Review of facility provided documentation failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for Resident R46's discharge on 12/28/25.

Interview with the Nursing Home Administrator on 2/18/26, at 1:00 p.m. indicated that the facility had missed a few months of written transportation notifications to the Office of the Long-Term Care Ombudsman and could not produce written evidence for three of twelve months (October 2025, November 2025, and December 2025).

28 Pa. Code 201.29(a)(c.3)(2) Resident rights.

Plan of Correction - To be completed: 04/08/2026

Upon identification of the deficiency, the facility conducted a retrospective review of all discharges for the months of October, November, December 2025. Compiled a complete and accurate list of all residents discharged during the identified three-month period. A report for the months missed in 2025 of all resident/patient discharges was submitted via email to the Pennsylvania Long-Term Care Ombudsman Program on February 26, 2026. Verified receipt of submission to the Ombudsman's office and retained documentation of confirmation. No residents were identified as harmed as a result of the reporting delay.
An audit of discharge records for the past six (6) months was completed on February 18, 2026 to ensure no additional months were missed. All required reports outside of the cited timeframe were verified as submitted appropriately. No additional missing reports were identified.
The Administrator or designee will run the discharge report electronically each month from PointClickCare, the facility's electronic health record to include the previous month's list of resident/patient discharges and the location of the discharge.
The reports will be submitted to the PA Long Term Care ombudsman via email with a delivery/read receipt request. Copies of the reports and the delivery receipts will be maintained for confirmation that the reports have been sent prior to the end of the month following the reported month.
A recurring calendar reminders have been scheduled for the 3rd business day of each month. A reminder email to the administrator and the social service director is scheduled to be sent on the 5th day of the month to confirm the report has been sent.
The Administrator or designee will audit Ombudsman submissions monthly for three (3) months. Audit findings will be reported at QAPI meetings. After three months of compliance, monitoring will transition to quarterly review. Any identified variances will result in immediate re-education and corrective action.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to adequately monitor and assess nutritional status for one of five resident's reviewed for nutritional concerns (Resident R3).

Findings include:

The facility policy "Dietary-Weights" last reviewed 11/5/25, revealed if a resident has experienced a 5-pound weight change a re-weigh will take place within 24 hours. If the weight change is evident through re-weigh, nursing will notify the dietitian, and interventions may be initiated if appropriate.

Review of clinical record indicated Resident R3 was admitted to the facility 12/4/25.

Review of Resident R3's Minimum Data Set (MDS-a periodic assessment of care needs) dated 12/26/25, indicated diagnoses diabetes mellitus (chronic condition characterized by high levels of glucose in the blood due to the body's inability to produce or effectively use insulin), dementia (pattern of mental decline occurring when brain cells die) and hypertension.

Review of Resident R3's weight summary indicated on 1/6/26 Resident R3's weight was 113.8. Resident R3 was weighed 2/2/26 at 106.8, which reflected a 7-pound weight loss (7%). There was a lack of evidence to support that the Registered Dietitian (RD) was notified of the significant weight loss. There was no documented evidence that Resident R3 was reweighed within 24 hours according to facility policy.

In an interview 2/18/26, at 11:30 a.m., the Registered Dietitian Employee E1 confirmed there was no reweigh or documentation regarding weight loss for Resident R3 as required.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/08/2026

Resident R3 was immediately reweighed on 2/19/26 and 2/26/26 to obtain an accurate current weight. The Registered Dietitian (RD) was notified of the identified 7-pound weight loss. A comprehensive nutritional assessment was completed by the RD. The interdisciplinary team (IDT) reviewed the residents' nutritional status. Interventions were initiated to include an increase in nutritional supplements, and encouraging the residents as needed with meals. Weekly weights ordered by the RD for four weeks. The care plan was updated to reflect current nutritional risk and interventions. The attending physician and responsible party were notified of the weight change and interventions.
A 30-day look-back audit was conducted for all current residents to identify any 5% loss or greater weight change in one month. The cited resident was re-weighed and any identified residents with significant weight loss will be reweighed and Registered Dietician will be notified to develop appropriate interventions. There were no negative outcomes for the resident cited. Any interventions will be updated in the residents' care plan. Any identified gaps will be immediately corrected
The facility will track and monitor "Significant Weight Changes and conduct a weekly reviews of significant weight changes for six weeks. The RD will be notified notified via the electronic health record when ≥5% weight change in 1 month; or 10% weight change within six months.
RD or designee will check vital stat alerts biweekly for six weeks. Significant weight loss will be addressed and documented by the registered dietitian.
Nursing staff will reweigh residents when a 5-pound change is identified. Documentation of reweight will be placed in the medical record.
The registered dietician will be re-educated by the regional registered dietician and the Director of nursing designee will re-educate Licensed nurses and CNA staff on Facility "Dietary–Weights" policy; Identifying significant weight loss; Timely reweigh procedures; RD notification requirements. Education will be completed by the compliance date.
Audits of the weight losses will presented at the quarterly QAPI meeting to identify and negative trends and develop appropriate improvement plans, if needed.

483.35(e)(4)-(6) REQUIREMENT Nurse Aide Registry Verification, Retraining:

§483.35(e)(4) Registry verification.
Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless-

(i) The individual is a full-time employee in a training and competency evaluation program approved by the State; or
(ii)The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered.

§483.35(e)(5) Multi-State registry verification.
Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act that the facility believes will include information on the individual.

§483.35(e)(6) Required retraining.
If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.

Observations:

Based on a review of facility provided documentation, and staff interviews, it was determined the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for one of five nurse aides reviewed (Nurse Aide (NA) Employee E3).

Findings include:

Review of facility provided documentation dated 2/16/26, indicated NA Employee E3's Pennsylvania Nurse Aide Registration expired on 10/11/25. The facility was unaware that NA Employee E3's registration was expired until it was discovered on 2/16/26.

Despite the expired registration, NA Employee E3 continued to work at the facility during the months of October 2025, November 2025, December 2025, January 2026, and February 2026.

Interview with the Nursing Home Administrator on 2/16/26, at 3:00 PM confirmed the facility was unaware of the expired registration and the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for one of five nurse aides reviewed (Nurse Aide NA Employee E3).

28 Pa. Code 201.29 Personnel Policies and Procedures.

Plan of Correction - To be completed: 04/08/2026

Upon identification of the deficiency on 2/16/26, the facility immediately removed Nurse Aide (NA) Employee E3 from the work schedule pending verification of registry status.
After Verification of the expiration date of NA Employee E3's Pennsylvania Nurse Aide Registration (expired 10/11/25), the employee was required to immediately complete the renewal process through the Pennsylvania Nurse Aide Registry. The employee E3 completed the process of renewing her certification on 2/18/2026 and obtained proof of renewal and registry verification prior to allowing the employee to return to work as a nurse aide.
A review of hours worked during the period of expiration was conducted. There were no identified negative resident outcomes related to this deficiency.
An audit of all currently employed nurse aides was conducted on February 23, 2026 to verify active registry status; expiration dates of c na certifications, and all other nurse aides were confirmed to have current, active registrations. No additional expired certifications were identified.
The facility posted the updated license /certification expiration list in the Director of Nursing's office. The Human Resources department will update the list weekly and review upcoming certification expirations at the weekly staffing meeting. Any employee identified to not have their certification updated within 24 hours of their shift will be removed from the schedule until the certification is completed and proof is provided to the Director of Nursing/designee.
Nurse aides will receive written notification at least 30 days prior to certification expiration. Employees are required to provide proof of renewal prior to expiration to remain on the schedule.
The staffing coordinator will verify active registry status prior to posting monthly schedules.

The Administrator or designee will audit the CNA registry verification log monthly for three (3) months to ensure compliance. Audit findings will be reviewed at QAPI meetings. After three months of sustained compliance, monitoring will continue quarterly. Any variance will result in immediate removal from schedule and corrective action.

483.40(d) REQUIREMENT Provision of Medically Related Social Service:

§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Observations:

Based on review of facility policy, clinical record, and staff interview it was determined that the facility failed to provide sufficient and timely social services for one of three residents reviewed (Resident R42).

Findings include:

Review of facility documentation "social services job description" indicated: " Summary Develops, implements, operates and supervises specialized counseling, education and psychosocial programs to meet the needs of residents and their family members. Identifies and suggest innovative approaches and participates in implementing performance improvement opportunities. Maintains compliance with Longwood at Oakmont policy and procedures in accordance with governing laws, regulations, regulatory agencies, accreditation bodies and facility standards. Demonstrates on a consistent basis individual and team behavior that supports culture change. Provides primary social work to assigned including direct resident and family contact, medical chart documentation, discharge planning and related social work duties. Develop a plan of care of each resident; puts into practice a person-centered philosophy. "

Review of admission record indicated Resident R42 was admitted on 4/23/24.

Review of Resident R42 admission record indicated diagnosis of COPD (ongoing lung condition caused by damage of the lungs), Parkinson (movement disorder of the nervous system that worsens overtime), and unspecified arterial fibrillation (an irregular and often very rapid heart rhythm).

Review of Resident R42 progress notes dated 9/3/25, indicated: "Staff providing personal care today c/o resident making sexual inappropriate comments stated to her "I bet you taste good let me eat you while attempting to grab at her breast and vaginal area. When re-directed states " why are you being mean to me that's not allowed" All you women are so uptight."

Review of Resident R42 progress notes dated 9/4/25, indicated: During morning medication administration resident became sexually inappropriate, stating "turn around I want to see your butt. Initial visit with patient. The patient is having inappropriate sexual behaviors with staff. Continue with non-pharmacological interventions. Continue to monitor for mood/behavioral changes."

Review of Resident R42 clinical record dated 10/15/25, visit type mind care psychiatric evaluation, indicated: initial evaluation per staff: pt has increased sexual behaviors. He is inappropriately grabbing staff and making sexual comments. Pt has baseline symptoms of depression and anxiety. Follow up recommendations - follow up in 90 days.

Review of Resident R42 care plans failed to include a care plan regarding sexually inappropriate behaviors.

Review of Resident R42 clinical record failed to include documentation of interventions, and mood/behavioral changes.

During an interview on 2/18/26, at 1:08 p.m. Social Service indicated that she does not do care plans or follow up from psychiatric evaluation.

During an interview on 2/18/26, at 2:37 p.m. Nursing Home Administrator and Director of Nursing were informed that the facility failed to provide sufficient and timely social services for one of three residents reviewed (Resident R42).

28 Pa. Code 201.14(b) Responsibility of licensee.
28 Pa. Code 201.29( a) Resident rights.
28 Pa. Code 211.16( a)(1) Social services

Plan of Correction - To be completed: 04/08/2026

The Social Services Director and social worker were re-educated on date about the need to review the established care plan for residents with behaviors that may be disruptive to their psychosocial well-being.
On 2/19/26, an interdisciplinary team (IDT) meeting was conducted. A comprehensive behavioral care plan was re-instated for resident R42 to include addressing sexually inappropriate behaviors, including Identified triggers and patterns; Non-pharmacological interventions; Redirection strategies; staff approach techniques; and monitoring and documentation expectations.
Social Services completed an updated psychosocial assessment. There were no recommendations after the initial visit on 10/15/25 from the psychiatric provider. The psychiatric provider will complete a follow up evaluation on her next visit and make recommendations as needed.
Social services will follow-up with the resident and the caregiving staff weekly with appropriate documentation for noted identified behaviors if they are present during the week of the visits.
Nursing and Social Services staff will be re-educated on documentation of behavioral symptoms and interventions before the compliance date.
On 2/20/26, an audit was conducted of all residents with psychiatric consults within the past 30 days or sexually inappropriate behaviors. Care plans and documentation will be reviewed and updated as needed.

Thea administrator and Licensed Nurse Assessment Coordinator reviewed Social Services responsibilities with Social Services Director and Social Worker and clarified to include the development and updating of behavioral care plans and documentation of psychosocial interventions.
Weekly audits will be conducted by social services/designee of residents with sexually inappropriate behaviors weekly for six weeks. Audit results will be reported to the QAPI committee for review. Any identified trends or areas of noncompliance will result in additional corrective action and follow-up education as indicated.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings with all the required committee members for one of four quarters(Quarter One on 1/28/25).

Findings Include:

The facility policy "Quality Assurance and Performance Improvement (QAPI) Plan" dated 11/5/25 indicated the QA&;A Committee consisted of the following members: Medical Director/Designee, Director of Nursing, Administrator, the Infection Preventionist and additional members at a minimum of two staff.

Review of Quality Assurance and Performance Improvement sign in sheets and attendance records for Quarter One of 2025, dated 1/28/25, failed to indicate the Infection Preventionist was in attendance.

During an interview on 2/18/26, at 11:00 a.m. the Nursing Home Administrator confirmed the facility could not provide documented evidence that the facility conducted Quality Assessment and Assurance (QAA) meetings with all the required committee members for one of four quarters (Quarter One on 1/28/25).

28 Pa Code: 201.18(e)(1)(2)(3)(4) Management.

Plan of Correction - To be completed: 04/08/2026

The 2026 Quality Assurance Performance Improvement (QAPI) meetings have been established. Communication about scheduled QAPI meetings will be sent to all committee members by the administrator prior to each meeting. Required QAPI Committee members will be re-educated by the Administrator by the compliance date on their required attendance at the quarterly qapi meetings. Committee members who do not RSVP or participate in the scheduled meeting will be asked to meet with the Administrator/DON to review the summary of the meeting to share their feedback. The sign in sheets will be viewed by the QAPI team prior to the close of the QAPI meeting to verify required participants have signed in as proof of participation in the QAPI meeting. Any identified trends by the QAPI or infection control committee will be addressed for performance improvement.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations:

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that pneumococcal vaccinations and influenza vaccinations were offered upon admission for two of five residents (Residents R11, and R13).

Findings include:

Review of the facility policy "Nursing- Influenza Policy" dated 11/5/25, indicated Residents or representatives will be provided a vaccine information statement. After completion of consent, the influenza vaccinations may be administered in accordance with physician-approved orders.

Review of the facility policy "Nursing- Pneumococcal Vaccine" dated 11/5/25, indicated each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician orders.

Review of the admission record indicated Resident R11 was admitted to the facility on 1/21/26.

Review of Resident R11's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/27/26, indicated the diagnoses of hypertension, heart failure, and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids).
Review of Resident R11's clinical record on 2/18/26, failed to provide evidence that the influenza or the pneumococcal vaccines were offered or administered as required for the influenza season of 2025.

Review of the admission record indicated Resident R13 was admitted to the facility on 11/23/25.

Review of Resident R13's MDS dated 11/29/25, indicated the diagnoses of hypertension, heart failure, and muscle weakness.

Review of Resident R13's clinical record on 2/18/26, failed to provide evidence that the influenza vaccines were offered or administered as required for influenza season 2025.

Interview on 2/18/26, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to make certain that pneumococcal vaccinations and influenza vaccinations were offered upon admission for two of five residents (Residents R11, and R13).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(3) Nursing services.

Plan of Correction - To be completed: 04/08/2026

Upon identification of the deficiency, the facility conducted a review of Residents R11 and R13.
Resident R11had been immunized but the documentation was not in the medical record for skilled nursing. Resident R13's documentation was entered into the medical record to reflect compliance with regulatory requirements.
There were no identified adverse outcomes related to this deficiency.

An audit was conducted of all current residents admitted during the 2025–2026 influenza season to verify documentation of vaccine education; offer of influenza vaccination (October 1–March 31); offer of pneumococcal vaccination, unless previously immunized or contraindicated and documentation of administration, refusal, or medical contraindication.
Any resident record found to be incomplete will be immediately corrected through education, consent review, vaccine offer, and proper documentation.
The facility implemented the following corrective measures:
The admission checklist was revised to include a mandatory immunization verification section prior to completion of the admission process. Nursing staff must document Vaccine Information Statement (VIS) was provided; consent obtained; vaccine administered, refused, contraindicated, or previously received

The infection preventionist/designee will provide education to admission nurses by the compliance date regarding:
Regulatory requirements under F-883
oInfluenza season requirements (October 1–March 31) ; Pneumococcal vaccine requirements; required documentation elements related to these vaccines.

The Influenza and Pneumococcal Vaccine policies were reviewed and reinforced to ensure clarity regarding admission timing requirements and documentation standards.
The Director of Nursing or designee will audit new admissions weekly for four (4) weeks to ensure proper vaccine education, offer, and documentation.

Audit results will be reviewed at QAPI meetings.
Any identified variance will result in immediate corrective action and re-education.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview and review of the facility's Infection Control Committee attendance records, it was determined the facility failed to ensure that the nine required multidisciplinary members were present at the Infection Control meetings for four of four quarters (Quarter one - 1/27/26, Quarter two - 4/29/25, and Quarter three - 7/29/25, and Quarter four - 10/28/25).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility. "A review of the applicable members at infection control meetings includes medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member, and a member of the infection control team.

Review of the facility's infection control attendance records for the year of January 2025 - January 2026 indicated the following quarter missing at least one of the nine required multidisciplinary members:
-Quarter one - 1/27/26, failed to include the Director of Nursing.
-Quarter two - 4/29/25, failed to include the Nursing Home Administrator.
-Quarter three - 7/29/25, failed to include a Laboratory Representative.
-Quarter four - 10/28/25, failed to include a Physical Plan representative.

Interview with the Director of Nursing on 2/18/26, at 2:00 p.m. confirmed the facility failed to ensure that the nine required multidisciplinary members were present at the Infection Control meetings for four of four quarters (Quarter one - 1/27/26, Quarter two - 4/29/25, and Quarter three - 7/29/25, and Quarter four - 10/28/25).

Plan of Correction - To be completed: 04/08/2026

The 2026 infection control meetings have been established. Communication about scheduled infection control meetings will be sent to all committee members prior to the next scheduled meeting each quarter. Required participants in Infection Control Committee meeting will be re-educated by the Administrator or Director of Nursing about the attendance requirement by the compliance date. Required Infection Control Committee members who do not RSVP or participate in the scheduled meeting will be asked to meet with the infection preventionist to review the summary of the meeting o to share their feedback. The infection preventionist will ensure that attendance is documented for all meetings and whether the committee member participated in person, via zoom, or via recording. The sign in sheets will be shared with the QAPI committee at the subsequent meeting to verify infection control committee required participation at least quarterly in 2026. Any identified trends by the QAPI or infection control committee will be addressed for performance improvement.

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