Pennsylvania Department of Health
 BRYN MAWR VILLAGE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BRYN MAWR VILLAGE
Inspection Results For:

There are  119 surveys for this facility. Please select a date to view the survey results.

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BRYN MAWR VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a Medicare Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on February 13, 2026, it was determined that Bryn Mawr Village 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 as they relate to the Health portion of the survey process.


 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on review of facility policy, facility documentation, clinical records, and staff interview it was determined the facility failed to ensure the resident environment remained free of accident hazards for one of 12 residents reviewed (Resident R47). This failure resulted in actual harm to Resident R47 who spilled a hot liquid on his/her thigh resulting in a burn. This deficiency was identified as past non-compliance.

Findings Include:

Review of facility policy "Assisting the Resident with In-Room Meals" revised December 2013 revealed staff should check that hot foods are hot (but not scalding temperature).

Review of Resident R47's comprehensive Minimum Data Set (MDS federally mandated resident assessment and care screening) dated September 20, 2025, revealed the resident was admitted to the facility on September 18, 2025, and had diagnoses of malnutrition (lack of sufficient nutrients in the body), muscle wasting, and muscle weakness.

Continued review of Resident R47's comprehensive MDS dated September 20, 2025, revealed the resident was cognitively intact and required setup or clean-up assistance with eating (helper sets up or cleans up).

Review of Resident R47's clinical record revealed a nursing note dated October 3, 2025, indicating the nurse aide responded to Resident R47's room after hearing resident call out for help. Upon entry, it was observed that a bowl of chicken broth from the dinner tray had spilled onto Resident R47's lap.
Review of facility documentation titled "Burn" incident report dated October 3, 2025, revealed the resident's soiled clothing was removed and the area was cleansed with cold water and cold compress was applied. A nursing assessment revealed a raised area to the left inner thigh, measuring approximately 30 centimeters (cm) (length) by 8 cm (width) in size. Resident R47 reported tenderness to touch.
Review of facility documentation revealed a statement obtained on October 3, 2025, from Resident R47, which indicated that while attempting to hold his/her cup of soup he/she dropped it because it was too hot. Resident R47 reported that he/she yelled out and the nurse responded/assisted.

Review of facility documentation revealed a written statement dated October 3, 2025, by nurse aide, Employee E10, that indicated the employee gave Resident R47 a bowl of soup and instructed the resident that the second bowl of soup on the meal tray was too hot and to wait to eat it. Nurse aide, Employee E10, reportedly left the room to assist other residents when he/she heard the resident cry out. Nurse aide, Employee E10, ran back to the room and Resident R47 told the nurse aide he/she picked up the soup that was identified as being too hot and it subsequently spilled onto Resident R47's thigh.

Interview on February 11, 2026, at 12:37 p.m. with nurse aide, Employee E10, revealed two bowls of chicken broth were requested to be sent with Resident R47's dinner tray on October 3, 2025. Resident R47 was reportedly positioned upright in bed with the overbed table set-up over Resident R47's lap.
Continued interview on February 11, 2026, at 12:37 p.m. with Nurse aide, Employee E10, revealed he/she delivered Resident 47 his/her dinner tray [which contained two bowls of chicken broth] and removed the lid of one bowl of soup, pushing it closer to the resident.

Interview conducted on February 11, 2026, at 12:37 p.m. with Nurse aide, Employee E10, revealed he/she only partially lifted the lid off the second bowl of soup and instructed Resident R47 to wait to eat it, as the soup bowel was identified to be hotter of the two bowls. Nurse aide, Employee E10, described the second bowl of soup to be hotter due to the condensation/steam observed beneath the lid. Just after nurse aide, Employee E10, left the room he/she heard Resident R47 cry out and promptly turned around to assist the resident.

Review of Resident R47's clinical record revealed a nursing note dated October 4, 2025, indicating the area was identified as a superficial burn and noted to be blistered and red.
Review of Resident R47's clinical record including a nursing note dated October 6, 2025, revealed the area was observed to be "very reddened and blistering. Warm to touch, and painful."

Review of Resident R47's wound care consult dated October 8, 2025, revealed the resident was seen for an initial consultation for wound care services for burn to the left thigh. The wound type was described as a burn with partial-thickness depth exposure. The wound size was described as a clustered wound and measured 22 cm (length) x 40.4 cm (width) x 0.1 cm (depth). Resident R47 was noted wild mild transient pain during the wound assessment.

On October 3, 2025, following the incident, the facility immediately implemented the following corrective action:

Resident R47 immediately assisted the resident by removing soiled clothing and cooling the affected area. A nursing assessment was completed and the physician was notified. Treatment orders were implemented, including prescribed topical treatment and dressings. The resident's family was notified, and the resident was monitored for changes in condition until healing was observed.All residents were reviewed for potential risk related to hot liquids. A hot liquid safety screening was completed for residents receiving hot beverages or hot foods. Residents identified with potential risk now have appropriate supervision, assistance, or safety interventions in place per individualized care plans.The facility updated the residents care plan to include supervision and safety precautions when hot liquids are served. Staff must remove or loosen lids prior to tray delivery to ensure safe placement of hot items. Education was provided to nursing, dietary, and nurse aide staff regarding hot liquid safety, tray delivery procedures, and monitoring requirements for residents consuming hot food or beverages.The Director of Nursing or designee will audit tray delivery and hot liquid safety practices weekly for four weeks, the monthly for three months to ensure compliance. Care plans and hot liquid risk screenings will be reviewed for accuracy. Findings will be reported through Quality Assurance Program (QAPI) and additional education provided if concerns are identified.Review of facility documentation revealed the facility implemented a revised "Hot Liquid Safety Policy and Procedure" effective October 6, 2025, which included safe temperature standards, identification of high-risk residents, and service and assistance requirements.

Review of facility documentation confirmed a full house audit was conducted to ensure all residents had a hot liquid safety assessment completed. Resident care plans were subsequently updated to reflect hot liquid safety interventions and supervision needs.

Review of staff education and staff interviews revealed dietary staff were educated on safe food handling, monitoring temperatures before meal service, and review and demonstration on thermometer calibration.

Continued review of staff education and staff interviews revealed education was provided to on removing the lids of all hot containers before fully serving. If residents request the food or drink to be heated the items must go to dietary to ensure proper temperature.

Review of facility documentation confirmed weekly, and monthly tray delivery and hot liquid safety audits were conducted to ensure compliance. Audits included observance of a hot liquid, set-up assistance of item, placement, supervision, was the care plan followed and were any issues identified.

This deficiency was identified as past non-compliance.

28 Pa. Code 211.10 (d) Resident care policies.

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






 Plan of Correction - To be completed: 03/02/2026

Past noncompliance: no plan of correction required.
483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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.
§483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

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

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

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

Based on clinical record review and staff interviews, it was determined that the facility failed to discuss the risks/benefits in advance for newly admitted resident for two of five resident records reviewed (Residents R1, and R23).

Findings include:

A review of the clinical record for Resident R1 revealed an admission date of July 21, 2025, with diagnosis of acute respiratory failure with hypoxia, parkinsonism, shortness of breath, heart failure, type 2 diabetes mellitus, depression, hypoxemia and acute kidney failure.

Further review of the clinical record indicated physician orders for Resident R1 that included the following medications: insulin glargine subcutaneous solution (100 units/mL), with instructions to inject 20 units in the evening for diabetes; pramipexole dihydrochloride 0.5 mg orally at bedtime for Parkinson's disease; Eliquis 5 mg orally twice daily for atrial flutter; nifedipine extended-release 30 mg orally once daily for hypertension; and metoprolol succinate extended-release 25 mg orally once daily for congestive heart failure (CHF).

Continued review of Resident 1's clinical record revealed no documentation of the facility providing education to the Resident or Representative of the risks and benefits associated with the use of the medication, including side effects and other adverse reactions.

An interview conducted on February 12, 2026, at 11:08 a.m. with the Administrator, Employee E1, Director of Nursing (DON), Employee E2, and Regional Nurse, Employee E3, confirmed that a review of the risks and benefits of Resident R1's medication and treatment was not conducted in advance with the resident or his/her representative at the time of admission on July 21, 2025. The review was subsequently conducted on September 18, 2025.

A review of the clinical record for Resident R23 revealed an admission date of January 07, 2026, with diagnosis cognitive communication deficit, major depressive disorder and anemia.

Further review of the clinical record indicated physician orders for Resident R23 that included the following medications: Lansoprazole 30 (milligrams) mg,Acetaminophen Tablet 325 mg, Fleet Enema 7-19 GM/118ML (Sodium Phosphates) Dulcolax Suppository (Bisacodyl), Mirtazapine Oral Tablet 7.5 MG (Mirtazapine).


Continued review of Resident 23's clinical record revealed no documentation of the facility providing education to the Resident or Representative of the risks and benefits associated with the use of the medication, including side effects and other adverse reactions.

An interview conducted on February 12, 2026, at 12:45pm with the Administrator, Employee E1, Director of Nursing (DON), Employee E2, and Regional Nurse, Employee E3, confirmed that a review of the risks and benefits of Resident R23's medication and treatment was not conducted in advance with the resident or his/her representative at the time of admission on January 07, 2026. The review was subsequently conducted on September 18, 2025.

28 Pa. Code 201.29(a) Resident Rights.

28 Pa. Code 201.29(a) Resident Rights.






 Plan of Correction - To be completed: 04/07/2026

Step 1-Facility cannot Retroactively correct.Resident R1 is currently not in the facility at this time. R23 A comprehensive risk/benefit education for Residents R1 and R23, including discussion of medication purpose, potential side effects, risks, benefits, and alternatives. Education was provided to the residents and/or responsible representatives, and acknowledgement was obtained and placed in the medical record.


Step 2 – An Admission Risk/Benefit Review Process has been implemented to ensure all newly admitted residents receive documented education prior to or at the time of initiation of medications and treatments. A standardized "Medication/Treatment Risk-Benefit Discussion" form has been added to the admission packet and will be completed by the admitting nurse prior to completion of the admission process. The DON or designee will verify completion within 24 hours of admission using an admission checklist to ensure compliance for residents.


Step 3 – NHA/Designee educated Admissions Director on the new admission form added to the admission packet. Licensed nurses and interdisciplinary team members involved in the admission process were educated on the new process including the requirement to provide and document risk/benefit discussions. Education included when the discussion must occur, required elements of documentation, and use of the new standardized form and checklist.


Step 4 – The DON or designee will audit 100% of new admissions weekly for four (4) weeks, then monthly for two (2) months, to ensure risk/benefit discussions are completed and documented timely. Audit results will be reviewed through the facility's QAPI process, and corrective action will be implemented immediately if non-compliance is identified. Monitoring will continue until sustained compliance is achieved.
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 review of facility policy, review of clinical record, and resident interview, it was determined that the facility failed to implement interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of 12 residents reviewed (Resident R19).

Findings Include:

Review of facility policy "Weight Assessment and Intervention" revised February 2021 revealed resident weight will be measured on admission and weekly for four weeks thereafter. Any weight change of 5% or more since the last weight assessment will be addressed by the Registered Dietitian.

Review of Resident R19's comprehensive Minimum Data Set (MDS federally mandated resident assessment and care screening) dated May 31, 2025, revealed the resident was admitted to the facility on May 25, 2025, and had diagnoses of cancer, diabetes mellitus, muscle wasting, and dysphagia (difficulty swallowing).

Continued review of Resident R19's comprehensive MDS dated May 31, 2025, revealed the resident had signs and symptoms of swallowing disorder such as holding food in mouth/cheeks and complaints of difficulty or pain with swallowing.

Review of Resident R19's clinical record revealed a nutrition assessment dated May 28, 2025, that Resident R19 was assessed at a weight of 149 pounds [obtained May 25, 2025] and was deemed at nutrition risk related to poor intake.

Further review of Resident R19's clinical record revealed a nutrition note dated May 28, 2025, that Resident R19 requested more Ensure (oral nutritional supplement). Further review of the nutrition note revealed the Registered Dietitian recommended Ensure nutritional supplement three times per day to aid in weight maintenance.

Review of Resident R19's clinical record revealed no documented evidence the nutritional supplement was provided per the dietitian recommendations.

Review of Resident R19's weight summary revealed a documented weight of 120.5 pounds on June 10, 2025, reflecting a 19% weight loss since May 25, 2025.

Review of Resident R19's clinical record revealed a nutrition note dated June 13, 2025, that Resident R19 sustained a 19% weight loss, was reassessed with a weight of 120.5 pounds and deemed underweight for range of age. Reassessment included use of Ensure nutrition supplement three times per day. Resident R19 was identified as at risk for malnutrition related to poor intakes and low body mass index (BMI).

Review of Resident R19's clinical record revealed no documented evidence the nutritional supplement Ensure three times per day was provided per recommendations.

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






 Plan of Correction - To be completed: 04/07/2026

Step 1 – Facility can not retroactively correct. Resident R19's current nutritional status was reviewed by the interdisciplinary team, including the Registered Dietitian. Resident is stable and being followed by the dietician.

Step 2 – The facility implemented a weekly weight meeting process to ensure that all dietitian recommendations (including supplements such as Ensure) are transcribed into physician orders, reflected on the MAR/TAR as applicable, and implemented timely. A weekly weight review meeting involving Nursing, Dietary, and the Registered Dietitian has been initiated to identify residents with significant weight changes (5% or greater) and ensure interventions are in place and documented.

Step 3 –NHA/Designee will educate IDT and dietician on the facility's "Weight Assessment and Intervention" policy, including required weekly weights after admission, timely dietitian referral for significant weight change, transcription of recommendations into active orders, and accurate documentation of supplement administration. Education emphasized interdisciplinary communication and accountability to ensure recommendations are implemented without delay.


Step 4 – The DON or designee, in collaboration with the Registered Dietitian, will audit all residents with significant weight loss weekly for four (4) weeks to ensure dietitian recommendations are implemented and documented. Thereafter, audits will occur monthly for two (2) additional months. Results will be reviewed through QAPI, and corrective action will be taken immediately if noncompliance is identified. Monitoring will continue until sustained compliance is achieved.
483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan: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.
§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on review of facility policy and review of clinical records, it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan for two of three newly admitted residents reviewed (Resident R38, and R45).

Findings:

A review of the facility policy titled "Care Plans-Baseline," last revised in March 2022, revealed that, "a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forth-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care pf the resident that meet professional standards of quality care and must include a minimum healthcare information necessary to properly care for the resident including, but not limited to the following; initial goals based on admission orders and discussion with there resident/representative, physician orders, dietary orders, therapy services, social services, and PASSSAR recommendation, if applicable". Under bulletin 4 it further states, " The resident and/or representative are provided a written summary of the baseline care plan in a language that the resident/representative can understand.

On February 11, 2026, at 1:55 p.m., the Director of Nursing (DON), Employee E2, confirmed that residents or their representatives do not automatically receive a copy of the baseline care plan unless they specifically request one.

On February 11, 2026, at 1:59 p.m., an interview was conducted with the Social Services Director, Employee E4, who also confirmed that a copy of the baseline care plan is provided only upon request.

On February 11, 2026, at 2:11 p.m., an interview was conducted with Resident R38, who is alert and oriented. Resident R38 reported that she was not offered a copy of her baseline care plan upon admission to the facility on January 2, 2026.

Review of Resident R45's Minimum Data Set (federally mandated resident assessment and care screening) dated November 15, 2025, revealed the resident was admitted to the facility on November 12, 2025, and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs), respiratory failure, and muscle weakness.

Review of Resident R45's clinical record revealed a nursing note dated November 13, 2025, that revealed resident was a new admission with the following diagnosis of "pain management".

Review of Resident R45's pain evaluation dated November 14, 2025, revealed the resident received both scheduled and as needed pain medication, and the resident reported frequent pain over the last five days. Per the pain evaluation dated November 14, 2025, Resident R45 was identified as at risk for pain.

Review of Resident R45's clinical record revealed no documented evidence a baseline care plan was developed and implemented with individualized goals and interventions for pain management.

Review of Resident R45's Minimum Data Set (federally mandated resident assessment and care screening) dated November 15, 2025, revealed the resident was admitted to the facility on November 12, 2025, and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs), respiratory failure, and muscle weakness.

Review of Resident R45's clinical record revealed a nursing note dated November 13, 2025, that revealed resident was a new admission with the following diagnosis of "pain management".

Review of Resident R45's pain evaluation dated November 14, 2025, revealed the resident received both scheduled and as needed pain medication, and the resident reported frequent pain over the last five days. Per the pain evaluation dated November 14, 2025, Resident R45 was identified as at risk for pain.

Review of Resident R45's clinical record revealed no documented evidence a baseline care plan was developed and implemented with individualized goals and interventions for pain management.

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






 Plan of Correction - To be completed: 04/07/2026

Step 1 – The facility immediately developed and/or reviewed the baseline care plans for Residents R38 and R45 to ensure they met regulatory requirements. For Resident R45, an individualized baseline care plan addressing pain management, including specific goals and interventions, was implemented. Written summaries of the baseline care plans were provided to the residents and/or their representatives, and acknowledgement of receipt was documented in the medical record.


Step 2 – The Admission Process was revised to require that a baseline care plan be developed within 48 hours of admission and that a Copy of the evaluation/Assessment completed be provided to the resident and/or representative, without requiring a request. A Baseline Care Plan add on question to the nurses before signing off on completion was added into PCC to print and offer the baseline to the resident/RP. The DON or designee will verify completion and documentation within 48 hours of each new admission.


Step 3 – NHA/Designee will educate RN supervisors/unit managers, Social Services, and the interdisciplinary team on the facility's "Care Plans – Baseline" policy and regulatory requirements, including timelines, required content, and the obligation to provide a written summary to residents/representatives in understandable language. Education emphasized individualized care planning based on identified risks (e.g. pain management) and proper documentation standards.

Step 4 –The DON or designee will audit 100% of new admissions weekly for four (4) weeks to ensure baseline care plans are developed within 48 hours and written summaries are provided and documented. Following this period, audits will occur monthly for two (2) additional months. Results will be reviewed through QAPI, and immediate corrective action will be taken if deficiencies are identified. Monitoring will continue until sustained compliance is achieved.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on observations, review facility policies and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment in resident care areas for one of two nursing units observed (CE Unit).

Findings include:

On February 9, 2026, at 10:45 a.m., an observation conducted in Room CE40 revealed that Resident R35 was seated in (her/his) wheelchair. The resident's bed was without sheets, a blanket, or a pillowcase. Two clear trash bags were observed next to Resident R35. One bag contained soiled linens, and the other contained a soiled brief and used gloves. The resident's toilet was observed to be soiled with brown feces on the interior surfaces.

Additionally, a wound VAC machine was also observed on the floor next to the window in Resident R35's room. According to the resident's family member, the wound VAC machine was no longer in use and had been left on the floor for several days. The family member stated that Resident R35 was no longer receiving treatment with the device.

On February 9, 2026, at 10:58 a.m., the above observations were confirmed by Registered Nurse (RN), Employee E7. Employee E7 removed the two trash bags from the room and placed them in the designated soiled utility area. Further observation revealed that the toilet was clogged with feces. Employee E7 attempted to clear the obstruction; however, the water level in the toilet began to rise and did not drain appropriately.

On February 10, 2026, at 9:39 a.m., an observation was conducted in Room CE45. Resident R6 was observed lying in bed receiving enteral feeding. The wall behind the bed, bedside dresser, bed rails, floor, and enteral feeding pole were observed to have dried brown and yellow feeding spills and drips present.
This observation was confirmed the same day at 9:45 a.m. by the Regional Nurse, Employee E3.

28 Pa. Code 201.14 (a) Responsibility of licensee.







 Plan of Correction - To be completed: 04/07/2026

Step 1 – Room CE40 and Room CE45 were immediately cleaned and sanitized. Soiled linens and trash were removed, and environmental services thoroughly cleaned and disinfected all surfaces. The clogged toilet in Room CE40 was addressed immediately, and maintenance was notified to ensure proper function. The unused wound VAC machine was removed from the room and returned to the appropriate storage area. Resident beds were properly made with clean linens. The enteral feeding spills in Room CE45 were cleaned from the walls, bed rails, floor, dresser, and feeding pole. Both residents' rooms were inspected by the Director of Nursing (DON) and Environmental Services Supervisor to ensure compliance.


Step 2 – The facility implemented a daily Environmental Rounding Tool for nursing and housekeeping to ensure resident rooms remain clean, free of clutter, and maintain a homelike environment. Clear expectations were reinforced regarding immediate removal of soiled linens, trash, unused equipment, and prompt reporting of plumbing or maintenance concerns. Nursing staff are now responsible for ensuring medical equipment no longer in use is removed promptly. Unit managers/Supervisors will conduct daily visual rounds on their assigned units to verify compliance.


Step 3 – NHA/Designee will educate IDT along with the RN supervisors/unit managers, housekeeping, and maintenance staff were re-educated on infection control standards, environmental cleanliness expectations, and maintaining a homelike environment in accordance with regulatory requirements. Education included proper disposal of soiled items, timely cleaning of spills (including enteral feeding), removal of unused medical equipment, and prompt reporting of environmental concerns.

Step 4 – The NHA/Designee/Environmental Services Supervisor, will conduct environmental audits on the CE Unit 5 days a week for two (2) weeks, then weekly for four (4) additional weeks. Audits will include room cleanliness, proper linen management, removal of unused equipment, and functioning plumbing. Findings will be reviewed in QAPI, and corrective action will be implemented immediately if concerns are identified. Monitoring will continue until sustained compliance is achieved.
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, review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure the call light was within easy reach for one of 12 residents reviewed (Resident R49).


Findings Include:

Review of facility policy "Answering the Call Light" revised October 2010 revealed when the resident is in bed or confined to a chair, the call light should be within easy reach of the resident.

Review of Resident R49's comprehensive Minimum Data Set (MDS federally mandated resident assessment and care screening) dated February 6, 2026, revealed the resident was newly admitted to the facility on February 1, 2026, and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypoxemia (low blood oxygen levels), need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility.

Review of Resident R49's comprehensive care plan dated February 2, 2026, revealed the resident had an activity of daily living self-care deficit related to physical limitations. Interventions dated February 2, 2026, revealed Resident R49 required extensive assistance from staff with toileting, transfers, bed mobility, and dressing.

Observations on February 9, 2026, at 10:15 a.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Resident R49 complained of discomfort and requested repositioning. Further observations revealed Resident R49's call light was on the floor and out of reach.

Interview/observation on February 9, 2026, at 10:20 a.m. with Licensed Nurse, Employee E6, confirmed Resident R49's call light was not within reach.

Observations on February 11, 2026, at approximately 1:24 p.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Resident R49 complained about being thirsty and requested water. Further observations revealed Resident R49's call light was out of reach.
Interview on February 11, 2026, at approximately 1:25 p.m. with nurse aide, Employee E12, confirmed Resident R49's call light was not within reach.

Observations on February 12, 2026, at approximately12:22 p.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Resident R49 complained about being uncomfortable in the wheelchair. Further observations revealed Resident R49's call light was out of reach.

Interview on February 12, 2026, at approximately 12:23 p.m. with Licensed Nurse, Employee E6, confirmed Resident R49's call light was not within reach.

Observations on February 13, 2026, at 10:58 a.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Further observations revealed Resident R49's call light was out of reach.
Interview on February 13, 2026, at approximately 11:00 a.m. with licensed nurse, Employee E8, confirmed Resident R48's call light was out of reach.

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






 Plan of Correction - To be completed: 04/07/2026

Step 1 – Upon identification, Resident R49's call light was immediately placed within easy reach. S

Step 2 –The facility implemented a Call Light Placement Standard requiring staff to check and verbally confirm call light accessibility before exiting a resident's room. A "5-Point Exit Check" (call light, water, personal items, positioning, safety) has been implemented for nursing assistants and licensed nurses. Unit managers will conduct daily environmental rounds to verify call lights are within reach for dependent residents, particularly those requiring extensive assistance.


Step 3 –Nursing staff, including licensed nurses and nurse aides, were re-educated on the "Answering the Call Light" policy and the importance of maintaining call light accessibility for resident safety and dignity. Education emphasized fall prevention, timely response to needs, and regulatory expectations.


Step 4 – The DON or designee will conduct daily random call light audits for two (2) weeks on each shift to ensure accessibility for residents requiring assistance. Thereafter, audits will be conducted weekly for four (4) additional weeks. Results will be reviewed through QAPI, and immediate corrective action will be taken if non-compliance is identified. Monitoring will continue until sustained compliance is achieved.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to implement infection control standards related to the use of personal protective equipment and wound care for one of 12 residents reviewed. (Resident R5)

Findings Include:

Review of memo "Enhanced Barrier Precautions in Nursing Homes" from the Centers for Medicare &; Medicaid Services dated March 20, 2024, revealed enhanced barrier precautions (EBP- involve gown and glove use during high-contact resident care activities ) recommendations include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status.

Review of facility policy "Wound Care" revealed staff should use disposable cloth to establish a clean field on resident's overbed table. The licensed staff should place all items to be used during procedure on the clean field and arrange the supplies so they can be easily reached.

Further review of facility policy "Wound Care" revealed staff should wear sterile gloves when physically touching the wound or holding a moist surface over the wound.

Review of Resident R5's comprehensive Minimum Data Set (federally mandated resident assessment and care screening) dated January 2, 2026, revealed the resident was admitted to the facility on December 26, 2025, and had at least one or more unhealed pressure ulcers.

Review of Resident R5's wound care consult dated February 2, 2026, revealed the resident had an abrasion to his/her left chest with wound care instructions to cleanse with normal saline, apply calcium alginate, and cover with a clean dry dressing with a frequency of daily and as needed.

Wound care observation was conducted on February 9, 2026, at 11:00 a.m. with Licensed Nurse, Employee E8, for Resident R5's left chest wound. Licensed Nurse, Employee E8, wore gloves and a mask for personal protective equipment (PPE) during wound care.

Observations during wound care for Resident R5 on February 9, 2026, at 11:00 a.m. revealed License Nurse, Employee E8, used sterile gloves to take scissors out of his/her scrubs pocket, use them to cut open the calcium alginate, and then further apply the clean bandage to the open wound.

Interview on February 9, 2026, at 12:55 p.m. with Licensed Nurse, Employee E8, confirmed he/she should have applied a new/clean pair of gloves after using the scissors and before applying the clean bandage to the open wound. Further interview with Licensed Nurse, Employee E8, confirmed there was no signage posted on the resident's room door to indicate Resident R5 was on enhanced barrier precautions, and that the employee failed to wear a gown, as required, during wound care.

28 Pa. Code 201.14(a) Responsibility of licensee.

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





 Plan of Correction - To be completed: 04/07/2026

Step 1 – Upon identification, wound care for Resident R5 was immediately reviewed and corrected. Enhanced Barrier Precautions signage was posted on the resident's door, and staff were instructed to don gown and gloves during high-contact care activities, including wound care. Wound care supplies were reorganized to ensure establishment of a clean field per policy. The licensed nurse involved was counseled on proper glove changes and sterile technique. Resident R5's wound was assessed for any signs of infection, and no adverse outcome was identified. The physician was notified as appropriate.


Step 2 – The facility implemented an Enhanced Barrier Precaution Verification Process to ensure residents meeting criteria (e.g., chronic wounds) are identified, flagged in the electronic medical record, and have appropriate door signage posted. A Wound Care Competency Checklist has been reintroduced requiring nurses to verify clean field setup, proper glove changes, use of gown and gloves per EBP guidelines, and adherence to sterile technique. Unit managers will conduct random wound care observations to ensure compliance.


Step 3 –Licensed nursing staff were re-educated by DON/Designee on Enhanced Barrier Precaution guidance and the facility's Wound Care Policy. Education included proper PPE use (gown and gloves), establishment of a clean field, sterile glove technique, changing gloves after contamination (e.g., after handling scissors from a pocket), and infection prevention principles.

Step 4 – The DON or designee will conduct weekly wound care observation audits for four (4) weeks to ensure compliance with EBP requirements, PPE use, sterile technique, and clean field setup. Thereafter, audits will be conducted monthly for two (2) additional months. Findings will be reviewed through QAPI, and corrective action will be implemented immediately if non-compliance is identified. Monitoring will continue until sustained compliance is achieved.


483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify the State Survey Agency of an allegation of verbal abuse within 24 hours for one of 12 residents reviewed. (Resident R 41)

Findings include:


Review of Resident 41's Minimum Data Set (MDS- assessment of residents care needs) revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively intact and able to accurately report concerns. Continue review of Resident R41's clinical record revealed that the resident's diagnoses include Type 2 Diabetes Mellitus (failure of the body to produce insulin) without complications, Dysphagia (difficulty swallowing), Muscle weakness, and other abnormalities of gait and mobility.

Resident R41 revealed during interview conduct on February 9, 2026, at 12:19 PM that (he/she) was verbally abuse by staff.

Facility Administrator (NHA) and Director of Nursing (DON) were notified of the allegation of verbal abuse presented by Resident #41 on February 9, 2026 at 1:46 PM.

Review of the Pennsylvania Electronic State Reporting System revealed that it was not until February 11, 2026, that the facility submitted a report regarding verbal abuse involving Resident R41, which was not within 24 hours of the allegation, as required.Pa Code 201.18(b)(3) Management

28 PA. Code 211.12(c) Nursing services










 Plan of Correction - To be completed: 04/07/2026

Step 1 – Upon identification of the concern, the facility immediately interviewed resident and started an investigation. Facility ensured Resident R41's safety and completed an internal investigation of the allegation. The required report was submitted to the Pennsylvania Electronic State Reporting System. The Administrator reviewed the incident to ensure all required documentation, notifications, and follow-up actions were completed in accordance with abuse reporting regulations.


Step 2 – The Governing Body re-educated the NHA on the facility Abuse Reporting Protocol, education included the 2 hour submission to the State Survey Agency initiated the same day to ensure compliance with the 24-hour reporting requirement. An Abuse Reporting Checklist was re-educated to guide NHA through required steps, including documentation, protective measures, and mandated reporting timelines. A secondary oversight review by Governing Body has been added to verify that all reportable events are submitted timely.


Step 3 – Governing Body educated the NHA on abuse protocol. NHA than educated IDT on the facility Abuse Prevention Policy, mandatory reporting requirements, and the obligation to report allegations immediately. Education emphasized the 24-hour reporting rule, chain of command notification, and documentation expectations.


Step 4 – The Administrator or designee will audit all incident reports and allegations daily for four (4) weeks to ensure if meeting the reporting requirements that reports were timely reported to the State Survey Agency, followed by monthly audits for two (2) additional months. Audit findings will be reviewed through QAPI, and immediate corrective action will be taken if any delays are identified. Monitoring will continue until sustained compliance is achieved.
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of twelve residents reviewed (Residents R31 and R6).

Findings:

A review of the clinical record for Resident R31 revealed an admission date of December 29, 2025, with a diagnosis of periprosthetic fracture around the internal prosthetic left hip joint.

Nursing progress notes dated January 7, 2026, at 2:56 p.m., indicated that the resident was observed to have redness to her right heel during the shift. No visible open area was present at that time. The resident denied pain and itching. An order was entered for skin preparation to the right heel daily. A voicemail message was left for the physician. The resident is identified as her own responsible party.

A review of the wound tracking sheet documented that on January 14, 2026, the resident was noted to have a right heel deep tissue pressure injury (DTPI) measuring 3.5 centimeters (cm) by 3.8 cm.

A physician order dated December 29, 2025, indicated, "Off-load bilateral heels as tolerated."
A review of the comprehensive care plan dated December 29, 2025, did not reflect that a comprehensive care plan was developed to address the intervention to off-load bilateral heels as tolerated.

Documentation indicated that the comprehensive care plan addressing this intervention was not developed until January 20, 2026.

On February 11, 2026, at 2:40 p.m., the Regional Nurse, Employee E4, confirmed that a comprehensive care plan for the off-loading of bilateral heels was not developed until January 20, 2026.

A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on August 12, 2025, with diagnoses including cerebral infarction (stroke caused by a blockage), muscle weakness, unspecified dementia, hemiplegia (paralysis of one side of the body), aphasia (impairment of communication), dysphagia (difficulty swallowing), and hypertension.

On February 9, 2026, at 11:03 a.m., an observation with Registered Nurse Employee E7 confirmed that Resident R6 was receiving oxygen therapy at 1.5 liters per minute.

On February 12, 2026, at 2:02 p.m., a review of the clinical record with the Director of Nursing (DON), Employee E2, confirmed that Resident R6 did not have a comprehensive care plan related to oxygen therapy in place prior to its last revision on January 19, 2026.

28 Pa. Code 211.10 (c)(d) Resident care policies

28 Pa. Code 211.12(d) Nursing services





 Plan of Correction - To be completed: 04/07/2026

Step 1 – The facility reviewed and updated the comprehensive care plans for Residents R31 and R6. Resident R31's care plan was revised to include individualized interventions for pressure injury prevention, including off-loading of bilateral heels, monitoring of skin integrity, and related nursing interventions. Resident R6's care plan was updated to include oxygen therapy management, monitoring parameters, safety precautions, and interdisciplinary interventions.

Step 2 – The facility implemented a Care Plan weekly meeting which will include the IDT and Unit managers.Meeting will include a review of the weeks new orders, wounds, and treatments to verify corresponding care plan updates were done.


Step 3 –NHA/designee will educate the RN supervisors and the interdisciplinary team on requirements for comprehensive, person-centered care planning, including timely incorporation of physician orders, treatments (e.g., oxygen therapy), and identified risks (e.g., skin integrity). Education emphasized regulatory expectations, interdisciplinary communication, and documentation responsibilities.


Step 4-The DON or designee will audit five (5) residents per week for four (4) weeks to ensure physician orders, treatments, and identified conditions are accurately reflected in comprehensive care plans. Thereafter, monthly audits will be conducted for two (2) additional months. Results will be reviewed through the QAPI process, and corrective action will be taken immediately if concerns are identified. Monitoring will continue until sustained compliance is achieved.


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of five residents observed during medication administration pass (Resident R31).

Findings include:
A review of the facility policy titled "Administering Medication" Revised April 2019, revealed "medication are administered in a safe and timely manner and as prescribed". It further indicated under bulletin #4. Medications are administered in accordance with prescribed orders, including any required time frame."

A review of the clinical record for Resident R31 revealed an admission date of December 29, 2025, with diagnoses including asthma and chronic obstructive pulmonary disease (COPD).

A review of the physician's order dated December 29, 2025, indicated that Resident R31 was prescribed Symbicort Inhalation Aerosol 160-4.5 mcg/act (budesonide-formoterol fumarate dihydrate), with instructions to inhale two puffs orally twice daily for COPD.

On February 9, 2026, at 11:48 a.m. Resident R31 reported that (she/he) did nor received (her/his) inhalation aerosol puffs since last Friday, February 6, 2026, facility has notified (her/him) that they do not have the inhaler medication available.

A progress note dated February 9, 2026, at 5:00 p.m., documented by Licensed Nurse (LN) Employee E11, stating: "Symbicort Inhalation Aerosol 160-4.5 mcg/act, inhale 2 puffs orally twice daily for COPD. Med not available; on order."

On February 10, 2026, at 9:56 a.m., an observation was conducted with Licensed Nurse, Employee E7. Employee E7 reported that the inhalation aerosol treatment had been administered that morning and documented as given for Resident R31. When asked to produce the inhaler, Employee E7 was unable to locate the inhaler in the medication cart. Employee E7 then stated that she would strike through the medication administration entry, as the treatment had not been administered.

On February 10, 2026, at 10:12 a.m. an interview was conducted with Director of Nursing who also confirmed that Symbicort Inhalation Aerosol 160-4.5 mcg/act was not available to the resident R31.
A progress note dated February 9, 2026, at 12:50 p.m., was documented by Employee E7 stating: "Medication (inhaler) was not available for the morning medication pass. The medication was struck out and reordered, awaiting pharmacy delivery. The physician was notified, and the medication is on hold until delivery."

28 Pa. Code 201.18(b)(1) Management.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.






 Plan of Correction - To be completed: 04/07/2026

Step 1 – The physician and pharmacy were immediately contacted to obtain the ordered Symbicort inhaler for Resident R31, and the medication was delivered and administered as prescribed. The resident's respiratory status was assessed, and no adverse outcome was noted. The physician was notified of the missed doses.


Step 2 – The facility implemented a Medication Availability Verification Process requiring nurses to review new admissions and active orders at the start of each shift to ensure medications are present in the medication cart or on order. A Pharmacy Communication Log has been implemented to track all stat and routine medication orders, delivery timelines, and follow-up. If a medication is unavailable, nurses must immediately notify the physician, pharmacy, and DON, obtain an alternative if appropriate, and document actions taken. The DON or designee will conduct daily checks to ensure all critical medications (e.g., respiratory, cardiac, anticoagulants) are available.



Step 3 –DOn/Designee educated Licensed nursing staff on medication administration standards, including verifying medication availability prior to documentation, proper procedures when medications are not available, timely physician/pharmacy notification, and accurate MAR documentation. Education emphasized that medications may not be documented as administered unless actually given.


Step 4 – The DON or designee will conduct medication cart and MAR audits three (3) times per week for four (4) weeks to verify medication availability and documentation accuracy. Thereafter, audits will be conducted monthly for two (2) additional months. Results will be reviewed through QAPI, and corrective action will be implemented immediately if issues are identified. Monitoring will continue until sustained compliance is achieved.


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 a review of clinical records, and interviews with residents, family members, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper nail care for one of the 12 residents reviewed (Residents R6).

Findings:

A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on August 12, 2025, with diagnoses including cerebral infarction (stroke caused by a blockage), muscle weakness, unspecified dementia, hemiplegia (paralysis of one side of the body), aphasia (impairment of communication), dysphagia (difficulty swallowing), and hypertension (high blood pressure).

Review of Resident R6's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted periodically to plan resident care) dated November 18, 2025, revealed that Resident R6 was totally dependent on staff for activities of daily living to include hygiene, bed mobility, transfers, toilet use and showers.

Continued review of the MDS revealed a Brief Interview for Mental Status (BIMS) not recorded which means the resident was unable to participate in the assessment due to severe cognitive impairment.
On February 10, 2026, at 10:24 a.m., a telephone interview was conducted with the resident's representative, who reported that Resident R6's nails had been long and dirty in the past. The representative further stated that Resident R6 uses (his/her) left hand to scratch (his/her) neck and that (his/her) nails should be kept short.

On February 11, 2026, at 1:50 p.m., an observation was conducted with the Director of Nursing (DON), Employee E2. The observation revealed that the resident had long fingernails on both hands, and the fingernails on the left hand were noted to be dirty.

28 Pa. Code 211.12 (d)(1) (5) Nursing Services






 Plan of Correction - To be completed: 04/07/2026

Step 1 – Resident R6's nail care was provided immediately. Fingernails were trimmed, cleaned, and assessed for any skin integrity concerns. The resident was evaluated for comfort and safety related to scratching behavior, and appropriate interventions were implemented. The care plan and ADL assignment were updated to specifically include routine nail care and monitoring.


Step 2 – The facility implemented a Personal Hygiene and Grooming Schedule to ensure routine nail care is provided for residents who are dependent on staff for ADLs. CNA assignments now include nail observation and nail care as a task, and licensed nurses will include nail care review during weekly skin and hygiene rounds if the resident is diabetic and can not have nail care done by a CNA.

Step 3 –DON and or Designee will educate Nursing assistants and licensed nursing staff on ADL assistance requirements, including routine nail care, observation for cleanliness, and reporting when grooming is needed. Education emphasized maintaining dignity, infection prevention, and individualized care for cognitively impaired residents who cannot request assistance.

Step 4 – The DON or designee will conduct weekly hygiene audits for four (4) weeks to ensure residents requiring assistance have appropriate nail care completed and documented. Thereafter, audits will be conducted monthly for two (2) additional months. Results will be reviewed through QAPI, and corrective action will be taken immediately if concerns are identified. Monitoring will continue until sustained compliance is achieved.


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

Based on review of clinical records, observations, and staff interviews it was determined that the facility failed to implement preventative care for a resident at risk of alterations in skin integrity for one of 12 residents reviewed (Resident R49).

Findings Include:

Review of Resident R49's comprehensive Minimum Data Set (MDS federally mandated resident assessment and care screening) dated February 6, 2026, revealed the resident was newly admitted to the facility on February 1, 2026, and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypoxemia (low blood oxygen levels), need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility.

Continued review of Resident R49's MDS dated February 6, 2026, revealed the resident was identified as at risk of developing pressure ulcers/injuries.

Review of Resident R49's admission skin evaluation dated February 1, 2026, revealed the resident was assessed with erythema (superficial reddening of the skin) to his/her sacral area.

Review of Resident R49's comprehensive care plan dated February 1, 2026, revealed the resident was at risk for alterations in skin integrity. Intervention dated February 1, 2026, revealed to use a pressure reduction device on bed/chair.

Observations on February 9, 2026, at approximately 10:15 a.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Resident R49 complained of discomfort on his/her buttock area and requested repositioning. Further observations revealed no cushion or pressure reduction device was on Resident R49's wheelchair seat.

Interview on February 9, 2026, at approximately 10:20 a.m. with Licensed Nurse, Employee E6, confirmed Resident R49 did not have a cushion or pressure reduction device on the wheelchair seat. Licensed nurse, Employee E6, subsequently went on to collect and apply the wheelchair seat cushion for Resident R49.

28 Pa. Code 201.14(a) Responsibility of licensee.

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





 Plan of Correction - To be completed: 04/07/2026

Step 1 – Upon identification, a pressure-reducing wheelchair cushion was immediately applied for Resident R49. The resident was repositioned and assessed for any change in skin condition. A skin assessment was completed, and the care plan was reviewed and reinforced to ensure all pressure injury prevention interventions (including use of pressure-reduction devices, repositioning schedule, and monitoring of sacral erythema) were in place and communicated to staff.


Step 2 – The facility implemented a Process with therapy requiring that residents on admission have required pressure-reducing cushion devices on wheel chair in place and verified within 24 hours. An admission Treatment/Equipment Audit review has been initiated to ensure if needed facility implements pressure-reduction devices (bed and wheelchair) are present and in use. Alert will be placed in Admission group email and on dashboard to alert team that speciality equipment is needed. Unit managersRN supervisors will complete daily environmental rounds to verify high-risk residents have appropriate devices in place.


Step 3 –DON/Designee will educate Licensed nurses and nursing assistants on pressure injury prevention protocols, including timely implementation of care plan interventions, proper use of pressure-reduction devices in both bed and wheelchair, and prompt response to resident complaints of discomfort. Education emphasized accountability for ensuring equipment is in place and consistent with the resident's individualized care plan.


Step 4 – The DON or designee will conduct weekly skin integrity and equipment compliance audits for four (4) weeks to ensure at-risk residents have ordered pressure-reduction devices in place and are following interventions per care plan. Thereafter, audits will occur monthly for two (2) additional months. Results will be reviewed in QAPI, and corrective action will be implemented immediately if concerns are identified. Monitoring will continue until sustained compliance is achieved.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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.
§483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on observation, clinical record review, and interviews with staff, it was determined that the facility failed to ensure enteral feedings were labeled in accordance with professional standards of practice, for one of one resident reviewed for tube feeding (Resident R6).

Findings include:

A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on August 12, 2025, with diagnoses including cerebral infarction (stroke caused by a blockage), muscle weakness, unspecified dementia, hemiplegia (paralysis of one side of the body), aphasia (impairment of communication), dysphagia (difficulty swallowing), and hypertension (high blood pressure).

A review of the physician's order for Resident R6, dated September 16, 2025, indicated an enteral feeding order as follows: "Glucerna 1.2 at a rate of 85 mL/hour for 18 hours, for a total volume of 1530 mL. Feeding to be initiated at 4:00 p.m. and discontinued at 10:00 a.m. each day."

On February 9, 2026, at 11:06 p.m., an observation was conducted with Licensed Nurse (LN) Employee E7. The observation revealed that Resident R6 was in bed receiving enteral feeding. The feeding bag was not labeled with the resident's name, date, or time of initiation. The bedside table contained multiple enteral feeding caps that were observed to be unsanitary. Additionally, the enteral feeding bottle was empty; however, per the physician's order, the feeding should have been discontinued at 10:00 a.m.

28 Pa Code 211.10(c) Resident care policies

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






 Plan of Correction - To be completed: 04/07/2026

Step 1 – Upon identification, the enteral feeding setup for Resident R6 was immediately corrected. The feeding bag was properly labeled with the resident's name, date, and time of initiation. The empty feeding bottle was removed, and the feeding schedule was reviewed to ensure administration and discontinuation times aligned with the physician's order. Unsanitary enteral caps were discarded and replaced with clean, properly stored supplies. The resident's enteral feeding process was reviewed for compliance, and the physician was notified as appropriate.


Step 2 – The facility did a full house audit on residents who are receiving enteral feeding to ensure the bottle was labeled (resident name, date, time), correct feeding rate, start/stop times, and cleanliness of supplies. A standardized labeling protocol has been reinforced for all enteral feeding bags and tubing. Unit managers will complete rounds to verify compliance for any resident receiving enteral nutrition.

Step 3 –DON/Designee to educate licensed nurses on enteral feeding standards of practice, including proper labeling requirements, infection control measures, timely discontinuation per physician orders, and safe handling and storage of enteral supplies. Education emphasized regulatory expectations and documentation accuracy.


Step 4 – The DON or designee will conduct weekly audits of all residents receiving enteral feedings for four (4) weeks to ensure proper labeling, sanitation, and adherence to physician orders. Thereafter, audits will be conducted monthly for two (2) additional months. Audit findings will be reviewed in QAPI, and immediate corrective action will be taken if non-compliance is identified. Monitoring will continue until sustained compliance is achieved.


483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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.
§ 483.25(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 a review of clinical records, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for one of one residents reviewed. (Resident R6).

Findings include:

A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on August 12, 2025, with diagnoses including cerebral infarction (stroke caused by a blockage), muscle weakness, unspecified dementia, hemiplegia (paralysis of one side of the body), aphasia (impairment of communication), dysphagia (difficulty swallowing), and hypertension (high blood pressure).

On February 9, 2026, at 11:03 a.m., an observation with Registered Nurse, Employee E7 confirmed that Resident R6 was receiving oxygen therapy at 1.5 liters per minute. The oxygen tubing was not labeled, and the filter behind the concentrator was dirty, with a layer of dust.

On February 12, 2026, at 2:02 p.m., a review of the clinical file with the Director of Nursing (DON), Employee E2, confirmed that Resident R6 did not have a physician order for oxygen therapy.

28 Pa. Code 211.10(c) Resident care policies

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






 Plan of Correction - To be completed: 04/07/2026

Step 1 – Upon identification, Resident R6's oxygen therapy was immediately reviewed. The attending physician was contacted to clarify the need for oxygen therapy and to obtain a valid physician order. Oxygen administration was reconciled with the physician's direction. The oxygen tubing was properly labeled, and the concentrator filter was cleaned and replaced as needed.



Step 2 – The facility audited current residents receiving oxygen to ensure oxygen tubing is labeled, concentrators are clean, filters are maintained, and equipment is functioning properly.


Step 3 – Licensed nursing staff were re-educated by DON/Designee on requirements for oxygen administration, including the necessity of a valid physician order prior to initiation or continuation, proper labeling of oxygen tubing, infection control standards for respiratory equipment, and routine maintenance checks with filters. Education emphasized documentation accuracy and accountability to ensure treatments provided align with active orders.


Step 4 – The DON or designee will conduct weekly audits of all residents receiving oxygen therapy for four (4) weeks to ensure presence of a valid physician order, correct flow rate, proper labeling, and clean equipment. Thereafter, audits will occur monthly for two (2) additional months. Results will be reviewed through QAPI, and immediate corrective action will be taken if non-compliance is identified. Monitoring will continue until sustained compliance is achieved.


483.25(k) REQUIREMENT Pain Management: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.
§483.25(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 review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to provide pain management consistent with a resident's assessed needs for one of 12 residents reviewed (Resident R45).

Findings Include:

Review of facility policy "Pain Clinical Protocol" revealed with input from the resident, the physician and staff will establish goals of pain treatment.

Review of Resident R45's Minimum Data Set (federally mandated resident assessment and care screening) dated November 15, 2025, revealed the resident was admitted to the facility on November 12, 2025, and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs), respiratory failure, and muscle weakness.

Review of Resident R45's after visit summary from the hospital dated November 12, 2025, revealed oxycodone 10 milliliters (ml) solution was recommended as needed.

Review of Resident R45's clinical record revealed a physician order dated November 13, 2025, to give oxycodone (opioid used to treat moderate to severe pain) oral solution 10 ml every 12 hours as needed for pain, and an order to give oxycodone oral tablet 5 milligrams (mg) every 6 hours as needed for severe pain.

Review of Resident R45's clinical record revealed a nursing note dated November 13, 2025, that Resident R45 refused any Tylenol for pain and is waiting for his/her narcotics.

Review of Resident R45's pain evaluation dated November 14, 2025, revealed the resident received both scheduled and as needed pain medication, and the resident reported frequent pain over the last five days. Per the pain evaluation dated November 14, 2025, Resident R45 was identified as at risk for pain.

Review of Resident R45's medication administration record revealed on November 14, 2025, the resident complained of a pain level of 7 and the nurse subsequently provided the as needed (PRN) 5 mg oxycodone oral. Per the medication administration record, the effectiveness was noted as "ineffective" with a linked nursing note, dated November 14, 2025, that indicated the PRN administration of the oxycodone was ineffective and Resident R45 continued to be in pain.

Continued review of Resident R45's clinical record revealed a progress note dated November 14, 2025, that the pharmacy was contacted regarding delivery of oxycodone oral solution. Per the nursing note, the pharmacist stated there was no script sent for the medication. The on-call physician was notified and phoned script into the pharmacy. It was confirmed with the pharmacy that the medication was going to be sent out that night [November 14, 2025].

Review of Resident R45's clinical record revealed a nursing note dated November 14, 2025, that the resident complained of abdominal pain and discomfort further stating he/she was not pleased with pain regimen. Per the nursing note, the nurse explained to Resident R45 that the oral liquid solution of the oxycodone was unavailable and in the meantime oxycodone tablet form would need to be administered.
Review of Resident R45's clinical record revealed a nursing note dated November 15, 2025, that the resident dialed 911 because he/she was unsatisfied with pain.

Further review of Resident R45's clinical record revealed a nursing note dated November 16, 2025, that the resident returned from the hospital and requested to leave against medical advice.

Review of Resident R45's medication administration record revealed Resident R45 never received the oxycodone oral solution per the hospital recommendations. Resident R45 continued to complain of pain and ineffectiveness of regimen.

28 Pa. Code 201.14 (a) Responsibility of licensee

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





 Plan of Correction - To be completed: 04/07/2026

Step 1 – Resident R45 is no longer a resident of the facility; therefore, no direct corrective action can be implemented for this individual.


Step 2 – The facility implemented a process with new admissions with getting a script from the hospital so there is no delay with receiving pain medications.
Nursing staff also will be educated on if a prescribed medication is unavailable to obtain an alternative order. Additionally, a Pharmacy Communication Log has been implemented to track high-risk or controlled medication orders to ensure timely receipt and administration as well as to add more pain medications into the pixes based on the trend of pain medications being admitted to the facility on.


Step 3 – Licensed nurses were re-educated by the DON/Designee on the facility's "Pain Clinical Protocol," including establishing resident-centered pain goals, reassessing pain after medication administration, timely escalation when pain remains uncontrolled, and proper documentation. Education emphasized proactive management of pain, especially when discharge summaries recommend narcotic therapy, and ensuring pharmacy coordination occurs without delay.

Step 4 – The DON or designee will conduct weekly audits for four (4) weeks of residents receiving opioid or high-risk pain medications to ensure:Pain medication prescribed is on hand, Ineffective pain relief is promptly escalated to the MD.
Pharmacy delivery issues are resolved timely. Pain care plans reflect individualized goals and interventions.
Thereafter, audits will occur monthly for two (2) additional months. Results will be reviewed through QAPI, and corrective action will be taken immediately if concerns are identified. Monitoring will continue until sustained compliance is achieved.
483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on review of facility policy and review of clinical records it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one of 12 residents reviewed.


Findings Include:

Review of facility policy "Medication Shortages/Unavailable Medications" revealed when medications are unavailable the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider.

Continued review of facility policy "Medication Shortages/Unavailable Medications" revealed a medication shortage is noted the nurse should notify the pharmacy and determine the status of the order. If the next available delivery results in a delay or missed dose in the resident's medication regimen the nurse should retrieve the medication from the emergency stock or request an emergency/stat delivery from the pharmacy. If an emergency delivery/emergency stock is not feasible, the licensed nurse should contact the attending physician and order orders which may include holding the dose, use of alternative medication, or a change in order.

Review of Resident R49's comprehensive Minimum Data Set (MDS federally mandated resident assessment and care screening) dated February 6, 2026, revealed the resident was newly admitted to the facility on February 1, 2026, and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypoxemia (low blood oxygen levels), need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility.

Review of Resident R49's clinical record revealed a physician order dated February 2, 2026, to administer carvedilol by mouth two times per day (scheduled for the morning and evening) for hypertension (high blood pressure).

Review of Resident R49's medication administration record revealed from February 2, 2026, through February 6, 2026 (total of 10 doses) the carvedilol was omitted seven times and signed out with a code for "other/see progress notes".

Review of Resident R49's clinical record revealed nursing notes dated February 2, February 3, February 4, February 5, and February 6, 2026, that the facility was "awaiting pharmacy" or "awaiting delivery" of the carvedilol.

Further review of Resident R49's clinical record revealed no documented evidence that the physician was made aware of the missed doses, that an alternate treatment was requested, or specific orders for monitoring while the medication was unavailable. Review of the clinical record revealed no documented evidence the licensed nurse determined the reason for unavailability, length of time medication is unavailable, and what efforts were attempted to obtain the medication.

28 Pa. Code 211.9 (a)(1) Pharmacy Services.

28 Pa. Code 211.9 (d) Pharmacy Services.

28 Pa. Code 211.12 (d)(1) Nursing Services.










 Plan of Correction - To be completed: 04/07/2026

Step 1 – Upon identification, Resident R49's physician was notified of the missed doses of carvedilol. The medication order was reconciled with the pharmacy to ensure immediate delivery and availability.

Step 2 – The facility implemented a Medication Unavailability Escalation Protocol requiring the licensed nurse to:
Immediately contact the pharmacy to determine the reason and expected delivery time. Access emergency stock or request stat delivery when appropriate. Notify the attending physician if a dose will be missed and obtain alternative or monitoring orders.Document all actions taken, including pharmacy communication and physician notification. A Medication Shortage Tracking Log has been implemented to document unavailable medications, actions taken, and resolution timelines. The DON or designee will review this log daily.

Step 3 – Licensed nurses were educated on the "Medication Shortages/Unavailable Medications" policy, including required steps when medications are not available, proper documentation, emergency stock procedures, and mandatory physician notification for missed doses. Education emphasized accountability for proactive resolution and resident safety when essential medications are delayed.


Step 4 – The DON or designee will audit medication administration records three (3) times per week for four (4) weeks to identify omitted doses coded as "other" and verify appropriate documentation and physician notification occurred. Thereafter, monthly audits will be conducted for two (2) additional months. Findings will be reviewed through QAPI, and corrective action will be implemented immediately if non-compliance is identified. Monitoring will continue until sustained compliance is achieved.


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 review of observation, resident and staff interviews, it was determined that the facility failed to properly secure a medication for one of 12 residents reviewed. (Resident R38).

Findings include:

A review of Resident R38's clinical record revealed an admission date of January 2, 2026, with a diagnosis of glaucoma (increase eye pressure resulting in the inability of fluid to drain from the inner eye).

A review of the physician's order dated January 2, 2026, revealed an order for Dorzolamide HCl ophthalmic solution 2%, instill one drop in both eyes twice daily for glaucoma.

On February 9, 2026, at 12:02 p.m., observation revealed the Dorzolamide HCl ophthalmic solution was located in Resident R38's bed. Resident R38 reported that the nurse left the medication at her bedside during the night shift.

On February 9, 2026, at 1:59 p.m., an interview was conducted with Resident R38, who reported that at times nursing staff would give (her/him) eye drop medication and Resident R38 would administer the medication (herself/himself).

On February 9, 2026, at 2:05 p.m., an observation was conducted with Registered Nurse, Employee E7. Two bottles of Dorzolamide HCl ophthalmic solution were observedone in the resident's bed and one on the dresser across from the bed. Employee E7 reported that Resident R38 is unable to self-administer medications and that the medication should have been stored in the locked medication cart.

On February 9, 2026, at 3:45 p.m. Director of Nursing, Employee E2 also reported that all medications for Resident R38 should be safely stored in the medication cart and Resident R38 is unable to self-administer medications.

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 211.9(b)(c)(d) Pharmacy services.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.






 Plan of Correction - To be completed: 04/07/2026

Step 1 – Upon identification, the Dorzolamide HCl ophthalmic solution was immediately removed from Resident R38's bedside and secured in the locked medication cart. A review of the resident's ability to self-administer medications was conducted and confirmed that Resident R38 is not authorized for self-administration.


Step 2 –The facility reinforced its Medication Storage and Security Policy requiring all medications to be stored in locked medication carts unless a resident has a physician order and documented assessment supporting self-administration. A Self-Administration Assessment Tool has been re-implemented to ensure proper evaluation and documentation prior to allowing any bedside medications. Unit managers will conduct routine environmental rounds to ensure no medications are left unsecured in resident rooms.

Step 3 –Licensed nursing staff were re-educated by DON/Designee on medication security requirements, including proper storage, supervision of administration, criteria for self-administration, and documentation standards. Education emphasized that medications may not be left at bedside unless specifically ordered and assessed as appropriate.


Step 4 – The DON or designee will conduct weekly medication storage audits for four (4) weeks to ensure compliance with medication security standards. Random room checks will be performed to verify no unsecured medications are present. Thereafter, audits will occur monthly for two (2) additional months. Findings will be reviewed in QAPI, and corrective action will be taken immediately if concerns are identified. Monitoring will continue until sustained compliance is achieved.
483.71(a)(1)(3)(b)(1)(c)(1)-(5) REQUIREMENT Facility Assessment:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.71 Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.

§483.71(a) The facility assessment must address or include the following:
§483.71(a)(1) The facility's resident population, including, but not limited to:
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population, using evidence-based, data-driven "methods" that considering the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments as required under § 483.20;
(iii) The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population;
(iv)The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

§483.71(a)(2) The facility's resources, including but not limited to the following:
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies;
(iv) All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

§483.71(a)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach as required in §483.73(a)(1).

§ 483.71(b) In conducting the facility assessment, the facility must ensure:
§ 483.71(b)(1) Active involvement of the following participants in the process:
(i) Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and
(ii) Direct care staff, including but not limited to, RNs, LPNs/LVNs, NAs, and representatives of the direct care staff, if applicable.
(iii) The facility must also solicit and consider input received from residents, resident representatives, and family members.

§483.71(c) The facility must use this facility assessment to:
§483.71(c)(1) Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in § 483.35(a)(3).

§483.71(c)(2) Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population.

§483.71(c)(3) Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population.

§483.71(c)(4) Develop and maintain a plan to maximize recruitment and retention of direct care staff.

§483.71(c)(5) Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care.
Observations:

Based on review of facility policy, review of facility assessment and staff interview, the facility failed to ensure include the direct care staff and input from residents, resident representatives and family members when conducting the facility assessment.

Findings include:

A review of the facility policy titled "Facility Assessment," last revised in June 2024, revealed that a facility assessment is conducted annually to determine and update the capacity to meet the needs of, and competently care for, residents during day-to-day operations, including nights, weekends, and emergencies. The policy further describes the team responsible for conducting, reviewing, and updating the facility assessment under bulletin #2. The team includes leadership and management, such as the Administrator, a representative of the governing body, the Medical Director, the Director of Nursing, and other department heads as needed. It also includes direct staff, such as RNs, LPNs/LVNs, nursing assistants, and a representative of the direct staff if applicable. Finally, the policy indicates that residents, resident representatives, and family members may also be part of the team.

Review of the facility's facility assessment provided revealed a last revision date of December 8, 2025. There was no indication that the facility involved direct care staff and input from residents.

During an interview conducted on February 13, 2026, at 1:00 p.m., the Administrator was asked who participated in the development and revision of the facility assessment. The Administrator stated that the leadership team conducted the facility assessment.

When asked whether direct care staff, residents, or resident representatives provided input during the meetings in which the facility assessment was revised, the Administrator did not provide documentation or other evidence to demonstrate that such individuals participated in the process.

28 Pa. Code 201.18(b)(3) Management

28 Pa. Code 211.12(c)(d)(1) Nursing services









 Plan of Correction - To be completed: 04/07/2026

Step 1 – The facility can not retroactively correct.


Step 2 – The facility revised its Facility Assessment process to require documented participation from: At least one representative from direct care nursing staff (RN/LPN/CNA). A resident and/or Resident Council representative. A family member and/or Family Council representative (if available). A standardized Facility Assessment Participation Log has been implemented to document attendees, roles, and input provided. The Administrator is responsible for ensuring invitations are extended and documented prior to finalization of any annual or interim revision.


Step 3 – GoverningBody to educated NHA on regulatory requirements related to the Facility Assessment, including required interdisciplinary participation and documentation standards. Education emphasized the importance of incorporating frontline staff insight and resident/family feedback into operational planning, staffing analysis, and emergency preparedness considerations.


Step 4 – The Administrator or designee will audit the Facility Assessment process annually and upon any interim revision to ensure required participants are included and documented. QAPI will review documentation to confirm compliance prior to final approval of any updated Facility Assessment. Ongoing oversight will ensure sustained compliance with regulatory requirements.
§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of nurse staffing data, it was determined that the facility failed to provide a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight for one of three weeks reviewed (02/05/2026 through 02/11/2026).

Findings Include:
A review of facility census data, nursing schedules, and staff punch reports over a period of three weeks revealed the facility failed to provide one nurse aide per 10 residents during the day shift on the following dates:
-02/05/2026, 02/06/2026, 02/08/2026

Continued review of facility documentation revealed the facility failed to provide 1 nurse aide per 11 residents during the evening shift on the following dates:

-02/05/2026, 02/06/2026, 02/07/2026, 02/08/2026

Further review of facility documentation revealed the facility failed to provide 1 nurse aide per 15 residents during the overnight shift on the following dates:

-02/05/2026, 02/06/2026, 02/07/2026, 02/08/2026, 02/09/2026







 Plan of Correction - To be completed: 04/07/2026

Step 1 – Facility can not retroactively correct.

Step 2 – The facility implemented a Daily call Monday thru Friday reviewing Staffing requiring the Staffing Coordinator and DON (or designee) to review projected census against scheduled staff for each shift (day, evening, and overnight) at least 24–48 hours in advance. A Staffing Grid Tool has been used to ensure staffing is scheduled to meet ratios.


Step 3 – The Administrator, DON, Staffing Coordinator, were re-educated on state staffing ratio requirements and regulatory expectations.


Step 4 – The Administrator or designee will audit staffing schedules and actual punch reports daily for four (4) weeks to ensure compliance with minimum nurse aide ratios on all shifts. Thereafter, audits will be conducted weekly for four (4) additional weeks. Results will be reviewed in QAPI, and corrective action will be taken immediately if staffing falls below required ratios. Monitoring will continue until sustained compliance is achieved.



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