Pennsylvania Department of Health
BROOKLINE NURSING AND REHAB
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BROOKLINE NURSING AND REHAB
Inspection Results For:

There are 107 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.


BROOKLINE NURSING AND REHAB - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification Survey completed on February 27, 2026, it was determined that Brookline Nursing and Rehab was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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.

Plan of Correction - To be completed: 04/15/2026

1. The shelves in the cupboard were fixed, the white pipe was cleaned, wall behind refrigerator was cleaned, peeling paint on ceiling was fixed, the gap in storage rooms was fixed, the black substance was cleaned, stained on the wall were cleaned, the hole in the wall of the dishwashing area was fixed, dishwasher temperature increased.

2. The kitchen and its storage rooms were toured to ensure that there are no holes, dust, flaking shelves, gaps at the ceiling. Dishwasher was audited to ensure temperature is reaching 155.

3. Dietary Staff will be educated on proper cleaning of dust and stains and reporting defects in the shelves, walls and ceiling. As well as proper dishwasher temps.

4. Audits will be completed to ensure dishwasher temps are at 155 or above, shelves aren't flaking, proper cleaning of kitchen is completed and there are no defects in walls or ceiling 2xwkly x2wks then monthly x2months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations: Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to store indwelling urinary catheter equipment in a manner to prevent the potential for infection for one of one resident reviewed for catheter concerns (Resident 9). Findings include: Clinical record review for Resident 9 revealed that his diagnoses included urinary retention (inability of the bladder to empty completely after urination). Review of Resident 9's active physician orders revealed instructions for staff to change a Foley catheter (flexible tubing inserted through the penis into the bladder to drain urine) as needed for obstruction or dislodgement, and every thirty days for routine care of the indwelling urinary catheter. An active physician order instructed staff to place a leg bag (smaller urinary collection bag secured by straps onto the leg underneath clothing) on Resident 9 in the morning and a drainage bag (larger bag used to contain a larger amount of urine that is hung below the bladder on an item such as the side of the bed) for Resident 9 during hours of sleep. Observation of Resident 9 on February 24, 2026, at 3:26 PM revealed him in his wheelchair, fully clothed. Resident 9 stated that his Foley urine collection bag was underneath his clothing, secured to his leg. Observation of the storage of the larger urinary collection bag equipment that was not in use at the time on February 24, 2026, at 3:26 PM with Employee 1 (licensed practical nurse), revealed that the larger urine collection bag was stored in an open plastic bag that was tied to the toilet assist bar. The tubing connected to the larger urinary collection bag was not capped, which exposed the tip to potential contamination. The plastic bag containing the collection bag also contained a plastic graduate (container marked with units of measurement such as milliliters for accurate measurements of urinary output). Interview with Employee 1 at the time of the observation confirmed that Resident 9's roommate ambulates independently and utilizes the bathroom for his toileting needs. Interview with the Nursing Home Administrator and the Director of Nursing on February 25, 2026, at 2:00 PM indicated that the facility had no policy, procedure, or competency education materials that relayed to staff the appropriate storage of indwelling urinary catheter equipment to prevent potential contamination from the environment (e.g., ensure the ends of all tubing are capped, and store equipment outside the bathroom area where another resident/roommate could inadvertently contaminate the equipment) during non-use. The surveyor reviewed the above concerns regarding Resident 9's urinary catheter equipment storage during the interview. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/15/2026

1. Resident #9's catheter bag was changed out and facility will develop a policy for proper storage of Catheter bags when not in use to maintain infection control practices.

2. Current residents with catheters will be audited to ensure catheter bags not in use are stored according to the Catheter Bag storage policy.

3. Nursing Staff will be educated on catheter bag storage policy.

4. Audits will be completed to ensure residents with catheters have bags stored properly according to policy 2xwkly x2wks then monthly x2months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved.

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 clinical record review and staff interview it was determined that the facility failed to identify and monitor the medical symptoms that warranted the use of an antipsychotic medication and monitor for potentialadverse consequences of antipsychotic medication use for one of five residents reviewed for potentially unnecessary medication (Resident 9). Findings include: Clinical record review for Resident 9 revealed active physician orders (dated January 9, 2026) for admission to the skilled care facility for diagnoses of: Major depressive disorder (persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems) PTSD (Post Traumatic Stress Disorder, thoughts, avoidance behaviors, negative changes in mood and cognition, and intrusive thoughts related to a traumatic event) Suicidal attempt CKD (chronic kidney disease, loss of the kidney(s)' ability to filter waste and excess fluid from the blood) Vascular dementia (decreased blood flow to the brain resulting in loss of memory and cognition) Progress note documentation from the facility's psychological services provider dated January 13, 2026, noted that Resident 9 was in the hospital after a suicide attempt (put call bell rope around his neck) due to losing his wife. Review of active physician orders for Resident 9 revealed instructions to administer Abilify (Aripiprazole, an antipsychotic medication that alters brain chemicals) 5 mg (milligrams) at bedtime from January 28, 2026, until decreased on February 24, 2026, to Aripiprazole 2.5 mg at bedtime. Resident 9's medication regime also included active physician orders for the following antidepressants: Mirtazapine 15 mg at bedtime Sertraline HCL (Zoloft) 150 mg daily The medication reference, Drugs.com, noted that important warnings for the use of Aripiprazole include that there is increased risk for mortality in elderly patients with dementia-related psychosis and suicidal thoughts and behaviors with antidepressant drugs. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis, suicidal thoughts, and behaviors.Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber. The medication reference also noted potential physical symptoms while using Aripiprazole: convulsions (seizures), difficulty with breathing, a fast heartbeat, a high fever, high or low blood pressure, increased sweating, loss of bladder control, severe muscle stiffness, unusually pale skin, or tiredness. These could be symptoms of a serious condition called neuroleptic malignant syndrome (NMS). Resident 9's clinical record did not include evidence that the facility identified the traumatic event that precipitated his PTSD, identified potential triggers that could worsen the symptoms of the disorder, implemented ongoing tracking of his distressing target behaviors that warranted the use of the antipsychotic, or established non-medicinal behavioral interventions used to reduce or eliminate distressing target behaviors. Resident 9's clinical record also did not provide evidence that the facility monitored Resident 9's potential physical side effects from the use of the antipsychotic. Review of plans of care developed by the facility to address Resident 9's care needs and psychotropic medication use did not provide evidence of a plan of care to address his potential distressing behaviors or symptoms (e.g., hallucinations, aggression, self-harm, isolation, etc.). The surveyor reviewed the above concerns regarding inadequate monitoring and adequate indications for Resident 9's use of the antipsychotic medication during an interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 10:50 AM. The facility initiated a plan of care following the surveyor's questioning (dated February 26, 2026) to address Resident 9's potential to exhibit behaviors that are a result of past trauma, which may impact moods or behaviors, including his suicide attempt on December 23, 2025. The facility also obtained a physician's order (dated February 26, 2026) to monitor potential side effects of antipsychotic medication use (e.g., blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, hallucinations) every shift, and a physician's order (dated February 26, 2026) to monitor potential socially inappropriate or disruptive behaviors (self-injury, pacing/wandering, screaming/yelling out, suicidal ideations, physically abusive behavior: hitting, kicking, pushing, biting, etc.) every shift. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/15/2026

1. Resident #9 care plan was updated to reflect behavior monitoring as well as a doctor's order was obtained to monitor potential side effects of antipsychotic medication use.

2. Current residents with physician orders for antipsychotic medication will have their care plans audited to ensure behavior monitoring and potential side effects are being addressed.

3. Education will be provided to licensed staff on policy on Antipsychotic Medications.

4. Audits will be completed to ensure behavior monitoring and potential side effect monitoring is in place 2xwkly x 2wks then monthly x 2months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved.

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

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

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

Plan of Correction - To be completed: 04/15/2026

1. Resident #12 will be offered the pneumonia vaccine.

2. Current resident will be audited to ensure pneumonia vaccines were offered.

3. Licensed staff will be educated on pneumonia vaccine.

4. Audits will be completed to ensure residents are offered the pneumonia vaccine 2xwkly x2wks then monthly x2months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations: Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications and pain parameters for one of one resident reviewed for pain (Resident 3). Findings include: Clinical record review for Resident 3 revealed a diagnosis list that included pain in unspecified shoulder and myalgia (muscle pain). Resident 3's care plan revealed the resident has pain related to the medical history. An intervention included pain medications per physician orders. Review of the current physician orders for Resident 3 revealed the following medications for pain: Tramadol (a pain medication used to treat moderate to moderate severe pain) HCl oral tablet 50 milligrams (mg) give one tablet by mouth every four hours as needed for moderate to severe pain AND give one tablet by mouth two times a day for moderate to severe pain dated December 3, 2025, at 4:45 PM. Acetaminophen (Tylenol, a medication used to treat mild pain and reduce fever) tablet 325 mg give two tablets by mouth every four hours as needed for pain dated August 21, 2025, at 11:52 AM. The order did not specify the pain parameters for administration. Morphine Sulfate (an opioid medication used to treat moderate to severe pain) oral solution 20 mg/ml (milliliter) give 0.5 ml by mouth every one hour as needed for shortness of breath / pain dated February 24, 2026, at 11:30 AM. The order did not specify the pain parameters for administration. The above information for Resident 3 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 26, 2026, at 2:10 PM. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/15/2026

1. Resident #3's pain medication orders were clarified to indicate pain parameters for administration.

2. Currents residents pain medication orders will be audited to ensure proper parameters are in place.

3. Licensed staff will be educated on medication orders needing to contain proper parameters.

4. Audits will be completed of residents pain medication orders to ensure proper parameters are in place 2xwkly x2wks then monthly x2months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved.

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

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

Observations: Based on review of select facility policy and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory care for non-invasive ventilation consistent with professional standards of practice and develop a comprehensive and person-centered care plan for one of two residents reviewed (Resident 5) and maintain respiratory related equipment supplies in a safe and sanitary manor in two of two dining rooms observed (main dining room and restorative dining room). Findings include: Review of the facility policy titled "CPAP (continuous positive airway pressure)/BiPAP (bilevel positive airway pressure) Support," revealed preparation for use included, in part, reviewing the physician's order to determine the oxygen concentration and flow and the PEEP (positive end expiratory pressure). Further review of the policy included a section on documentation that noted, in part, that mode and settings for the device should be documented in the resident's medical record. Clinical record review for Resident 5 revealed a diagnosis list that included acute and chronic respiratory failure with hypercapnia (high levels of carbon dioxide in the blood) and obstructive sleep apnea (periods of breathing cessation during sleep). A review of current physician orders for Resident 5 revealed an order dated December 23, 2025, for NIV (non-invasive ventilation) at night and with naps; make sure the machine is upright and not lying flat to prevent air intake from being blocked. There were no settings for the device in the physician order. A review of the February 2026 Treatment Administration Record (TAR) for Resident 5 revealed that staff were documenting the application of the device. A review of Resident 5's current care plan revealed that the resident was at risk for respiratory impairment related to the medical history. An intervention included NIV (CPAP) use per physician orders. The care plan did not address additional areas (i.e. settings, cleaning the device, resident assessment, and/or monitoring for complications). An interview with Employee 6, registered nurse, on February 26, 2026, at 10:05 AM revealed that the settings for the device should be located in the physician orders. Observation of the restorative dining room on February 26, 2026, at 9:40 AM revealed a suction unit on a countertop. The following packaged items kept with the suction were expired: connection tubing (expired February 1, 2024), connective tubing (expired June 1, 2025), and connection tubing 6' (expired August 1, 2023). Observation of the main dining room on February 26, 2026, at 9:55 AM revealed a suction unit on a countertop. The following packaged items kept with the suction were expired: connective tubing (expired August 1, 2023) and a yankauer suction tip (expired March 1, 2020). The Director of Nursing was notified of the expired items on February 26, 2026, at 10:05 AM. The above information for Resident 5 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 26, 2026, at 10:45 AM. 483.25(i) Respiratory/tracheostomy Care and Suctioning Previously cited deficiency 3/21/2025 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/15/2026

1. Resident #5's care plan will be updated to reflect specifications of NIV. Suction machine tubing will be replaced.

2. Current residents with NIV machines will be audited to ensure care plans contain specifications of NIV. Suction Machine tubing will be audited for expiration date.

3. Licensed staff will be educated on care planning of NIV's and expiration dates on tubing.

4. Audits will be completed of residents with NIV's to ensure care plans reflect specification of machine. Audits of suction machines will be completed to ensure tubing is not expired 2xwkly x2wks then monthly x2months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§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 clinical record review, observation, and staff and family interview, it was determined that the facility failed to ensure assistance with activities of daily living for a dependent resident for one of one resident reviewed for activities of daily living concerns (Resident 66). Findings include: Interview with Resident 66's daughter on February 24, 2026, at 11:15 AM revealed that she believed that her father's fingernails were long, that his hair was long, and that she was upset by how he looked during her visit on February 12, 2026. Review of a plan of care developed by the facility on December 11, 2025, to address Resident 66's self-care deficits with activities of daily living (ADL) revealed that Resident 66 was dependent on staff for showering/bathing and personal hygiene needs. Observation of Resident 66 on February 25, 2026, at 8:50 AM revealed that his hair was cut short. Resident 66 stated that he was on his way to the therapy department where he was going to shave. Interview with Resident 66 on February 25, 2026, at 9:12 AM indicated that the barber cut his hair that morning. Observation of Resident 66's fingernails revealed that they were long (several millimeters beyond the tips of his fingers), uneven, and the fingernail of his right ring finger was broken. Resident 66 stated that he needed to cut his fingernails, however, he confirmed that he did not have clippers to cut his fingernails. Interview with Employee 4 (nurse aide) on February 25, 2026, at 9:11 AM indicated that staff should trim a resident's nails with each shower, however, Employee 4 confirmed that it appeared that Resident 66 did not have his fingernails trimmed with his shower. Employee 4 asked Resident 66's permission to cut his fingernails at that time and Resident 66 offered no resistance to the care. Review of Documentation Survey Report (electronic documentation completed by nurse aide staff to record completed assistance with ADL care) information for Resident 66 revealed that he had a shower on January 7, 14, 21, and 28, 2026. Staff documented that a shower was, "not applicable," on February 4, 2026, and that he only had a bed bath on February 11 and 15, 2026. Staff initialed the completion of a shower for Resident 66 on February 22, 2026 (three days before the observation of his fingernails documented above). Although the documentation indicated that Resident 66 was to shower every Sunday, staff only referenced bathing for Resident 66 on Wednesdays; and that he only received one shower between January 28, 2026, and February 22, 2026. The surveyor reviewed the above concerns regarding Resident 66's showers and nail care during an interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/15/2026

1. Resident #66 had his fingers trimmed and filed he also had his shower days corrected in POC.

2. Current residents will have finger nails audited to ensure they are trimmed on shower days and that showers are documented.

3. Education will be provided on nail care and documentation of showers.

4. Audits will be completed of resident finger nails to ensure they are trimmed on shower day and that showers are documented 2xwkly x2wks then monthly x2 months. Results of these audits will be reviewed 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 clinical record review and staff interview it was determined that the facility failed to develop and implement a comprehensive, person-centered, trauma-informed care plan to meet a resident's mental and psychosocial needs for one of 18 residents reviewed (Resident 9). Findings include: Clinical record review for Resident 9 revealed nursing documentation dated December 23, 2025, at 9:42 AM that Resident 9 was noted in his bed with a cord around his neck. Resident stated that he wanted to get staff's attention, so he decided to wrap it around his neck. Resident 9 then started with paranoid thoughts and stated that his daughter killed his wife and shot her in the chest. He stated that, "(acquaintances' surname) was also in on it to help cover it up." Resident 9 continued with paranoid thoughts on how his daughter killed his wife and, "to try and kill him so she can get his pension and get all of his money." Resident 9 left the topic of conversation easily and was noted with scattered thought processes. Resident 9 stated that he could easily wrap his hands around someone's neck and just, "snap," it and no one would ever know. Resident 9 had paranoid thoughts of his wife marrying him because of money, and that his mother cheated on his father and had a baby. Resident 9 stated that, "they threw the (ethnic description) baby into the river," because no one wanted the baby. Resident 9 was described as very distraught with expressions of how people go away to the war and women, "do what they want and cheat on people." Clinical record review for Resident 9 revealed psychiatry progress note documentation dated December 26, 2025, that Resident 9 was a military veteran and his wife died three weeks before the assessment. Diagnoses listed by the practitioner included PTSD (Post Traumatic Stress Disorder, thoughts, avoidance behaviors, negative changes in mood and cognition, and intrusive thoughts related to a traumatic event). An active physician's order dated January 9, 2026, admitted Resident 9 to skilled care for diagnoses that included PTSD. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 16, 2026, revealed that staff coded the MDS item for PTSD incorrectly as that Resident 9 did not have PTSD. Resident 9's clinical record did not include evidence that the facility identified the traumatic event that precipitated his PTSD, identified potential triggers that could worsen the symptoms of the disorder, implemented ongoing tracking of his distressing target behaviors, or established non-medicinal behavioral interventions used to reduce or eliminate distressing target behaviors. Review of plans of care developed by the facility to address Resident 9's care needs did not provide evidence of a plan of care to address his potential distressing behaviors or symptoms (e.g., hallucinations, aggression, self-harm, isolation, etc.). The surveyor reviewed the concern that the facility had not developed a plan of care for Resident 9's PTSD diagnosis during an interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 10:50 AM. The facility initiated a plan of care following the surveyor's questioning (dated February 26, 2026) to address Resident 9's potential to exhibit behaviors that are a result of past trauma, which may impact moods or behaviors, including his suicide attempt on December 23, 2025. The facility also obtained a physician's order (dated February 26, 2026) to monitor potential side effects of antipsychotic medication use (e.g., blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, hallucinations) every shift; and a physician's order (dated February 26, 2026) to monitor potential socially inappropriate or disruptive behaviors (self-injury, pacing/wandering, screaming/yelling out, suicidal ideations, physically abusive behavior: hitting, kicking, pushing, biting, etc.) every shift. Interview with the Director of Nursing on February 27, 2026, at 8:45 AM confirmed that staff failed to initiate a plan of care upon Resident 9's readmission to the facility following his in-patient psychiatric stay to incorporate his PTSD diagnosis, grief secondary to the recent death of his wife, and his suicide attempt. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/15/2026

1. Resident #9's care plan was updated to reflect current PTSD diagnosis and potential triggers.

2. Current residents with a diagnosis of PTSD will have their care plans audited to ensure care plans are in place and accurate with potential triggers.

3. Education will be provided to licensed staff on PTSD Care Planning.

4. Audits will be completed of care plans of residents with a PTSD diagnosis to ensure accurate care planning of potential triggers 2xwkly x2wks then monthly x2 months. Results of these audits will be reviewed QAPI until substantial compliance is achieved.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

§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 interview it was determined that the facility failed to ensure an assessment accurately reflected the resident's status for one of 18 residents reviewed (Resident 9). Findings include: Clinical record review for Resident 9 revealed psychiatry progress note documentation dated December 26, 2025, that Resident 9 was a military veteran and his wife died three weeks before the assessment. Diagnoses listed by the practitioner included PTSD (Post Traumatic Stress Disorder, thoughts, avoidance behaviors, negative changes in mood and cognition, and intrusive thoughts related to a traumatic event). An active physician's order dated January 9, 2026, admitted Resident 9 to skilled care for diagnoses that included PTSD. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 16, 2026, revealed that staff coded the MDS item for PTSD incorrectly as that Resident 9 did not have PTSD. Interview with the Director of Nursing on February 27, 2026, at 8:45 AM confirmed that staff failed to code Resident 9's admission MDS to include his PTSD diagnosis. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Plan of Correction - To be completed: 04/15/2026

1. Resident #9's MDS was updated to reflect PTSD diagnosis.

2. Current residents MDS' will be audited to ensure resident's with PTSD diagnosis are coded properly.

3. Education will be provided to staff on coding MDS' properly

4. Audits will be completed of MDS' to ensure proper coding of PTSD 2xwkly x2wks then monthly x2 months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved

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

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

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

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

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

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

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

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

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

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

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

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

Observations: Based on clinical record review, review of facility documentation, and staff interview it was determined that the facility failed to provide written notice of transfer to the resident representative for three of six residents reviewed (Residents 5, 9, and 12) and written notice of the facility bed-hold policy for two of six residents reviewed for hospitalization (Residents 9 and 12). Findings include: Clinical record review for Resident 5 revealed the resident had an emergency contact listed. Nursing documentation for Resident 5 dated December 16, 2025, at 9:36 AM revealed the resident had a change in condition and the licensed practical nurse (LPN) evaluated the resident. Nursing documentation for Resident 5 dated December 16, 2025, at 10:19 AM revealed that a message was left for the responsible party and son. Nursing documentation for Resident 5 dated December 16, 2025, at 10:45 AM revealed that EMS (emergency medical services) arrived and care was transferred to EMS. Nursing documentation for Resident 5 dated December 16, 2025, at 5:00 PM revealed that the resident was being admitted to the hospital for bilateral kidney stones. Facility documentation titled, "Notice of Transfer or Discharge," dated December 16, 2025, noted the resident was transferred to the hospital due to the medical condition. The resident signed and dated the document on December 16, 2025. There was no evidence of any documentation that the resident representative was notified in writing as soon as it was practicable of Resident 5's transfer to the hospital. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on February 27, 2026, at 1:08 PM. Clinical record review for Resident 9 revealed profile information that listed a daughter and a son as potential resident representatives. Nursing documentation dated December 23, 2025, at 9:42 AM revealed that Resident 9 left the facility via emergency medical services transport due to a mental health crisis. Review of a Bed-Hold Notification form dated December 23, 2025, indicated that Resident 9 signed the notice on December 23, 2025. The section of the notice for the resident's responsible party (representative) signature was blank. Review of a Notice of Transfer or Discharge dated December 23, 2025, indicated that Resident 9 signed the notice on December 23, 2025. There was no documentation on the notice to indicate that the facility ensured that either of Resident 9's designated resident representatives received a written copy of the notice. Interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 2:00 PM confirmed that the facility had no evidence that Resident 9's resident representative received written notice of either the transfer or the bed-hold notices. Clinical record review for Resident 12 revealed profile information that listed an ex-wife as his first emergency contact and his daughter as his second emergency contact (potential resident representatives). Nursing documentation dated January 27, 2026, at 4:11 AM revealed that Resident 12 transferred out of the facility to the hospital for a surgical procedure. Nursing documentation dated February 6, 2026, at 5:12 PM indicated that Resident 12 returned to the facility following the surgical procedure. Review of a Bed-Hold Notification form dated January 27, 2026, indicated that Resident 12 signed the notice on January 27, 2026. The section of the notice for the resident's responsible party (representative) signature was blank. Review of a Notice of Transfer or Discharge dated January 27, 2026, indicated that Resident 12 signed the notice on January 27, 2026. There was no documentation on the notice to indicate that the facility ensured that either of Resident 12's designated resident representatives received a written copy of the notice. Interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 2:00 PM confirmed that the facility did not take measures to ensure Resident 12's representative received a written copy of either the Bed-Hold Notification or Notice of Transfer in response to his January 27, 2026, transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 04/15/2026

1. Resident representatives for residents #5, #9 and #12 will be given written notice of transfer and Residents #9 and #12 will be given written notice of the bed hold policy as well.

2. Current resident records will be audited to ensure resident representatives were given written notice of transfer and bed hold policy.

3. Education will be provided to staff on the bed hold and transfer policy.

4. Audits will be completed to ensure resident representatives were given written notice of transfer and bed hold policy 2xwkly x 2wks then monthly x 2months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved.

§ 201.22(b) LICENSURE Prevention, control and surveillance of tuber:

(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations: Based on a review of select personnel records and staff interview it was determined that the facility failed to adhere to recommendations of the Centers for Disease Control and Prevention (CDC) related to screening newly hired employees for TB for two of five newly hired employees reviewed (Employees 2 and 3). Findings include: The current CDC guidance, Baseline Tuberculosis (TB) Screening and Testing for Health Care Personnel, stipulates that all United States health care personnel should be screened for tuberculosis upon hire. This process includes a risk assessment, symptom evaluation, and TB blood test or TB skin test. If a person has had a documented negative TB skin test result within the previous 12 months, a single TB skin test can be administered. Review of Employee 2's (registered nurse) personnel record revealed that the facility hired the employee on December 8, 2025. The facility provided documentation that Employee 2 had a negative (zero millimeter) reading of a TB skin test on January 24, 2025, and February 3, 2025 (within 12 months prior to being hired). There was no evidence that the facility completed a one-step TB skin test, or TB blood test, upon hire to the facility or prior to patient contact or shared airspace at the facility. Review of Employee 3's (licensed practical nurse) personnel record revealed that the facility hired the employee on February 11, 2026. The facility provided documentation that Employee 3 had a negative TB blood test (Quantiferon Gold test, blood test used to diagnose latent or active TB disease) on September 18, 2025 (almost five months before the employee's hire date). There was no evidence that the facility completed a one-step TB skin test, or TB blood test, upon hire to the facility or prior to patient contact or shared airspace at the facility. Interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 10:50 AM confirmed the above findings.

Plan of Correction - To be completed: 04/15/2026

1. Employees #2 and #3 will be given one step PPDs.

2. Employee hired within the last year will be audited to ensure one step PPD's are completed prior to hire date.

3. HR Director will be educated on PPD protocol.

4. Employee files will be audited to ensure PPD's are given as required 2xwkly x2wks then monthly x2months. Results of these audits will be reviewed at QAPI until substantial compliance is achieved.

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