Pennsylvania Department of Health
DEER MEADOWS REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

DEER MEADOWS REHABILITATION CENTER
Inspection Results For:

There are 191 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


DEER MEADOWS REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to one complaint, completed on August 21, 2026, it was determined that facility 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 related to the health portion of the survey process.

Plan of Correction:

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

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.

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations: Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was properly disposed. Finding Include: Observations were made of the facility's loading dock on, August 18, 2026, at 11:30 a.m. with the Food Service Director. Upon first entering the loading dock/dumpster area on the first tier was a wooden chair, two PVC bins (normally used for dirty laundry), and six wooden pellets. Stepping down to the area of the trash bins was a pile of trash with cups, lids, liquids on the ground. Per the Food Service Director, the trash company had recently taken the dumpster and will be returning the dumpster within an hour. Left in its place was loose trash consisting of cups, lids etc. A few feet away from the same area was a thick yellow sludge 3-4 feet x 3-4 feet wide. Two dumpsters were seen in the same area. The Food Service Director stated the kitchen uses the dumpster to the left for boxes. On the ground next to that dumpster was an uncontained bag of trash. The dumpster to the right had a recliner chair, a PVC shower bed, wooden pellets. The entire area had a strong stench and appeared unkept. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 207.2 (a) Administrator's responsibility

Plan of Correction - To be completed: 10/12/2026

The pile of trash was removed from the loading dock/dumpster site
NHA will complete Education with Housekeeping director, Maintenance director, and Director of dietary about F0814 that garbage is properly disposed of.
Maintenance director, Dietary Manager and Housekeeping director will complete education with staff responsible for putting trash in the dumpster about F0814
Housekeeping director or designee will complete weekly audit of the loading dock/dumpster for cleanliness weekly x4, monthly x3
Director of dietary will complete weekly audit of the loading dock/dumpster area so that all dietary garbage is disposed of properly in loading dock/dumpster area weekly x4, monthly x3
Result of audits will be presented at monthly QAPI until substantial compliance is achieved.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations: Based on review of clinical records, review of facility documentation, review of facility policy, and interviews with resident and staff it was determined that the facility failed to ensure each resident is treated with dignity and respect when providing care for one of 35 resident records reviewed (Resident R25). Findings include: Review of the facility's policy titled, Resident Rights revised July 2023, states, "Employees shall treat all residents with kindness, respect, and dignity". Resident R25 was admitted to the facility April 25, 2025, diagnosed with Rheumatoid arthritis (a chronic autoimmune disease-causing inflammation of the joints). Review of Resident R25's care plan revealed the resident had a pulmonary embolism (blood clot in lungs) that caused difficulty breathing and to ensure the resident with proper body alignment for optimal breathing, dated April 28, 2025. The resident had a self-care deficit that required two people to assist the resident using a mechanical lift (Hoyer Lift) for transfers, dated May 5, 2025. The resident had a psychosocial well-being problem related to potential, PTSD (post-traumatic stress disorder) due to a report of physical abuse on May 5, 2026. Interventions included supportive care for talk therapy and meeting one on one with Social Services. Review of Resident R25's nursing progress notes dated May 5, 2026, stated the resident was upset and crying when the resident stated that when the resident was in her Geri chair (a chair used for long-term comfort and therapeutic positioning), the nurse aide (NA, Employee E18) was rough and pushed the resident's Geri chair too hard, and the resident's leg hit the cabinet. Interview with Resident R25 on August 19, 2026, at 2:00 pm stated, "I was sitting in my wheelchair waiting for the aides to transfer me with the Hoyer. One of the aides (Nurse Aide (NA) Employee E18) came in my room with an attitude, she didn't say much. For some reason as she was getting me ready for the Hoyer, she kept jerking my chair around. I said, "What are you doing!?" Then she forcefully pushed me, while I was in my chair, so hard that my wheelchair went into my tall dresser in front of me and then my right leg hit the bureau next to it. It really hurt. I told the NA to leave the room, but she wouldn't. Instead, she was trying to justify her actions. She wouldn't leave until a nurse told her to leave my room". Interview with licensed practical nurse (LPN) Employee E12 on August 21, 2026, at 3:30 p.m. stated, "I heard the resident yelling and screaming telling the aide to get out. It's not like the resident, if you look at her chart she never causes anyone any problems. She was so upset she couldn't stop crying and I started crying with her. The LPN's witness statement stated, "The resident is normally quiet, not aggressive. The resident stated that the aide became aggressive and pushed her chair into the dresser which caused the resident to hit her leg on the dresser. Review of facility documentation revealed a witness statement from the second aide, NA Employee E14 that came to Resident R25's room to assist in the resident's transfer with NA Employee E18. NA Employee E14 heard Resident R25 yelling at NA Employee E18 saying how rough she was. The NA heard the other NA raise her voice at the resident being defensive asking the resident, 'How was I rough with you?' The NA stated that when the NA was adjusting the Geri chair she (NA E18) wasn't gentle and she was rushing. 28 Pa. Code 201.29 (a) Resident rights

Plan of Correction - To be completed: 10/12/2026

The provider submits the following plan of correction in good faith and to comply with Federal regulation. This plan is not admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the statement deficiencies.
Resident R25 physician was notified, X-ray was ordered for the knee which was completed on May 6, 2026. X-ray result shows no injury but arthritis and osteoporosis.
Alleged nurse's aide was suspended and terminated after completion of investigation. DOH was notified on May 5, 2026 and PB 22 was submitted
Director of nursing or designee will complete education with nursing staff about F-Tag- 550; resident rights/Exercise rights
Social service will complete 10% resident interview about resident right/exercise right weekly x4, monthly x4
Results of resident right interview audit will be presented at Monthly QAPI until substantial compliance is achieved.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

§483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Observations: Based on review of the clinical record, and staff and resident interviews it was determined that the facility failed to ensure that informed consent was obtained prior to administering a drug test to a resident for one out of 35 residents reviewed (Resident R161). Findings include: Review of the facility policy "Illegal Drug Possession and Us," with a creation date of July 28, 2026, stated that the possession, use, distribution, or sale of illegal drugs or controlled substances without a valid prescription is prohibited on facility property. Continued review of the policy indicated that the facility will respond promptly to suspected or confirmed incidents in accordance with specific State and Federal regulations. Review of Resident R161's clinical record included the following diagnoses: anxiety disorder (intense, excessive, persistent worry or fear),cerebral infarction (a stroke - damage to the brain), and substance abuse (the harmful or hazardous use of psychoactive substances, including alcohol, prescription medications, and illegal drugs, that negatively impacts health, relationships, and daily functioning). Review of Resident R161's clinical record revealed a nursing note dated April 29, 2026, at 6:56 p.m. stated that the resident was observed returning back into the building with his/her roommate's mother. Continued review of the nursing note stated that the resident was educated by the Unit Manger that he/she cannot go outside to smoke with the roommate's mother since she is not facility staff. The nursing note also stated that the roommate's mother disagreed with what the Unit Manager said, went in Resident R161's room with Resident R161, and shut the room door for approximately 10-15 minutes with Resident R161 inside the room. Continued review of the nursing note indicated that once the resident's roommate's mother left Resident R161's room "the resident appeared to be heavily sedated, slumped over, leaning forward in his/her geri chair and slow to arouse. Residents were told to sit up or get in bed for safety measures. Resident R161 refused to get in bed, put a pillow on his/her side table and leaned on that instead." Continued review of the nursing note indicated that Resident R161's vital signs were taken, and the Unit Manager was notified. Review of a nursing note dated April 30, 2026, at 8:39 a.m. indicated that the resident was still being monitored for behaviors, and that the resident slept through the current shift, "slumped over in chair and not easily aroused at times with head hanging off to the side of bedside table. Resident noted about to fall out of chair and falls prevented several times by staff. When awaken by Nurse to take medications, resident would be awake for a minute then fall back to sleep. Drunken behavior noted with talking in slurred speech at times when name called. No pain or discomfort noted. Will monitor." Continued review of a nursing note dated April 30, 2026, at 11: 37 a.m. indicated that the unit manager notified the nurse practitioner, and that a new order was given for drug testing to be completed on the resident. Continued review of a nursing note dated April 30, 2026, at 11:37 a.m. indicated that the unit manager notified the nurse practitioner, and that a new order was given for drug testing to be completed on the resident. Review of the a "Preliminary Drug Screen Result Form", indicated that drug test was administered by Employee E4 (licensed nurse) on April 29, 2026 and on April 30,2026, Continued review of the clinical record and the "Preliminary Drug Screen Form did not show evidence that that informed consent was obtained prior to the administration of the drug tests to ensure that the resident was informed about why the facility felt it was needed, to ensure that the resident understood the risk, benefits and any alternatives to the drug test that may or may not be offered, and to ensure that the resident was provided with the right to agree or to refuse the administration of the drug test. During an interview with the licensed nurse, Employee E4, on August 20, 2026, at 9:15 a.m. the licensed nurse confirmed that no information in the clinical record or on the "Preliminary Drug Screen Result Form" could be produced to show evidence that informed consent was obtained from Resident R161 prior to the administration of the drug tests. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa Code 201.29 (c.3)(1)(2) Resident rights. 28 Pa Code 211.12 (d)(5) Nursing services.

Plan of Correction - To be completed: 10/12/2026

Resident R161 has had no further drug screen that requires informed consent
Facility drug screen form revised to include resident/responsible party informed consent prior to drug screen after physician order
Director of nursing or designee will educate employee E4 (ICP) regarding facility policy about resident right and informed consent prior to drug screen after receiving physician order
Director of nursing will complete draff education of all licensed staff regarding facility policy about resident right, and informed consent prior to drug screen after receiving physician order
Director of nursing or designee will audit past 3 months physician orders for drug screening weekly x 4 weeks and monthly x 3 months
Results of audit will be presented at monthly QAPI until substantial compliance is achieved

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:

§483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

Observations: Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that resident preferences were honored related to choice of dining location for one of 35 resident records reviewed (Resident R14). Findings include: Review of Resident R14's clinical record the resident was admitted to the facility on May 20, 2026, is alert and oriented, and has a diagnosis heart disease. On August 19, 2026, at 12:08 p.m. on the ground floor, A unit dining room Resident R14 was observed in a wheelchair being pushed by Nurse aide (NA) Employee E13 yelling, "I don't want to eat here I want to eat in my room! " But the NA continued to place the resident at a table ignoring the request. During an interview with Nurse aide, Employee E13, on August 20, 2026, at 1:02 PM the NA was asked why the resident was made to eat in the dining room when the resident made it clear he/she wanted to eat in his/her room. The NA said the aides are told to get the residents out of bed because if we don't it looks like we aren't doing our jobs, The surveyor asked even when the resident refuses? The NA, Employee E13, stated that the resident eventually stopped complaining. Interview with Resident R14 on August 20, 2026, at 1:30 PM confirmed he/she did not want to eat in the dining room and prefers to eat in his/her room. 28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 10/12/2026

Care conference with resident, resident informed that he has a right to eat in his room or choose activity of his choice
Employee E13 educated by DON/designee regarding F561-resident right and self determination to make their own choices
Director of nursing or designee will educate all nursing staff regarding F561 – resident right and self determination to make their own choices.
Social service will complete 10% resident interview audits about resident right and self determination to make their own choice about where to eat/right to eat in their room weekly x4, then monthly x3
Results of audit will be presented at monthly QAPI until substantial compliance is achieved

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations: Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a comfortable and homelike environment related to linens for one resident (Resident R73) and dining room repair for one of eight units observed (Bair unit). Findings include: Interview on August 18, 2026, at 1:35 p.m. Resident R73 stated that the bed sheets were raggedy. Observation on August 18, 2026, at 1:46 p.m. revealed a that there was a large hole in Resident R73's bedsheet, exposing the mattress. Resident R73 stated that the sheets were just changed this morning. Interview on August 18, 2026, at 2:08 p.m. Employee E5, licensed nurse, confirmed the large hole in Resident R73's bed sheet. Employee E5 also stated that the bed linens were just changed this morning and doesn't know why a staff member would use bed linens with holes in them. During a tour on the locked memory care unit, 2 Bair, on August 19, 2026, at 10:42 a.m., it was observed that there were three areas in the dining room where large areas of wallpaper were peeling off the wall. In an interview with the Assistant Director of Nursing, Employee E3, on August 21, 2026, at 10:30 a.m., it was confirmed that the unit was in need of a "refresh", including the wallpaper in the dining room. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Plan of Correction - To be completed: 10/12/2026

Resident R73 bed sheet was replaced on August 18, 2026
Peeling wallpaper in Bair 2 dining room was repaired
Housekeeping/Laundry director completed initial audit of at hands linen in circulation and no other linen with hole found
Director of nursing or designee will in-service nursing staff not to use any bed sheet/linen with holes
Director of housekeeping/Laundry will in-service laundry staff to inspect and rag out any bed sheet or linen with holes
Maintenance Director completes initial audit of the dining rooms with wallpaper for repair, and repairs will be completed at the time of the audit
Maintenance director will complete weekly audit of the dining rooms with wallpaper weekly x4, then monthly x3
Director of housekeeping/Laundry will complete 20% audit of resident bed linens for holes weekly x4m, then 10%monthly x3 months
Results of audit will be presented at monthly QAPI until substantial compliance is achieved

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations: Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan on orthopedic device use for two of 35 residents reviewed (R137, R168). Findings include: Review of the Facility Policy on Care Planning Process and Care Conference reviewed on May 2025 and May 2026, indicated that, "to foster the philosophy of the facility, in compliance with Federal and State Regulations and in accordance with HIPAA Regulations (HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. It is a United States federal law created to keep an individual's private medical information safe and secure), the facility will develop a comprehensive, resident centered care plan for each resident/patient. The care plan is a working tool that provides a profile of the needs of the individual resident/patient; the resident/patient care plan will be available for use by staff caring for the resident". Review of Resident R137's clinical record revealed that the resident was admitted to the facility on December 31, 2024, with diagnoses that included Catatonic Disorder due to Known Physiological Condition (a neuropsychiatric syndrome characterized by abnormal movement, behavior, and responsiveness), and Aphasia (loss of ability to understand or express speech, caused by brain damage). Review of physician order for R137, dated January 17, 2025, indicated an order for " Patient to wear blue splint on Left elbow daily. Put on after morning care and remove after 2 hrs. Check skin and report any changes to charge nurse". Review of physician order for R137, dated March 14, 2025, indicated an order for "Bilateral Elbow guards for skin protection, every shift". Review of Resident R137's clinical record revealed no documented evidence a comprehensive care plan was developed to include a focus,outcomes (goals), and interventions, for Resident R137's orthopedic devices. Interview on August 20, 2026, at 2:15 p.m., with the Director of Nursing confirmed the above findings. Review of Resident R168's clinical record revealed that the resident was admitted to the facility on December 15, 2023, with diagnoses that included Dysarthria (motor speech disorder), Hemiplegia and Hemiparesis Affecting Right Dominant Side (Hemiparesis is weakness on one side of the body, while hemiplegia is complete paralysis on one side of the body), and Dysphagia (swallowing difficulty). Review of physician order for R168, dated April2, 2026, indicated an order to apply " Bilateral Heel Boots on at all times every shift". Review of physician order for R168, dated July 29, 2026, indicated an order to " apply splint to right hand after morning care one time a day for Restorative Nursing Program and remove per schedule". Review of Resident R168's clinical record revealed no documented evidence a comprehensive care plan was developed to include a focus, outcomes (goals), and interventions, for Resident R168's heel boots and splint. Interview on August 21, 2026, at 1:27 p.m., with the Director of Nursing confirmed the above findings. 28 Pa Code 211.10 (c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 10/12/2026

Resident R137 application of splint to right hand and bilateral elbow protector care planned. Resident R168. Resident R168 bilateral heel boots and right-hand splint care planned
Facility completed audit of residents with orders for splints/elbow pad/heel pads to ensure they are care planned
Director of nursing or designee will complete education of Licensed staff about person centered comprehensive care plan for splint/elbow pad/heel pads
Director of nursing or designee will complete 10% audit of residents wearing heel boots, elbow pads and splint weekly x4 for care planning, then monthly x3 months
Results of audit will be presented at monthly QAPI until substantial compliance is achieved

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:

§483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.

Observations: Based on observations, review of clinical records and interviews with residents and staff, it was determined that the facility failed to ensure that appropriate language translation services were in use for one resident and did not ensure that resident nails were appropriately cared for, for two of 35 residents reviewed (Resident R14 and R113). Findings include: Review of the facility policy for nail care revised March 2024 states "Nail Care will be provided on shower days and as necessary. It is the policy of this facility to clean and trim fingernails and toenails in order to: 1. Provide cleanliness. 3. Provide comfort. 4. Prevent skin injury problems. Review of Resident R14 clinical record the resident was admitted to the facility on May 20, 2026, is alert and oriented, and has a diagnosis of heart disease. Reviewing the physician orders with Resident R14 on August 18, 2026, at 12:30 p.m., in response to a wound on the resident's chest wall, Resident R14 said it was from scratching the area with his/her nails. It was observed that the resident had long nails and appeared dirty with a dark colored substance under them. The resident stated he/she has been waiting a while for someone to cut them and said he/she does not like them long. Interview with Nurse Aide (NA) Employee E13 on August 20, 2026, at 1:00 p.m. stated he/she was aware the resident's nails were long and dirty and the aides are responsible to maintain the resident's nail care. Interview on August 19, 2026, at 9:38 a.m. Resident R113 stated that he/she speaks Cambodian. Resident R113 tried to express concerns regarding the food, but was unable to communicate any further due to the communication barrier. Resident R113 stated that he/she would prefer to use language translation services. Observation at the time of the interview revealed no communication devices were readily available for Resident R113. Interview on August 19, 2026, at 12:38 p.m. Employee E11, licensed nurse, confirmed that Resident R113 speaks Cambodian. Employee E11 stated that the facility has an electronic tablet with translation available, but was unaware of any staff using it. Employee E11 was unable to show the surveyor the tablet device. Employee E11 stated that they were unaware of any other language translation services available for use at the facility. Employee E11 confirmed that he/she had never used language communication services to speak to Resident R113. Interview on August 19, 2026, at 2:40 p.m. the Director of Nursing revealed that the facility has information for language translation services via phone with a live interpreter posted at nurses stations and that it should also be posted in residents' rooms for any resident that needs language translation services. Review of Resident R113's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated June 30, 2026, revealed that the resident was admitted to the facility on June 23, 2026, and had diagnoses including cancer and malnutrition. Review of Resident R113's care plan, dated June 23, 2026, revealed that no care plan was developed related to the resident's language communication needs. An interview was conducted with the use of a live language interpreter, on August 20, 2026, at 9:45 a.m. with Resident R113. Resident R113 stated that no language translation services have been used by any staff since his/her admission to the facility. Resident R113 stated that it was difficult being at the facility because "no one here can communicate with me, nobody understands what I want." Resident R113 stated that he/she would like to use language translation services while at the facility. Interview on August 20, 2026, at 10:10 a.m. Employee E8, nurse aide, stated that he/she only speaks English with Resident R113 because the resident is able to say a few words and express very basic needs. Continued interview confirmed that Employee E8 had never used language communication services to speak to Resident R113. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 10/12/2026

Resident 113 provided with a language line # to assist with staff communication with her
Resident R14 hand nails trimmed and podiatry consult ordered for his toe nails
Initial audit will be completed by director of social service or designee for residents needing language line/communication board for communication. Correction will be made at the time of audit and care planned.
Initial audit will be completed by the director of nursing/designee for residents needing fingernails and toenail care. Correction will be made at the time of the audit
NHA will complete education with social service about assessment and ensure that residents that need language line or communication board are provided with one
Director of nursing or designee will complete education of nursing staff about providing finger nails and toe nails care during ADL
Director of nursing or designee will complete 10% resident nail audit weekly x4 weeks and monthly x4
Social service director will complete audit of new admission for need for language line/communication board for communication weekly x4, then monthly x 3 months
Results of audit will be presented at monthly QAPI until substantial compliance is achieved

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations: Based on interviews and the review of clinical records, it was determined that the facility failed to ensure residents received care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 35 residents reviewed (Resident R161). Findings include: Review of Resident R161's clinical record revealed the resident was admitted into the facility on October 1, 2025, with diagnoses that included the following: anxiety disorder (a condition that causes fear, worry and a constant feeling of being overwhelmed); substance abuse (the harmful or hazardous use of psychoactive substances, including alcohol, prescription medications, and illegal drugs, that negatively impacts health, relationships, and daily functioning), and cerebral infarction (a stroke - brain damage). Review of a nurse practitioner's admission note dated October 2, 2025, at 9:23 p.m. stated that Resident R161 was admitted into the facility from the hospital for care and rehabilitation services. Review of the nurse practitioner's admission note indicated Resident R161 has a history of substance abuse and was treated for aspiration pneumonia and a stroke while in the hospital when he/she presented with left sided vision loss and left side weakness. Continued review of the nurse practitioner's admission note indicated that the resident's follow up appointment with the neurologist, related to the recent stroke, was scheduled for December 19, 2025. Review of a nursing note dated April 29, 2026, at 6:56 p.m. written by Employee E19 (licensed nurse) stated that the resident was observed returning back into the building with his/her roommate's mother. Continued review of the nursing note stated that the resident was educated by the Unit Manger that he/she cannot go outside to smoke with his roommate's mother since she is not facility staff. The nursing note also stated that the roommate's mother disagreed with what the Unit Manager said, went in Resident R161's room with Resident R161, and shut the room door for approximately 10-15 minutes with Resident R161 inside the room. Continued review of the nursing note indicated that once the resident's roommate's mother left Resident R161's room "the resident appeared to be heavily sedated, slumped over, leaning forward in his/her geri chair and slow to arouse. Residents were told to sit up or get in bed for safety measures. he refused to get in bed, put a pillow on his side table and leaned on that instead." Continued review of the nursing note indicated that the resident's vital signs were taken, were within normal limits, and the Unit Manager was notified. Review of a nursing note dated April 30, 2026, at 8:39 a.m. indicated that Resident R161 was still being monitored for behaviors, and that the resident slept through the current shift, "slumped over in chair and not easily aroused at times with head hanging off to the side of bedside table. Resident noted about to fall out of chair and falls prevented several times by staff. When awaken by Nurse to take medications, resident would be awake for a minute then fall back to sleep. Drunken behavior noted with talking in slurred speech at times when name called, no pain or discomfort noted. Will monitor." Continued review of a nursing note dated April 30, 2026, at 11: 37 a.m. indicated that the unit manager notified the nurse practitioner, and that a new order was given for drug testing to be completed on the resident. Continued review of a nursing note dated April 30, 2026, at 11:37 a.m. indicated that the unit manager notified the nurse practitioner, and that a new order was given for drug testing to be completed on Resident R161. Review of the "Preliminary Drug Screen Result Form," Review of the a "Preliminary Drug Screen Result Form" indicated that drug test was administered by Employee E4 (licensed nurse) on April 29, 2026, and on April 30, 2026, and the results of both tests were negative. Review of Resident R161's nursing notes did not show evidence that any other follow-up was initiated by the facility regarding any other additional clinical assessments completed to rule out any other sources of the resident's symptoms related to his change in condition that the resident started exhibiting after his roommate's sister left (e.g. observed as having "slurred speech," "heavily sedated," "slumped over, "leaning forward in his geri chair," "slow to arouse," having "falls prevented several times by staff," and the "drunken" behavior that nursing staff documented the resident as having) to ensure that appropriate care, services, treatment needed could be provided to the resident. During an interview with licensed nurse (Employee E19) on August 20, 2026, at 2:30 p.m. the resident's nursing note from April 29, 2026, at 8:39 a.m. was reviewed, and the licensed nurse reiterated that Resident R161 and his roommate's sister were outside smoking together, and after they returned to the unit, Resident R161 and his roommate's sister went to Resident R161's room and the licensed nurse saw Resident R161's roommate sister shut the door after they both entered. The licensed nurse reported that she noticed Resident R161's change in condition after Resident R161's roommate's sister left the facility, and that she told the Unit Manager what she observed after Resident R161's sister left the facility. During a discussion with the Director of Nursing on August 22, 2026, at 2:45 p.m. it was discussed that there were no additional follow-up after the negative drug testing was completed by the facility to identify any additional source(s) of the resident's symptoms that the resident was presenting, During the above-mentioned discussion with the Director of Nursing, it was confirmed that there was no investigation completed by the facility regarding the change in Resident R161's condition that was observed by nursing staff following visitation with the resident's roommate's sister on April 29, 2026. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Plan of Correction - To be completed: 10/12/2026

Resident 161 was seen by CRNP on 5/19/26 and 5/21/26
Director of nursing will complete education with licensed nursing staff regarding following up with physician/CRNP after a resident that has a change in condition with order for drug screening, and preliminary drug screen is negative for new orders or recommendation.
Director of nursing or designee will audit resident with order for drug screening for change in the last 45 days for additional follow up with physician. Physician will be notified for any residents identified with no other follow up apart from drug screening.
Resident identified with change in condition will be reviewed daily at clinical stand up M-F weekly for 1 week, then weekly x4 weeks, then monthly x3 months
Results of audits will be reviewed at monthly stand up until substantial compliance is achieved

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations: Based on review of facility policy, review of clinical records, and interviews with staff it was determined the facility failed to ensure a resident received the necessary services and treatment to prevent pressure ulcers for one of 35 resident records reviewed (Resident R5). Findings include: Review of the facility policy titled, Risk Assessment and Prevention, revised October 2023 states that the facility will strive to ensure that a resident entering the Facility without pressure ulcers/pressure injuries (PU/PI) does not develop pressure ulcers/injuries unless the resident's clinical condition demonstrates unavoidable skin breakdown. Prevention of pressure ulcers/injuries (PU/PI) requires early identification of at-risk residents and the implementation of prevention strategies: 1. Identify residents at risk for developing pressure ulcers/injuries (PU/PI) and initiate an early prevention program. 2. Implement appropriate strategies/plans to: a. Attain/maintain intact skin b. Prevent complications c. Promptly identify or manage complications d. Involve the resident and Responsible Party in decisions. 3. Implement cost-effective strategies/plans that prevent and treat pressure ulcers/injuries. 4. A skin assessment will be completed upon admission. Braden/Norton assessments will be completed on admission and weekly x4 after admission, quarterly, annually and with significant changes. Interventions based on assessment will be implemented and care planned. Review of Resident R5's clinical record revealed the resident was admitted to the facility on December 24, 2025, and has diagnoses of heart disease, schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations), cognitive communication deficit, and unspecified intellectual disabilities. Review of Resident R5's Admission MDS (an assessment of resident needs) dated December 30, 2026, assessed the resident as dependent (the resident does none of the effort to complete the activity) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), and is dependent on staff for showers/bathing, personal hygiene, bed mobility (roll left and right), chair/bed-to-chair transfer, and toilet transfers. The same MDS assessed the resident as frequently incontinent (having no control) of bowel and bladder. Review of Resident R5's care plan for risk of pressure ulcer injury dated December 26, 2025, had interventions that included monitoring the skin, preventative skin care and the use of barrier cream. Due to the resident being dependent on staff for bed mobility further review of the resident's clinical chart revealed no evidence the facility developed appropriate strategies/plans to prevent the resident from pressure injury. On January 6, 2026, Resident R5 was assessed with a deep tissue injury on the resident's right heel measuring 3.0 x 4.5. It was only after the pressure injury was found that the facility included intervention for the resident to wear heel boots to offload the heels and for staff to turn and reposition the resident every two hours to prevent pressure to the boney areas. The above was confirmed with the Assistant Director of Nursing on August 21, 2026 at 10:00 a.m. that the facility failed to have interventions in place to prevent Resident R5 from pressure injuries. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 10/12/2026

Resident R 5 has interventions in place to prevent and treat pressure injury
Director of nursing or designee will complete assessment of resident at risk for developing pressure ulcers on admission/readmission and quarterly according to facility policy, residents identified at risk will have care planned interventions to prevent pressure ulcer injury
Director of nursing or designee will complete education with nursing staff about implementing and care planning interventions to prevent pressure ulcers.
Director of nursing or designee will complete an initial audit on all current residents with Braden scales score at Risk, to ensure that interventions are in place to place to prevent any pressure injury
Director of nursing or designee will complete 10% of residents at risk to ensure that interventions are in place weekly x4, then monthly x3 months
Results of audit will be presented at monthly QAPI until substantial compliance is achieved

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations: Based on review of clinical record, review of facility policy, review of facility documentation, and interviews with resident and staff it was determined that the facility failed to provide adequate assistance during a mechanical lift by failing to evaluate the hazards and risks to prevent an avoidable accident resulting in a fall for one of 35 resident records reviewed (Resident R25). Findings include: Review of the facility policy titled, ADL Care, Resident Transfers, and Mechanical Lifts, revised March 2024 states, "Residents who require total assistance with transfer may be transferred with use of a mechanical left. It is used by a trained staff for lifting/transferring residents when assessed as safe and appropriate for resident use based on collaboration between Physical Therapy and nursing as per plan of care. The policy states that before using a left device assess the resident's current condition including physical/cognitive and emotional. Check to make sure the resident's head, neck and back are supported, check the resident's comfort level by asking or observing for signs of pinching or pulling of the skin. Review of facility documentation titled, Mechanical Lift, is a clinical performance evaluation checklist shows the standard steps utilized by staff using mechanical lifts. The checklist instructs to "Center sling behind resident and fanfold halfway under resident's body with lower edge of seat slightly below the resident's buttocks. Turn resident toward you, across folded sling. Straighten sling and turn resident on to back ensuring he/she is centered on sling, with lower edge now right below the buttocks (Correct placement permits the resident to be lifted evenly with minimal shifting) Pull the straps up between the resident's legs and cross the straps. Raise the head of bed. (Makes application of lift to sling easier and places resident in the position they will be in when lifted off of bed in sling). Select the shorter shoulder loops and longer leg loops for a more seated position, select longer shoulder loops and shorter leg loops for a more reclined position. Review of Resident R25's clinical record revealed the resident was admitted to the facility April 25, 2025, and has a diagnosis of Rheumatoid arthritis (a chronic autoimmune disease-causing inflammation of the joints). Review of Resident R25's care plan revealed the resident had a pulmonary embolism (blood clot in lungs) that caused difficulty breathing. The care plan included positioning the resident with proper body alignment for optimal breathing, dated April 28, 2025. The resident had a self-care deficit that required two people to assist the resident using a mechanical lift (Hoyer Lift) for transfers, dated May 5, 2025. Review of facility documentation revealed an incident report that stated on June 11, 2026, Resident R25 was being transferred into his/her Geri-chair (a chair used for long-term comfort and therapeutic positioning) by two aides using the Hoyer lift. While the aides were moving the resident in the Hoyer the resident started flailing kicking and saying he/she couldn't breathe. The aides told the resident they were almost finished and close to the chair. The lift titled sideways, rested on a dresser, and the resident was sitting on the floor still in the sling. During an interview, the resident said the Hoyer fell to the side and that the sling pad was under his/her head making it feel like he/she couldn't breathe. Interview with Resident R5 on August 19, 2026, at 2:00 p.m. revealed he/she was in bed with the Hoyer sling under him/her. Resident R5 stated "I knew something didn't feel right. I said something to the two aides but instead of stopping and listening to me they continued to transfer me with the Hoyer to my chair. They had the sling too high up near the back of my head so when I was lifted it made my head bend forward and my chin was on my chest, and I felt like I couldn't breathe. When they tried to put me in the chair the chair fell over and I was dropped on the floor. I fell on my left side, and I already had problems with my left knee that made it worse". During an interview with nurse aide (NA) Employee E15 on August 21, 2026, at 11:30 a.m. stated that when Resident R5 was in bed, the resident complained he/she couldn't breathe. Nurse aide, Employee E15, stated she was trying to position Resident R5 in the sling, but the resident had the bed raised and was in a sitting position. Nurse aide, Employee E15, stated she told Resident R5 she couldn't position him/her in the sling with the bed back raised and that he/she needed to lay flat. Nurse aide, Employee E15, stated before starting the transfer, Resident R5's sling was not positioned correctly. Continued interview with NA, Employee E15, revealed Resident R5's head was positioned too far down into the sling; the resident could have been further up in the sling for more head room, but nurse aide, Employee E15, continued with the transfer. When Resident R5 said he/she couldn't breathe and started kicking his/her arms and legs, it made the positioning even worse and Resident R5 slid further down in the sling. Nurse aide, Employee E15, stated that she knew the resident was not positioned properly in the sling and if she could do it again, she would have put the resident back in bed and repositioned the resident. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 10/12/2026

Resident R25 has no further incident regarding use of mechanical lift
Staff competency was completed immediately after the incident with staff E15 and the other staff involved in the use of mechanical lift to transfer resident
Director of nursing or designee will complete nursing staff re-education about positioning of the sling when using mechanical Hoyer lift
Director of nursing or designee will complete staff competency for use of mechanical lift for 2 residents/unit weekly x4, then monthly x3
Results of audit will be presented at monthly QAPI until substantial compliance is achieved

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 clinical records, review of facility documentation, and interviews with staff it was determined that the facility failed to accurately record a resident's weight to ensure appropriate interventions were implemented for 1 of 35 records reviewed (Resident R13). Findings include: Review of the facility policy, "Weight and Height Assessment and Interventions," with a review date of May 2026, indicated that any weight change of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation with the licensed nurse confirming the reweight. The policy stated that if the weight is verified, nursing will immediately notify the dietician in writing. Review of Resident R13's clinical record revealed the following diagnoses:substance abuse; cerebral infarction (a stroke - brain damage); arthritis (a group of conditions that cause joint pain, stiffness, and inflammation, affecting mobility and quality of life), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R13's clinical record indicated that on June 5, 2026, the resident's weight was recorded by nursing staff as being 184.5 pounds. The resident's weight on June 25, 2026, was recorded by nursing staff as being 173.6 pounds. Review of a reweight that was completed by nursing staff on June 26, 2026, also recorded the resident's weight as being 173.6, confirming an overall weight loss of 10.9 pounds and a significant weight loss of -5.9% over a 21-day period. Review of Resident R13's clinical record revealed a Registered Dietitian's note dated June 26, 2026, at 11:27 a.m. confirmed weight loss and a request for a re-weight to be completed. "Reweight needed to confirmreview of Resident R13's clinical record indicated that a nutritional supplement for the resident to consume one time a day was ordered for the resident on June 26, 2026, and monthly thereafter. "Health shake one time a day" to address the resident's above-referenced weight loss. Continued review of Resident R13's clinical record indicated that the weights that nursing staff recorded on June 25, 2026, and whose significant weight loss was confirmed on June 26, 20026 were both crossed out by the registered dietician on July 15, 2026, 21 days after the significant weight loss was confirmed and interventions were implemented to address the significant weight loss, which consisted of ordering nutrition supplements for the resident to consume. During an interview with the Registered Dietitian on August 20, 2026, at 9:43 a.m. the Registered Dietitian confirmed that a nutritional supplement was ordered for Resident R13 to consume one time a day and was added to address the resident's recent weight loss that was confirmed on June 26, 2026. During the interview, the Registered Dietitian reported that when she reviewed the resident's weights on July 15, 2026, she determined that the resident's weight loss confirmed on June 26, 2026, was not a true weight loss, and that the determination that it was not a true weight loss was made "based on what the facility had in addition to what the hospital weight was". The Registered Dietitian also reported that the scale was broken. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Plan of Correction - To be completed: 10/12/2026

Resident R13 weight is stable and no further weight loss
Director of nursing will complete education with dietician regarding facility weight policy, re-weight for weight loss accuracy to determine significant weight change
Director of nursing will complete nursing staff education about facility weight policy and reweight to confirm weight accuracy and significant weight changes
Dietician will complete audit of residents with significant weight change in the last 90 days for weight accuracy.
Resident physician will be notified of any weight errors for significant change

Dietician will complete 10% of residents with weight changes for accuracy for weight changes weekly x4, then monthly x3
Results of audits will be presented at monthly QAPI until substantial compliance is achieved

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations: Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that medications were discarded according to manufacturer instructions for one of six medication carts reviewed (Medication Cart W1 B). Findings include: On August 21, 2026, at 11:35 a.m., during review of the Medication Cart of 'Nursing Unit W1 B' in the presence of a Licensed Nurse, Employee E17, detected a blister pack with remaining 12 tablets of Tramadol HCl Oral Tablet 25 mg, marked for Resident R7, having expiration date as July 20, 2026. Interview with the Licensed Nurse, Employee E17, at the time of the finding, confirmed that the expired medications should have been discarded according to manufacturer instructions, and facility policy. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 10/12/2026

Resident R 7 expired medication was removed and destroyed according to policy
Audits of all medication carts were completed immediately for expired medication, and none were found
Director of nursing or designee will complete education with licensed nurse's ab out checking medication expiration date and discard medication according to facility policy
Director of nursing or designee will complete 2 units med carts audit for expired medication weekly x4, monthly x3
Results of audit will be presented at monthly QAPI until substantial compliance is achieved

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations: Based on observations, review of facility documents and interviews with residents and staff, it was determined that the facility failed to follow menu extensions related to pureed diets and meals were not served in accordance with posted meal times and meal tickets, for two of eight nursing units observed (Walton Ground floor Section C unit and Walton First floor Section C unit). Findings include: Observation of the Walton Ground C unit on August 18, 2026, at 1:25 p.m. revealed several residents gathered by the nurses station, waiting for lunch to arrive. Six residents stated that they were hungry and wanted to know why lunch was so late. Interview with Employee E5, licensed nurse, confirmed that lunch had not arrived yet to the unit. Observation of the dining room on the Walton Ground C unit revealed meal times were posted and indicated that lunch was scheduled to be served on this unit at 12:40 p.m. Continued observation revealed that lunch was not delivered to the Walton Ground C unit until 1:51 p.m. Review of the menu posted revealed that for August 18, 2026, the lunch meal was apple spice pork roast with gravy, bowtie pasta, capri vegetables and chilled pears. The alternate meal was oven fried chicken, mashed potatoes and parslied cauliflower. Review of the menu extensions for pureed diets revealed the lunch meal was pureed apple spice pork roast, pureed capri vegetables, pureed bowtie pasta and pureed chilled pears. Continued observation of the lunch meal on August 18, 2026, revealed: Resident R120 did not receive the pork and pears in accordance with the meal ticket; Resident R73 did not receive double portions in accordance with the meal ticket; Resident R10 did not receive ice cream in accordance with the meal ticket. Continued observation of the lunch meal on August 18, 2026, at 2:12 p.m. revealed Residents R50 and R77 received total feeding assistance from Employee E5, licensed nurse, and E6, nurse aide. Both residents received pureed meals consisting of a runny white pureed substance, a runny green pureed substance and mashed potatoes. Interview with Employees E5 and E6 revealed that they did not know what the white and green pureed food items were, and guessed that they were chicken and broccoli. Employees E5 and E6 confirmed that R50 and R77 did not receive the bowtie pasta or the pears. Review of the menu posted revealed that for August 19, 2026, the lunch meal was country meatloaf with ketchup glaze, lyonnaise potatoes, corn o'brian and pineapple tidbits. The alternate meal was baked macaroni and cheese, carrots and steamed rice. Review of the menu extensions for pureed diets revealed the lunch meal was pureed country meatloaf with ketchup glaze, pureed lyonnaise potatoes, pureed carrots and pureed pineapple. A test tray of the regular and pureed lunch meals was conducted on August 19, 2026, on the Walton first floor C unit with Employee E7, dietary manager. Tray line was observed in the kitchen at 11:50 a.m. and the food truck was followed up to the nursing unit at 11:59 a.m. The pureed meal that was served consisted of pureed meatloaf, mashed potatoes, an unidentified runny green vegetable and applesauce. Employee E7 was unsure what the green vegetable was and was unsure what the planned menu was for the pureed diet extension. The mashed potatoes did not have the same seasoning or flavor of the lyonnaise potatoes. No pureed carrots were observed on the lunch plate. Employee E7 was unable to explain why the same green vegetable and mashed potatoes were served for lunch on both August 18 and 19, 2026, and that neither foods were in accordance with the planned pureed menu extensions. Employee E7 further confirmed that applesauce was served instead of pureed pineapple. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 211.6(a) Dietary services

Plan of Correction - To be completed: 10/12/2026

Director of dietary or designee completed education with Dietary Manager regarding facility meal delivery time
Director of dietary or designee completed education with Dietary Manager about meal accuracy according to meal tickets for R120, R73, R10, R50, and R77
Director of dietary or designee will complete education with Kitchen staff about meal delivery time and meal tickets accuracy
Director of dietary/designee will complete 10% audits of breakfast, lunch and dinner tickets weekly x4, monthly x3
Dietary director/designee will complete audit of meal delivery time for all meals M-F for the 1st week, then weekly x4, and monthly x3
Dietary Director or designee will complete audit of 10 residents puree meal trays that meals matches diet posted and has seasoning daily x 5days then weekly x4 weeks, monthly x3 months
Results of audits will be presented at monthly QAPI until substantial compliance is achieved

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations: Based on observations, review of facility documents and interviews with residents and staff, it was determined that the facility failed to ensure that foods were served at appropriate temperatures and that pureed foods were appropriately seasoned and served in a visually appealing way, for two of eight nursing units observed (Walton Ground floor Section C unit and Walton First floor Section C unit). Findings include: Interview on August 18, 2026, at 1:06 p.m. Resident R60 stated that the food was cold. Interview on August 18, 2026, at 1:10 p.m. Resident R210 stated that the food was cold. Interview on August 18, 2026, at 1:50 p.m. Resident R4 stated that the food was inedible. Review of the menu posted revealed that for August 18, 2026, the lunch meal was apple spice pork roast with gravy, bowtie pasta, capri vegetables and chilled pears. The alternate meal was oven fried chicken, mashed potatoes and parslied cauliflower. Review of the menu extensions for pureed diets revealed the lunch meal was pureed apple spice pork roast, pureed capri vegetables, pureed bowtie pasta and pureed chilled pears. Continued observation of the lunch meal on August 18, 2026, at 2:12 p.m. revealed Residents R50 and R77 received total feeding assistance from Employee E5, licensed nurse, and E6, nurse aide. Both residents received pureed meals consisting of a runny white pureed substance, a runny green pureed substance and mashed potatoes. The pureed white and green substances lacked form and swirled together on the plate. Interview with Employees E5 and E6 revealed that the pureed meal was not appetizing in appearance. Review of the menu posted revealed that for August 19, 2026, the lunch meal was country meatloaf with ketchup glaze, lyonnaise potatoes, corn o'brian and pineapple tidbits. The alternate meal was baked macaroni and cheese, carrots and steamed rice. Review of the menu extensions for pureed diets revealed the lunch meal was pureed country meatloaf with ketchup glaze, pureed lyonnaise potatoes, pureed carrots and pureed pineapple. A test tray of the regular and pureed lunch meals was conducted on August 19, 2026, on the Walton first floor C unit with Employee E7, Dietary Manager. Tray line was observed in the kitchen at 11:50 a.m. and the food truck was followed up to the nursing unit at 11:59 a.m. The food was sampled after all the trays had been distributed to residents at 12:16 p.m. The regular meal plate contained meatloaf with ketchup glaze, lyonnaise potatoes, corn o'brian and pineapple tidbits. Coffee and milk were also sampled. The coffee was 135 degrees Fahrenheit and the milk was 50 degrees. The meatloaf was 124 degrees, the lyonnaise potatoes were 127 degrees, the corn o'brian was 121 degrees and the pineapple was 49 degrees. The pureed meal that was served consisted of runny pureed meatloaf, mashed potatoes, an unidentified runny green vegetable and applesauce. Employee E7 was unsure what the green vegetable was. The pureed meatloaf was 124 degrees Fahrenheit, the mashed potatoes were 130 degrees and the green vegetable was 125 degrees. The pureed meatloaf and pureed green vegetable lacked form and swirled together on the plate. The pureed meatloaf and pureed green vegetable also had a taste and texture of food thickener, which was unappealing. The pureed meatloaf was bland, unseasoned and did not have the same flavor as the regular meatloaf. The pureed green vegetable was bland and unseasoned. The mashed potatoes did not have the same seasoning or flavor of the lyonnaise potatoes. Interview with Employee E7, Dietary Manager, at the time of the observation, confirmed that the foods didn't taste hot, that the pureed meatloaf and pureed green vegetable were unseasoned and that the appearance of the pureed foods was runny and not appetizing. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 211.6(a) Dietary services

Plan of Correction - To be completed: 10/12/2026

Director of dietary/designee will complete education with dietary manager about food palatability/prefer temp according to F0804
Director of dietary/designee will complete education with the cooks and servers about food palatability/prefer temp according to F0804
Director of nursing will educate nursing staff about timely delivery of meal trays to residents after delivery to the units to ensure food is served at preferred temperature
Dietary manager will complete 20% meal temperature for breakfast, lunch, and dinner M-F x1 week, then 10% weekly x4 weeks, monthly x3 months
Director of dietary will complete 20% of puree meals M-F for palatability and formed in appearance for 1-week, weekly x4, monthly x3 months
Results of audits will be presented at monthly QAPI until substantial compliance is achieved

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