Pennsylvania Department of Health
 AMOROSO HEALTHCARE AND REHABILITATION WOODRIDGE
Patient Care Inspection Results

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AMOROSO HEALTHCARE AND REHABILITATION WOODRIDGE
Inspection Results For:

There are  279 surveys for this facility. Please select a date to view the survey results.

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AMOROSO HEALTHCARE AND REHABILITATION WOODRIDGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey completed on November 26, 2025, it was determined that Amoroso Healthcare and Rehabilitation Woodridge 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:


483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.
Observations: Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident condition for six of 19 residents reviewed (Residents 2, 4, 5, 7, 15, and 32). Findings include: Review of Resident 2's clinical record revealed diagnoses that included pressure ulcer of sacral region, stage 4 (injury to the skin and underlying tissue caused by prolonged pressure on the skin), hypertension (persistent high blood pressure), and schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior). Review of Resident 2's Annual MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental and psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of May 18, 2025, revealed under Section M- Skin Conditions, Resident 2 was marked "no" to indicate he was not at risk of a pressure ulcer. During an interview with the Director of Nursing (DON) on October 21, 2025, at 1:09 PM, she revealed the aforementioned MDS was coded incorrectly, and she would expect the MDS to be coded accurately. Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 4's physician orders revealed orders for a consistent carbohydrate diet with a pureed texture and thin liquids, dated December 10, 2024; and hospice services, dated January 7, 2025. Review of Resident 4's Quarterly MDS with the assessment reference date of March 26, 2025, revealed in Section K. Swallowing/Nutritional Status that Resident 4's was not coded as receiving a therapeutic diet; and in Section O. Special Treatments, Procedures, and Programs that Resident 4 was not coded as receiving hospice care. Review of Resident 4's Modified Quarterly MDS with the assessment reference date of June 26, 2025, revealed in Section O. Special Treatments, Procedures, and Programs that Resident 4 was not coded as receiving hospice care. Review of Resident 4's Quarterly MDS with the assessment reference date of September 24, 2025, revealed in Section K. Swallowing/Nutritional Status that Resident 4's was not coded as receiving a therapeutic diet; and in Section O. Special Treatments, Procedures, and Programs that Resident 4 was not coded as receiving hospice care. During a staff interview with the Nursing Home Administrator (NHA) and DON on October 1, 2025, at 11:29 AM, the DON confirmed that Resident 4's aforementioned assessments were coded inaccurately and that modifications would be completed. Review of Resident 5's clinical record revealed diagnoses which included atrial fibrillation (irregular heartbeat) and chronic respiratory failure (respiratory disease that results in decreased ability of the lungs to either oxygenate the blood or remove carbon dioxide from the blood). Review of Resident 5's physician orders revealed an order for olanzapine (atypical antipsychotic medication used to treat mental health conditions) 5 milligrams twice a day, which was active since January 29, 2025. Review of Resident 5's Quarterly MDS with an assessment reference date of May 4, 2025, revealed Section N - Medications was coded to reflect Resident 5 was not receiving an antipsychotic medication; however, review of Resident 5's medication administration record revealed that at the time of the Quarterly MDS, Resident 5 had been receiving the antipsychotic medication. During a staff interview on October 21, 2025, at approximately 1:10 PM, the DON confirmed that Resident 5's Quarterly MDS with assessment reference date of May 4, 2025, should have been coded to reflect Resident 5's use of an antipsychotic medication. Review of Resident 7's clinical record revealed diagnoses that included gastrostomy status (refers to the presence of an artificial opening in the stomach for feeding patients who cannot ingest food orally), feeding difficulties, and abnormal posture. Review of Resident 7's Quarterly MDS with ARD of August 4, 2025, revealed under Section K- Swallowing/Nutritional Status was marked "yes" to indicate he had received intravenous (IV) fluids during the look back period for the assessment. Review of Resident 7's clinical record failed to reveal notation that they received IV fluids during the lookback. During an interview with the DON on October 21, 2025, at 1:09 PM, she revealed the aforementioned MDS was coded incorrectly, and she would expect the MDS to be coded accurately. Review of Resident 15's clinical record revealed diagnoses that included acute and chronic respiratory failure with hypoxia (conditions where the lungs cannot adequately exchange gases leading to low oxygen levels and potentially high carbon dioxide levels) and encounter for palliative care (specialized medical care aimed at enhancing the quality of life for patients with serious illnesses). Review of Resident 15's clinical record revealed she was admitted to hospice care (medical care for people who are expected to live six months or less, and focus on comfort and quality of life) on July 13, 2024, with an admitting diagnosis of chronic respiratory failure and hypoxia. Review of Resident 15's Quarterly MDS with ARD of July 19, 2025, revealed under Section I- Active Diagnoses, subsection I6300. Respiratory failure, it was marked "no" to indicate she did not have that active diagnosis. During an interview with the DON on October 21, 2025, at 1:09 PM, she revealed the aforementioned MDS was coded incorrectly, and she would expect the MDS to be coded accurately. Review of Resident 32's clinical record revealed diagnoses that included type II diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin) and chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Residents 32's Annual MDS with an ARD of April 7, 2025, and Quarterly MDS's with assessment reference dates of July 28, 2025, and September 23, 2025, revealed that Resident 32 was coded in Section N. Medications that he had received one insulin injection in all the aforementioned assessment periods. Review of Resident 32's clinical record physician orders and Medication Administration Records for April 2025, July 2025, and September 2025, failed to reveal that Resident 32 was ordered or received any insulin injections during the assessment periods. During a staff interview with the NHA and DON on October 1, 2025, at 11:20 AM, the DON indicated that Resident 32 had received Ozempic injections during the assessment periods and that it was coded inaccurately as insulin on Resident 32's aforementioned assessments. She further indicated that assessment modifications would be completed. 28 Pa code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 12/09/2025

1. Resident's 2 assessment dated 5/18/25 was corrected to show that they are at risk for skin breakdown. Resident's 4 assessment dated 3/26/25 was modified to show therapeutic diet and Hospice Services. Resident 4 assessment dated 6/26/25 was modified to show Hospice care. Resident's 4 assessment dated 9/24/25 was modified as receiving therapeutic diet and Hospice services. Residents' 5 assessment date dated 5/4/25 was modified to show the use of anti-psychotic medication. Resident's 7 assessment dated 8/4/25 was modified to show IV use in the look back period. Resident's 15 assessment dated 7/19/25 was modified to show respiratory failure. Resident's 32 assessment dated 4/7/25, 7/28/25 and 9/23/25 were modified to show that an insulin injection was not administered.
2. The MDS coordinator will ensure that the resident's assessments are accurate before closing the assessment.
3. The RNAC did educate the MDS coordinator on the importance to ensure that the resident's assessments are accurate on 11/11/25.
4. The RNAC will audit 10 assessments form the last quarter to ensure that they are accurate. The RNAC will audit 10% of the resident's assessments weekly X 4 weeks then monthly to ensure that they are accurate. Results to be reviewed by the QAPI committee.
5. Compliance by 12/9/25.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations: Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and three of three pantry areas. Findings include: Review of facility policy, titled "Policy: Storage Areas" last reviewed May 21, 2025, read, in part, "All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All freezer units are always kept clean and in good working condition." Review of facility policy, titled "Food from Outside Sources" last reviewed May 21, 2025, read, in part, "Visitors/family member will label food and beverages with the resident's name, room number, and date. Perishable foods with a 'use by' date which is 3 days from the date that it was brought into the facility." Observation of the dry storage area on September 29, 2025, at 9:27 AM, revealed one bag of spiral pasta open without an open date, and one bag of elbow pasta open without an open date. Interview with Employee 2 (Cook) on September 29, 2025, at 9:28 AM, revealed bags of pasta should be labeled with an open date once opened. Observation of the reach-in freezer 1 in the main kitchen on September 29, 2025, at 9:31 AM, revealed two bags of steak fries with one open and both not dated; one package of hot dogs not dated with a heavy presence of ice crystals; and one package of sausages not dated with a heavy presence of ice crystals. Observation of the reach-in freezer 2 in the main kitchen on September 29, 2025, at 9:33 AM, revealed one bag of sausage patties open and not dated. Further observation of the reach-in freezer 2 in the main kitchen on September 29, 2025, at 9:34 AM, revealed the bottom of the freezer was heavily soiled with food debris. Interview with Employee 2 on September 29, 2025, at 9:35 AM, revealed she was not aware of a formal cleaning schedule for kitchen equipment, but it is the expectation that kitchen equipment is kept clean at all times. Observation in the Unit 2 Pantry Refrigerator on September 29, 2025, at 9:39 AM, revealed two bags of food from outside sources not labeled with resident names or dates. Observation in the Unit 2 Pantry Freezer on September 29, 2025, at 9:40 AM, revealed one ice cream container spilled over without a lid; two frozen beverages from outside sources without resident names or dates; and one frozen meal from an outside source with an expiration date of August 25, 2025. Observation of the April 2025 Unit 2 Refrigerator/Freezer Temperature Log revealed the refrigerator temperature failed to be recorded on April 5. Observation in the Unit 1 Pantry Refrigerator on September 29, 2025, at 9:43 AM, revealed cream of wheat in a Styrofoam cup without a date; a bag of food labeled with a resident's name, dated August 4 that appeared rotten; and a container of wilted salad, labeled with a resident's name, not dated, with a four odor. Observation of the September 2025 Unit 1 Refrigerator/Freezer Temperature Log on September 29, 2025, at 9:44 AM, revealed temperatures failed to be recorded on September 13, 21-23; and temperatures were already filled for September 30. Observation of the August 2025 Unit 1 Refrigerator/Freezer Temperature Log revealed temperatures failed to be recorded on August 5 for the refrigerator and August 19 for both the refrigerator and the freezer. Observation in the Unit 3 Pantry Refrigerator on September 29, 2025, at 9:47 AM, revealed four containers of applesauce not dated; one can of kidney beans from an outside source open and not properly sealed; and one container of food from an outside source not labeled with a resident's name or date. Interview with the Nursing Home Administrator on October 1, 2025, at 10:40 AM, revealed his expectation that expired items are discarded, foods items are labeled and dated per facility policies, and food storage equipment is utilized in accordance with professional standards. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(f) Dietary services
 Plan of Correction - To be completed: 12/09/2025

1. The FSD discarded the unlabeled and undated items on 9/29/25.
2. No residents were identified.
3. NHA to educate the FSD and licensed staff on the policy for storage areas and the policy on foods brought in by family/visitors, also for the fridges and freezers to have temps monitored daily on 11/13/25.
4. FSD/Designee will audit the dry storage and freezer area weekly X 4 weeks then monthly to ensure that open items are dated when they are opened. FSD/Designee will audit freezers weekly X 4 weeks then monthly to ensure that the freezers are cleaned. The FSD/Designee will audit weekly X 4 weeks then monthly the pantry fridges have resident's names and are dated. The FSD/Designee will audit the pantry fridges and freezers weekly X 4 weeks then monthly to ensure that the temps are filled out. Results to be reviewed with the QAPI committee.
5. Compliance by 12/9/25.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(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 facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for two of 19 residents reviewed (Residents 4 and 85). Findings include: Review of facility policy, titled "Weighing and Measuring a Resident" last reviewed May 21, 2025, read, in part, "The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. Review the resident's care plan to assess for any special needs of the resident." Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 4's physician orders revealed the following orders: Glucerna with Carb Steady 1.5 calories 300 milliliters via feeding tube every six hours, dated September 8, 2025; a consistent carbohydrate diet with a pureed texture and thin liquids; may have pleasure foods per hospice, dated December 10, 2024; and hospice services, dated January 7, 2025. Review of Resident 4's physician order history revealed that she had an order for monthly weights until September 11, 2025. Review of Resident 4's weight documentation revealed that no weight was documented in January 2025, February 2025, April 2025, May 2025, or July 2025. Further review of Resident 4's documented weights revealed that on March 11, 2025, she weighed 225 pounds; June 1, 2025, she weighed 201 pounds; August 5, 2025, she weighed 200 pounds; and September 1, 2025, she weighed 192.4 pounds. Review of Resident 4's clinical record revealed that she had no nutritional assessments completed by the facility dietician between December 11, 2024, and September 8, 2025. Review of Resident 4's clinical record failed to reveal any documentation that Resident 4's physician, hospice provider or family were notified of her 24 pound weight loss in June 2025. Review of Resident 4's hospice nurse's visit note dated June 4, 2025, revealed that she was "tolerating tube feedings and refusing to be fed orally. Pt is spitting food out." The note failed to include any documentation about the 24-pound weight loss. Review or Resident 4's hospice nurse's visit note dated June 13, 2025, revealed that she was "tolerating tube feedings," but failed to include any documentation of the 24-pound weight loss. Review of Resident 4's "Resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated June 18, 2025, revealed that the hospice physician documented Resident 4 was receiving Glucerna 1.5 calories 250 milliliters every six hours via her feeding tube with 120 milliliter water flushes before after feedings; that she was allowed comfort feedings with pureed diet and nectar thick liquids as tolerated. The note failed to include any notation of Resident 4's 24-pound weight loss but did include that Resident 4 "no longer responds to her daughter or takes anything by mouth from her." Review of Resident 4's "Resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated July 16, 2025, the hospice physician again documented the use of tube feeding for Resident 4 but failed to include any documentation of her weight loss. Review of Resident 4's "Resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated August 13, 2025, the physician again documented the use of a tube feeding for Resident 4 and indicated that she no longer takes anything by mouth but failed to include any documentation of her weight loss. Review of Resident 4's progress notes revealed a note by the dietician dated September 8, 2025, at 5:57 PM, that indicated she was evaluating Resident 4 for a new onset of a pressure injury and that she was triggering for desirable significant weight loss of 32-33lb (-14.5%) over six months. The note further indicated that she had recommended changes to Resident 4's tube feeding amount, water flushes, and added vitamins to promote wound healing. During a staff interview with the Director of Nursing (DON) on October 1, 2025, at 1:30 PM, she indicated that the facility dietician does not complete nutritional assessments on residents receiving hospice services. She said that this would be deferred to hospice since she was under their services. She further indicated that the facility does not typically weigh people on hospice. During a final interview with the Nursing Home Administrator (NHA) and DON on October 21, 2025, at 1:14 PM, the DON indicated that Resident 4 was a unique case given she is under hospice services, but receiving tube feedings and remaining a full code. She confirmed that staff should have been weighing her monthly since that was the physician's order. The DON further confirmed that Resident 4's physician, hospice provider, and Representative should have been notified of the weight loss in June 2025 when it was noted to have occurred to have possibly prevented further weight loss. She confirmed that there was no documentation to support that Resident 4's provider, hospice provider, or the dietician had been made aware of Resident 4's weight loss or made in changes in her treatment regimen until September 8, 2025. Review of Resident 85's clinical record revealed diagnoses that included infection following a procedure, dysphagia (difficulty swallowing), and repeated falls. During an interview with Resident 85 on September 29, 2025, at 10:59 AM, he revealed he has been losing weight at the facility because he sometimes receives food he can't eat and doesn't get food per his preference. Review of Resident 85's care plan revealed a focus area that read, in part, "The resident has [a] potential nutritional problem related to food allergies/sensitivities" with an intervention for "Obtain weight as ordered. Notify Medical Doctor, Registered Dietitian of any significant changes for further review," with a start date of September 11, 2025. Review of Resident 85's physician orders revealed an order for "Weigh daily times 3 then weekly times 4 then monthly, every day shift every Sunday for 4 weeks," with a start date of September 9, 2025. Review of Resident 85's clinical record revealed he had a weight measure obtained on September 14, 2025, and not again until September 28, 2025. Review of Resident 85's weight change from September 14 to 28, 2025, revealed he had experienced a 5.1% significant weight loss from 138.8 pounds to 131.6 pounds. Review of Resident 85's clinical record revealed the facility obtained another weight measure on October 1, 2025, that was back up to 139.2 pounds. During an interview with the DON on October 1, 2025, at 10:34 AM, she revealed the facility weight policy indicated weight is usually measured upon admission and monthly during the resident's stay, but since current professional standards of practice recommend residents should be weighed weekly for the first 4 weeks after admission it should be updated. She further revealed since the Resident had a physician order for weekly weights at that time, it should have been followed. The DON also stated that staff had obtained a reweigh measure in response to the weight measure on September 28, 2025, due to it likely being a discrepancy, but she would expect reweigh weight measures to be completed within 24 hours. 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)Resident care policies 28 Pa Code 211.12(d)(1)(2)(3)(5) Nursing services
 Plan of Correction - To be completed: 12/09/2025

1. Resident 4 did not have any adverse reaction. The facility did remove the order for monthly weights as the resident is on Hospice. Resident 85 did not have any adverse reaction. Resident 85 was educated on the foods that are within his diet. Resident's 85 care plan was updated to reflect the education provided to him and the family regarding his diet and non-compliance with his diet.
2. The facility did change its policy to reflect doing weekly weights for 4 weeks on all new admissions. The DON/Designee will audit 10 random charts to ensure that the residents do not have any missing weights, if the resident was noted to have a significant change that the registered dietician was notified for a timely assessment.
3. The DON/Designee did educate the RN's in the policy change on 11/13/25.
4. The DON/Designee will audit all new admission weekly for 4 weeks then monthly to ensure that weights are obtained weekly. If any significant weight changes that they are reviewed with the Registered Dietician to ensure that we have timely assessments. Results to be reviewed with the QAPI committee.
5. Compliance by 12/9/25.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to provide interventions to prevent accidents for two out of 19 residents reviewed (Residents 4 and 83). Findings include: Review of the facility policy, titled "Falls - Clinical Protocol", with a last revised date of March 2018, and a last reviewed date of May 21, 2025, revealed, "The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. The staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling." Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes, which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 4's clinical record progress notes revealed that she had a fall from her bed on September 20, 2025. Review of Resident 4's clinical record progress note dated September 20, 2025, at 9:55 AM, that revealed that the facility had contacted Resident 4's hospice provider about providing Resident 4 with a different bed that could be positioned lower to the floor since the one that they had already provided could be positioned in this manner. In addition, a progress note dated September 20, 2025, at 10:29 AM, indicated that the facility had contacted Resident 4's Representative to update her on the incident. The note further indicated that Resident 4's Representative requested that Resident 4 be provided with a second body pillow and that fall mats be placed on the floor for safety. Review of Resident 4's care plan revealed a care plan focus for potential for falls with interventions that included, but were not limited to, body pillow to left and right side when in bed, dated September 20, 2025; keep bed in lowest position, dated July 26, 2024; and fall mats to bilateral sides of bed requested by [representative], dated September 20, 2025. Observation of Resident 4 on September 29, 2025, at 1:30 PM, revealed that she was in bed with bilateral body pillows placed, her bed was approximately two feet off the floor, and no fall mats were present. Subsequent observations on September 30, 2025, at 10:00 AM and 12:25 PM; and on October 1, 2025, at 8:55 AM, all revealed the same findings: the Resident was in bed with bilateral body pillows placed, her bed was approximately two feet off the floor, and no fall mats were present. During a staff interview on October 1, 2025, at 11:07 AM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), observations and care plan findings were shared by the surveyor. The NHA indicated that the fall mats were not placed because the interdisciplinary team had reviewed the request by Resident 4's Representative and decided against them and, therefore, the fall mats should not have been care planned. When observation of the bed height of approximately two feet in the lowest position was discussed, the DON indicated that they were awaiting a different bed from hospice and that hospice had provided her current bed. During a staff interview with Employee 5 (Nurse Aide) on October 1, 2025, at 11:45 AM, she demonstrated that the bed was as low as it could go. She indicated that she had told administrative staff about it several times. Observation of Resident 4 on October 1, 2025, at 12:35 PM, revealed that the bilateral fall mats had been placed on both sides of her bed. Observation of Resident 4 on October 21, 2025, at 9:00 AM, revealed she was in bed with bilateral body pillows in place, her bed was approximately two feet off the floor, and the bilateral fall mats were present at both sides of her bed. During a final staff interview with the NHA and DON on October 21, 2025, at 11:17, the NHA again indicated that, although the interdisciplinary team had decided against the fall mats, staff went ahead and implemented them since they were care planned. The NHA confirmed that since they were care-planned, they should have been in place since September 20, 2025. He also confirmed that Resident 4's lowest bed height was still approximately two feet from the floor and that the falls mats could help prevent injuries should Resident 4 fall from bed again. Review of Resident 83's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 83's comprehensive care plan revealed a fall risk care plan with an intervention for Resident 83 to have a fall mat to the right side of the bed, initiated on February 7, 2025, and revised on February 8, 2025; and an intervention to keep bed in lowest position, initiated on February 14, 2024. Review of a fall incident report on Resident 83 that occurred on July 3, 2025, revealed the Resident had an unwitnessed fall in their room and was found lying on the right side of the bed, without injury. Further review of the incident report revealed Resident 83's bed was not in a low position at the time of the fall and their fall mat was not present. Observation of Resident 83 on September 30, 2025, at 1:55 PM, revealed the Resident was lying in bed with no fall mat present on the floor and their bed was not in the lowest position. Interview conducted with the NHA on October 21, 2025, at 11:05 AM, revealed they would have expected Resident 83's interventions to have been in place. 28 Pa. Code 201.18(b)(1)(2) Management 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services
 Plan of Correction - To be completed: 12/09/2025

1. No adverse reactions happened for resident 4 and 83.
2. DON/Designee will review residents with fall care plans to ensure that interventions are in place.
3. DON/Designee did educate licensed staff on 11/13/25 to ensure that when they put an intervention in for a fall, that the interventions are in place and care planned accordingly.
4. Residents with falls will be audited weekly for 4 weeks then monthly during the fall meeting to ensure that the interventions are care planned and in place. Results to be reviewed with the QAPI committee.
5. Complinace by 12/9/25.
483.10(e)(1), 483.12(a)(2), 483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

§483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations: Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 9). Findings include: Review of facility policy, titled "Psychotropic Medication Use," with a last review date of May 21, 2025, revealed, in part, "Assessment and Evaluation of the Resident: 1. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. 2. Circumstances that warrant an evaluation of the resident's underlying medical condition and medications include: a. admission or readmission; c. an irregularity identified during the drug regimen review. Behavioral and Other Non-Pharmacological Interventions: 1. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support gradual dose reduction. Informed consent: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. non-pharmacological alternatives; b. the indications and rationale for the recommendation; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and d. the resident's/representatives right to accept or decline treatment. Dose, Duration, and Duplicate Therapy: 3. Duplicate therapy (use of two or more medications of the same pharmacological class or category ...) is generally not indicated unless there is a documented clinical rationale for the use of multiple medications from the same class or with similar effects. 5. Medications prescribed by a specialist or began in another care setting, such as the hospital, must be clinically indicated and documented in the resident's medical record." Review of facility policy, titled "Medication Regimen Reviews," with a last review date of May 21, 2025, revealed, in part, "Timeframe for Reporting: 3. The consultant pharmacist provides the director of nursing and medical director with a written, signed, dated copy of all medication regimen reports. 4. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. Physician Response: 1. Upon receiving the MRR [Medication Regimen Review] report from the pharmacist, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them. 2. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator." Review of Resident 9's clinical record revealed that she was admitted to the facility on June 19, 2025, with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 9's current physician orders revealed orders for duloxetine (a medication used to treat depression) 60 milligrams one capsule daily, dated June 19, 2025; mirtazapine (a medication used to treat depression)15 milligrams one tablet at bedtime, dated June 19, 2025; sertraline (a medication used to treat depression) 150 milligrams daily, dated June 19, 2025; quetiapine (a medication used to treat psychotic disorders) 100 milligrams administer one and a half tablets at bedtime, dated June 19, 2025; quetiapine 25 milligrams administer one tablet one time daily, dated September 5, 2025; and consult psychiatry to evaluate and treat as needed, dated August 21, 2025. Review of Resident 9's clinical record failed to reveal any documentation that education was provided to Resident 9 or her Representative regarding the risk versus benefit of the ordered antipsychotic and antidepressant medications or that consent was obtained to administer the medications. Review of Resident 9's clinical record failed to reveal any documentation of Resident 9's identified target behaviors, any behavior monitoring for the use of the antipsychotic medication, or any side effect monitoring of the antipsychotic medication. Review of Resident 9's care plan failed to reveal any identified target behaviors. Review of Resident 9's clinical record revealed that the facility consultant pharmacist issued a recommendation to Resident 9's physician on July 15, 2025, which indicated, in part, "Black box warning ...Residents with dementia-related psychosis treated with atypical antipsychotics are at an increased risk of death ...increased incidence of cerebrovascular adverse events (including fatalities) has been reported in elderly patients with dementia-related psychosis ...Please evaluate current therapy and indicate below the appropriate option for this resident." The form failed to reveal any physician documentation or review signature. Review of Resident 9's clinical record revealed an initial psychiatry consult note dated September 4, 2025, which indicated that Resident 9 had no supporting diagnosis for the quetiapine and that a gradual dose reduction would be initiated. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on October 1, 2025, at 11:15 AM, the DON indicated that Resident 9 was admitted to the facility on all the psychotropic medications. She said that the practitioner at the facility was not comfortable adjusting any of Resident 9's medications because of her long-term use of the medications. The DON indicated that the practitioner wanted psychiatric services to evaluate Resident 9 regarding the July 2025 recommendation and to assume management of Resident 9's psychotropic medications. The DON said that she could not answer as to why the practitioner did not consult psychiatric services until August 21, 2025, instead of in July 2025 when the pharmacist had made the recommendation to review the antipsychotic medication. Review of Resident 9's progress notes revealed that she was seen by her practitioner at the facility on July 18, 22, and 28, 2025; and August 14, 2025, and, although documentation included the medications Resident 9 was taking and her mood status at the time of the visit, the documentation failed to include any documentation regarding consulting psychiatry services to manage her psychotropic medications. Further review of Resident 9's progress notes revealed a note by her practitioner dated August 19, 2025, which indicated that a "psych consult has been placed for recommendations." During a staff interview with the NHA and the DON on October 1, 2025, at 1:25 PM, the DON indicated that Resident 9 was admitted to the facility on all her psychotropic medications so the facility would not have obtained any consents. During a final staff interview with the NHA and the DON on October 21, 2025, at 11:22 AM, both confirmed that Resident 9's target behaviors should have been identified, and care planned and that behavior monitoring and side effect monitoring should have been in place. The DON confirmed that this should have been done at time of Resident 9's admission to the facility in June 2025. The DON confirmed that the pharmacy recommendation from July 15, 2025, was not addressed until September 4, 2025, when the psychiatry finally saw the Resident and began reducing the antipsychotic medication dose because Resident 9 was noted to have no supporting diagnosis for its use. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services
 Plan of Correction - To be completed: 12/09/2025

1. Resident 9 was seen by the psychiatric CRNP. The psychiatric CRNP did discuss the risk vs. benefits with Resident 9. The psychiatric CRNP will continue to follow Resident 9 to monitor medications.
2. The DON/Designee will review residents in the facility on psychotropic medications to ensure that resident or the resident's representative have been reviewed the risks VS the benefits and that they have the proper diagnosis for the medication. Also, to ensure that the target behaviors are care planned, that the resident has the documentation of any side effects, pharmacy reviews have been discussed with the resident's physician in a timely manner, and that any black box warnings were reviewed with the resident and/or the residents responsible representative.
3. The DON/Designee did educate RN's on 11/13/25 that they need to notify the providers of any resident admitted with psychotropic medications, and when a psychotropic medication is added. This is to ensure that the resident is reviewed the risk and benefits of the psychotropic medications and to ensure that the resident has proper diagnosis for the medication. Also, that they need to identify the target behaviors and have them care planned, the importance of monitoring side effects, ensuring that we review the pharmacy recommendations with the resident's provider. Reviewing black box warnings with the resident and/or responsible representative.
4. The DON/Designee will audit all new admissions weekly X 4 weeks then monthly to ensure that the resident has been notified of the risks and benefits of the medications and that they have the proper diagnosis. Also, DON/Designee will audit 5 charts weekly for 4 weeks then monthly to ensure that they have been notified of risk vs benefits and that they have the proper diagnosis. Also, audit will include what the target behaviors are, if they are care planned, if they have been assessed for any side effects, if the pharmacy reviews have been reviewed been reviewed timely with the residents' physician, and if the black box warning reviews were reviewed with the resident and/or residents responsible representative. Results to be reviewed with the QAPI committee.
5. Compliance by 12/09/25.

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 facility policy reviews, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure residents received a transfer notice with required included information upon transfer/discharge; failed to provide residents with a copy of the facility's bed hold policy for three of four residents reviewed for hospitalization (Residents 8, 12, and 85). Findings include: Review of facility policy, titled "Bed-Holds and Returns" last reviewed May 21, 2025, read, in part, "1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours)." Review of facility policy, titled "Transfer or Discharge," last reviewed May 21, 2025, revealed that subsection titled "Transfer or Discharge Documentation in the Medical Record," stated, "1. When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: ...b. That an appropriate notice was provided to the resident and/or legal representative ... " Review of Resident 8's clinical record revealed diagnoses that included congestive heart failure (disease process that results in the decreased ability of the heart to pump blood through the body effectively) and chronic kidney disease (disease of the kidneys that affects kidney function). Review of Resident 8's clinical record revealed that on June 22, 2025, Resident 8 was sent to the hospital for an acute medical change in condition. Resident was admitted to the hospital and returned to the facility on June 26, 2025. Review of available documentation revealed no evidence that Resident 8 nor Resident 8's Representative Party were provided a notice of transfer or bed hold policy. Resident 8 was also transferred to the hospital for an acute medical change in condition on July 12, 2025. Resident 8 returned to the facility on July 16, 2025. Review of available documentation revealed no evidence that Resident 8 nor Resident 8's Representative Party were provided with a notice of transfer or bed hold policy. Review of Resident 12's clinical record revealed diagnoses that included vascular dementia (changes in the blood vessels of the brain that results in decreased ability to perform activities of daily living and decreased contact with reality) and atrial fibrillation (irregular heartbeat). Review of Resident 12's clinical record revealed that on August 23, 2025, Resident 12 was sent to the hospital after an acute medical change. Review of the available documentation revealed no evidence that Resident 12 nor Resident 12's Representative Party were provided a notice of transfer or bed hold policy. Review of Resident 85's clinical record revealed diagnoses that included infection following a procedure, dysphagia (difficulty swallowing), and repeated falls. Review of Resident 85's clinical record revealed he was transferred to the hospital for an acute medical change in condition on August 15, 2025. Resident 85 returned to the facility on August 21, 2025. Review of available documentation failed to reveal evidence that Resident 85 was provided with a notice of transfer or bed hold policy. Review of Resident 85's clinical record revealed he was also transferred to the hospital for an acute medical change in condition on August 31, 2025. Resident 85 returned to the facility on September 6, 2025. Review of available documentation failed to reveal evidence that Resident 85 was provided with a notice of transfer or bed hold policy. During an email correspondence with the Nursing Home Administrator (NHA) on September 30, 2025, at 2:15 PM, the surveyor revealed the concern with the facility not being able to provide the bed hold and transfer notices for Resident 85's aforementioned hospital transfers. The NHA revealed he agreed with the concern about the notices as he does not have proof that they were sent. 28 Pa. Code 201.14(a) Responsibility of licensee
 Plan of Correction - To be completed: 12/09/2025

1. Resident's 8, 12 and 85 all returned to the facility.
2. The facility will ensure that future residents that are transferred out of the facility are transferred with the bed hold policy, notified of the Practitioner responsible for the care of the resident, the name of the residents representative and the information including the contact information, all special instructions or precautions for the ongoing care, comprehensive care plan goals, copy of discharge summary.
3. Licensed nursing staff were educated by the DON/Designee on 11/13/25 that the residents who are transferred out of the facility need to have a copy of the bed hold policy, the residents practitioner responsible for the care of the resident, residents representative information including contact information, advance directive, all special instructions or precautions for ongoing care, comprehensive care plan goals, copy of the residents discharge summary and documented in the residents' EMR. Also, that the transfer discharge notice include the specific reason for the transfer or discharge. The effective date of transfer or discharge. The specific location to which the resident is to be transferred or discharged to. A statement of the resident's appeal rights. The name, address and telephone number of the Office of the state long term care ombudsman.
4. DON/Designee will audit all residents who were transferred out of the facility weekly for 4 weeks then monthly to ensure that the resident left with a copy of the bed hold policy, name of the residents partitioner responsible for their care, residents representative information including contact information, all special instructions or precautions for ongoing care, comprehensive care plan goals, copy of the resident discharge summary, and that it was documented in the resident's EMR.
5. Coompliance by 12/09/25.
483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations: Based on policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of 19 residents reviewed (Residents 18 and 83). Findings include: Review of the facility policy, titled "Activities of Daily Living (ADL), Supporting" with a last revised date of April 2025, and a last reviewed date of May 21, 2025, revealed "5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care including appropriate support and assistance with: mobility (transfer and ambulation). " Review of Resident 18's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and hypertension (high blood pressure). Review of Resident 18's comprehensive care plan revealed an ADL care plan with an intervention that Resident 18 requires total lift and 2-staff participation with transfers, with an initiation date of March 6, 2023, and a revision date of June 30, 2025. Another intervention included in Resident 18's ADL care plan includes that they prefer to be out of bed in their chair after they are changed, initiated on March 22, 2023, and revised on July 26, 2024. Further review of Resident 18's care plan revealed a focus area that there is a potential risk of adjustment due to resident age is younger than general population, with an initiation date of March 7, 2023, and a revision date of April 20, 2023; and an intervention that Resident 18 would like to arise at 7:00 AM and be put back to bed at approximately 9:30 PM - 10:00 PM. Interview conducted with Resident 18 on September 29, 2025, at 10:00 AM, the Resident revealed that the Resident was waiting to get up out of bed. Interview conducted with Employee 4 on September 29, 2025, at 10:02 AM, revealed that Resident 18 is hard to understand and that the Resident was waiting to get up. Observations of Resident 18 on September 29, 2025, at 10:20 AM, 11:14 AM, and 11:40 AM, revealed Resident 18 was still lying in bed waiting to get up. Observation at 11:47 AM revealed two staff members went into Resident 18's room with a lift to get them up out of bed. During an interview with the Nursing Home Administrator (NHA) on October 21, 2024, at 11:05 AM, he revealed he would have expected Resident 18's care plan to have been followed. Review of Resident 83's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 83's comprehensive care plan revealed an ADL care plan with an intervention that the Resident required total lift and 2-staff participation with transfers, initiated on February 14, 2024, and revised on July 26, 2024. Further review of Resident 83's care plan revealed a care plan for dialysis and an intervention that after Resident 83 returns from dialysis, to offer them rest period in bed (Resident request to be laid down after she gets back from dialysis), initiated on August 15, 2025. Observation conducted on September 30, 2025, at 1:04 PM, revealed Resident 83's call light was on. Interview conducted with Resident 83 on September 30, 2025, at 1:17 PM, revealed that she wanted to get put back in bed and has been back from dialysis since 11:00 AM, and does not feel well. Observation conducted on September 30, 2025, at 1:22 PM, revealed a staff member going into Resident 83's room and turning the call bell off and exiting the room. Interview conducted with Resident 83 on September 30, 2025, at 1:24 PM, revealed that the staff member told Resident 83 they will get someone to assist putting Resident 83 into bed. Observation on September 30, 2025, at 1:52 PM, revealed two staff members going into Resident 83's room with a lift to assist them into bed. During an interview with the NHA on October 1, 2025, at 10:52 AM, they revealed that they would expect Resident 18's plan of care to have been followed, and for Resident 83 to have been put back into bed upon returning from dialysis. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 12/09/2025

1. Resident's 18 and 83 did not have any adverse reactions due to their care plan not being followed. CNA's were educated on Resident's 18 and 83's interventions.
2. DON/Designee will audit 10 residents care plans form the last quarter to ensure that interventions are being followed. Care plans will be addressed for proper interventions as the residents care plan meetings are held.
3. DON/Designee did educate the nursing staff on 11/13/25 on the importance of following the resident's care plan.
4. DON/Designee will audit 9 residents weekly then monthly to ensure their care plans are being followed. Results to be reviewed with the QAPI committee.
5. Compliance by 12/9/25.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(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 facility policy review, observation, manufacturer product information, and staff interviews, it was determined that the facility failed to discard expired medications in a timely manner in one of three medication carts reviewed (Unit 2 Cart 4). Findings include: Review of facility policy, titled "Medication Labeling and Storage," with a last review date of May 21, 2025, revealed, in part, "The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner." Review of facility policy, titled "Administering Medications," with a last review date of May 21, 2025 revealed, in part, "The expiration/beyond use date on the label must be checked prior to administering." During a medication pass observation on Unit 2 on October 1, 2025, at 9:05 AM, Employee 1 was administering medications from Cart 4. Employee 1 retrieved a house stock bottle of famotidine 10 mg (milligrams) (an over-the-counter medication used to reduce stomach acid) in preparation to administer to Resident 50. Surveyor review of the bottle noted that an open date of March 4, 2025, was written on the bottle and that the manufacturer expiration date was January 2025. Employee 1 was observed confirming the medication name and dose on the bottle to Resident 50's orders, but Employee 1 failed to confirm the expiration date of the medication. During an immediate interview with Employee 1 on October 1, 2025, at 9:08 AM, she confirmed that the bottle was opened three months after the manufacturer expiration date. She also confirmed that there were no other bottles of famotidine in the cart and that staff would have been administering from this bottle. The bottle was approximately one-third full. During a staff interview with the Nursing Home Administrator and Director of Nursing on October 21, 2025, at 11:30 AM, both confirmed that the medication should not have been opened and utilized past the manufacturer expiration date. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(b)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services
 Plan of Correction - To be completed: 12/09/2025

1. Resident 50 did not receive the expired medication. And the expired medication was disposed of.
2. The medication carts were audited on 10/22/25 for any expired medications.
3.. DON/Designee did educate the licensed staff on 11/13/25 to ensure that they check the expiration of medications prior to giving the medication to a resident.
4. DON/Designee will audit 6 medication bottles on each cart weekly for 4 weeks then monthly for expired medications. Results will be reviewed with the QAPI committee.
5. Compliance by 12/9/25.

483.90(g)(1)(2) REQUIREMENT Resident Call System: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.
§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.
Observations: Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for one of 19 residents observed (Resident 74). Findings include: Review of the facility policy titled, "Answering the Call Light" with last revised date of September 2022, and a last reviewed date of May 21, 2025, revealed "4. Be sure that the call light is plugged in and functioning at all times." Review of Resident 74's clinical record revealed diagnosis including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing). Review of Resident 74's comprehensive care plan reveals an ADL (Activities of daily living) care plan with an intervention for the Resident's call bell to be within reach, initiated on July 9, 2018. Observation conducted on September 30, 2025, at 12:30 PM, revealed Resident 74 was lying in bed with no call bell attached to their room or accessible to the Resident. Further observations conducted at 1:06 PM and 1:36 PM revealed Resident 74 still did not have a call bell attached or accessible to them in their room. Interview conducted with Employee 4 on September 30, 2025, at 1:51 PM, revealed that they were not sure why Resident 74 did not have a call bell, and further inspecting revealed the cord broke off. Employee 4 revealed that no one put a ticket for maintenance to look at it in their system and then left the room and returned at 1:54 PM with a new cord and plugged it in to ensure it worked. During an interview with the Nursing Home Administrator on October 1, 2025, at 11:05 AM, he revealed that he would have expected Resident 74 to have had a call bell attached to his room and accessible for the Resident to use and was unable to determine how long it was not functioning. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management
 Plan of Correction - To be completed: 12/09/2025

1. Resident 74's call bell was replaced immediately.
2. The staff did an audit of all residents' rooms on 9/30/25 to ensure that they had a call bell.
3. DON/Designee did educate nursing staff to report any residents that do not have a call bell in their room on 11/13/25.
4. DON/Designee will audit 10 rooms weekly then monthly to ensure that the residents have call bells in their room. Results will be reviewed with the QAPI committee.
5. Compliance by 12/9/25

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