Pennsylvania Department of Health
 WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Patient Care Inspection Results

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WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Inspection Results For:

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WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on February 27, 2026, it was determined that Windber Woods Senior Living and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations. 
 Plan of Correction:


483.10(e)(1), 483.12(a)(2), 483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:This is a less serious (but not lowest level) deficiency and 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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

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

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

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

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

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

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

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

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

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for four of 33 residents reviewed (Residents 10, 13, 14, 92).

Findings include:

The facility's policy regarding psychotropic medication use, dated December 18, 2025, indicated that non-pharmacological approaches (intervention intended to improve the health or well-being of individuals that do not involve the use of drugs or medicine) are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.

A significant change Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 10 dated January 26, 2025, indicated that the resident had cognitive impairment, required assistance from staff for daily care needs, and had diagnosis that included dementia and depression.

Physician's orders for Resident 10 dated January 21, 2026, included an order for the resident to receive 50 milligrams (mg) of Trazadone (an antidepressant medication) every eight hours as needed for anxiety and agitation.

Review of the Medication Administration Record (MAR) for Resident 10 dated February 2026 revealed that 50 mg of Trazodone was administered to the resident on February 1 at 8:29 a.m.; on February 2 at 7:22 a.m.; on February 4 at 9:53 a.m.; on February 6 at 9:58 a.m.; on February 7 at 8:35 a.m.; on February 7 at 10:09 p.m.; on February 9 at 8:40 a.m.; on February 10 at 8:29 a.m.; on February 11 at 7:28 a.m.; on February 12 at 7:18 a.m.; on February 13 at 7:40 a.m.; on February 14 at 7:33 a.m.; on February 15 at 7:06 a.m.; on February 16 at 7:53 a.m.; on February 17 at 7:46 a.m.; on February 18 at 7:22 a.m.; on February 19 at 7:55 a.m.; on February 20 at 9:17 a.m.; on February 24 at 9:38 a.m.; on February 25 at 8:01 a.m.; and on February 26 at 8:38 a.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Tramadol on these dates and times.

Interview with the Nursing Home Administrator on February 27, 2026, at 12:45 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering Tramadol to Resident 10 on the above-mentioned dates and times and there should have been. She also confirmed that there was no duration included in the physician's order on January 21, 2026, and no documented evidence from a physician or prescriber to indicate the rationale to extend the as needed Tramadol for Resident 10 beyond 14 days.

An admission MDS assessment for Resident 13 dated December 16, 2025, indicated that the resident had cognitive impairment, required assistance from staff for daily care needs, and had diagnosis that included dementia and depression

Physician's orders for Resident 13 dated January 28, 2026, included an order for the resident to receive 0.25 milligrams (mg) of Xanax (an antianxiety medication) every twelve hours as needed for anxiety and agitation for fourteen days.

Review of the Medication Administration Record (MAR) for Resident 13 dated January and February 2026 revealed that 0.25 mg of Xanax was administered to the resident on January 28 at 7:49 a.m.; on January 29 at 6:45 p.m.; on January 30 at 7:15 p.m.; on February 1 at 8:29 a.m.; on February 1 at 9:13 p.m.; on February 3 at 8:35 a.m.; on February 4 at 8:29 a.m.; on February 4 at 8:32 p.m.; on February 5 at 9:05 a.m.; on February 7 at 7:00 p.m.; on February 9 at 8:24 a.m.; and on February 10 at 8:14 a.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Xanax on these dates and times.

Interview with the Nursing Home Administrator on February 27, 2026, at 12:45 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering Xanax to Resident 13 on the above-mentioned dates and times and there should have been.

A quarterly MD assessment for Resident 14 dated January 26, 2025, indicated that the resident had cognitive impairment, required assistance from staff for daily care needs.

Physician's orders for Resident 14 dated June 7, 2026, included an order for the resident to receive 0.5 mg of Ativan (an antianxiety medication) every eight hours as needed for anxiety and behaviors.

Review of the MAR for Resident 14 dated June 2025 revealed that 0.5mg of Ativan was administered to the resident on June 9 at 4:24 p.m., June 10 at 3:30 p.m., June 11 at 6:21 p.m., and June 12 art 7:32 p.m.

There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Ativan on these dates and times.

Interview with the Nursing Home Administrator on February 24, 2026, at 2:45 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering Ativan to Resident 14 on the above-mentioned dates and times and there should have been.

A quarterly MDS assessment for Resident 92, dated November 19, 2025, indicated that the resident was cognitively impaired, had no behavioral symptoms, received psychotropic medications including antianxiety medications, and had diagnosis that included anxiety and depression.

Physician's orders for Resident 92, dated November 21, 2025, December 8, 2025, January 2, 2026, January 19, 2026, and February 11, 2026, included orders for the resident to receive 1 mg of Ativan (an antianxiety medication) every six hours as needed for anxiety and agitation for fourteen days.

Review of the MAR for Resident 92, dated December 2025, through February 2026, revealed that 1 mg of Ativan was administered to the resident on December 1 at 3:22 p.m.; December 3 at 9:53 a.m. and 5:46 p.m.; December 4 at 9:00 a.m. and 4:50 p.m.; December 5 at 2:03 a.m.; December 8 at 7:03 p.m.; December 11 at 12:34 p.m. and 10:43 p.m.; December 14 at 5:43 p.m.; December 15 at 5:41 p.m.; December 20 at 5:53 p.m.; January 2 at 7:21 p.m.; January 3 at 5:48 p.m.; January 5 at 3:33 p.m.; January 9 at 2:10 a.m. and 5:54 p.m.; January 11 at 6:08 p.m.; January 14 at 4:58 p.m.; January 19 at 7:27 p.m.; January 24 at 9:56 a.m.; January 26 at 4:51 p.m.; January 28 at 3:24 p.m.; January 29 at 3:28 a.m.; and February 12 at 10:07 a.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Ativan on these dates and times.

Interview with the Nursing Home Administrator on February 26, 2026, at 4:33 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering as needed Ativan to Resident 92 on the above-mentioned dates and times.

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







 Plan of Correction - To be completed: 04/27/2026

1. Corrective Action
- Resident 10 As needed (PRN) trazadone order was discontinued by the provider.
- Resident 13 non-pharmacological interventions will be documented prior to future administration of PRN Xanax.
- Resident 14 non-pharmacological interventions will be documented prior to future administration of PRN Ativan.
- Resident 92 non-pharmacological interventions will be documented prior to future administration of PRN Ativan.

2. Identifying other residents
- Residents with current orders for PRN psychotropic medications have the potential to be affected.
- Director of Nursing (DON)/Assistant Director of Nursing (ADON) audited current orders for PRN psychotropics to ensure non-pharmacological interventions will be used and documented prior to future PRN administration.

3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F605 including:
- Psychotropic Medication policy
- Use and document non-pharmacological interventions prior to PRN administration
- Include the duration of 14 days for PRN psychotropic medications when orders are obtained.
- DON/Administrator shall in-service facility Providers regarding F605 including:
- Documentation from prescriber to indicate the rationale to extend PRN psychotropic medications
- PRN Psychotropic medication orders are limited to 14 days and cannot be renewed unless provider evaluates the resident for appropriateness of the medication.
- These in-services were either in-person or 1:1 either in person or by telephone.

- DON/ADON shall create new template orders in the electronic medical record for nurses to document and to monitor psychotropic side effects and use of non-pharmacological interventions
- DON/designee shall in-service nurses including agency staff regarding new Electronic medical record order templates for use of non-pharmacological interventions.

- DON/designee shall audit residents with orders for PRN psychotropic medications to ensure non-pharmacological interventions are used and documented prior to PRN administration Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(i) Food safety requirements.
The facility must -

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

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Findings include:

A facility policy for food storage dated December 18, 2025, revealed that food would be stored closed to open air and that no employee food or drinks would be stored in pantry refrigerators.

Observations of the walk in cooler on February 24 ,2026 at 9:09 a.m. revealed a half of a box of dinner rolls and a full box of dough balls open to air. Observations in the prep refrigerator in the kitchen revealed an employee fountain drink that was half full.

Observations of the refrigerator in the medication room on Spruce on February 27, 2026, at 8:45 a.m. revealed a cup of Sheetz coffee, a sandwich, two containers of yogurt and an Oikos yogurt drink belonging to an employee.

Interview with the Dietary Director on February 24, 2026, at 9:12 a.m. indicated that food should be stored closed to air and employee food should never be stored in the prep refrigerator.

Interview with the Assistant Director of Nursing on February 27, 2026, at 9:08 a.m. confirmed that no food should be stored in the medication refrigerator in the medication room and that there is a separate refrigerator.

28 Pa. Code 211.6(f) Dietary Services.

28 Pa. Code 207.4 Ice Containers and Storage.













 Plan of Correction - To be completed: 04/27/2026

1. Corrective Action
- Half of a box of dinner rolls and a full box of dough balls from the kitchen walk in cooler were immediately discarded.
- Employee fountain drink was immediately discarded from the prep refrigerator
- Food items in the Spruce medication room refrigerator were immediately discarded.

2. Identifying other residents
- Kitchen and medication refrigerators have the potential to affected.
- The Dietary Manager (DM)/Director of Nursing (DON) audited all refrigerators to ensure food items are properly stored and covered, and no employee food/drink items are stored in medication refrigerators.

3. Systemic Changes
- Dietary Manager/designee shall in-service dietary staff and DON/Assistant Director of Nursing (ADON) shall in-service nursing staff including agency regarding F812 including:
- Food Storage policy
- No employee food or drink stored in pantry refrigerators
4. Monitoring
- DON/designee shall audit medication refrigerators to ensure no employee food items are stored daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- DM/designee shall audit kitchen coolers/freezers/refrigerators to ensure food items are properly stored and no employee items are observed daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate

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

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

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

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations: Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to the administration of the medication for two of 33 residents reviewed (Residents 1 and 14). Findings include: A facility policy related to psychotropic medications, dated December 18, 2025, indicated that resident and/or representatives have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 22, 2025, revealed that the resident was cognitively intact, received psychotropic medications, including antidepressant medications, and had a diagnosis of depression. A nursing note for Resident 1, dated November 20, 2025, at 3:21 p.m. revealed that the resident was seen by the physician and orders were obtained to increase her Sertraline (an antidepressant medication) dose to 100 milligrams (mg) daily. Physician's orders for Resident 1, dated November 21, 2025, included an order for the resident to receive 100 mg of Sertraline daily for depression. There was no documented evidence in Resident 1's clinical record to indicate that the resident and/or resident representative were informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Sertraline. Interview with the Nursing Home Administrator on February 25, 2026, at 4:15 p.m., confirmed that there was no documented evidence in Resident 1's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Sertraline. She indicated that she was not aware that an informed consent needed to be completed when initiating or increasing psychotropic medications. A Quarterly MDS assessment Resident 14, dated May 27, 2026, revealed that the resident was cognitively impaired, received psychotropic medications, including antidepressant medications. Physician's orders for Resident 14, dated June 7, 2025, included an order for the resident to receive 0.5mg of Ativan (an antianxiety medication) every 8 hours as needed for anxiety and behaviors. There was no documented evidence in Resident 14's clinical record to indicate that the resident and/or resident representative were informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Ativan. Interview with the Nursing Home Administrator on February 24, 2026, at 2:26 p.m., confirmed that there was no documented evidence in Resident 14's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Ativan. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights.
 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 1 no longer resides in the home
- Resident 14/Responsible party was notified by the Director of Nursing and provided with psychotropic medication information regarding the risks and benefits including treatment alternatives. Psychotropic Consent was obtained on 3/20/2026 for Ativan.


2. Identifying other residents
- Residents currently on psychotropic medications have the potential to be affected.
- The Director of Nursing (DON)/Assistant Director of Nursing (ADON) completed an audit of all current residents on psychotropic medications to ensure consents are obtained and information regarding the risks and benefits including treatment alternatives are provided to resident/Responsible Party.


3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F552 including:
- Psychotropic Med use policy
- Psychotropic Consents
- DON/ADON will review new and/or increased dosages of psychotropic medication orders during clinical meeting to ensure consents have been obtained that includes information regarding the risks and benefits and treatment alternatives.


4. Monitoring
- DON/designee shall audit new or increased dosages of psychotropic medication orders to ensure consents have been obtained that includes information regarding the risks and benefits and treatment alternatives daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement (QAPI) for analysis and to be addressed as appropriate.






483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation of a bruise to rule out neglect and/or abuse for one of 33 residents reviewed (Resident 61).

Findings include:

The facility's policy for abuse prohibition, dated December 18, 2025, indicated that the facility will have procedures in place to identify suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse. This information may be obtained through or risk management reporting policy currently in place.

The facility's policy for risk management reporting, dated December 18, 2025, indicated that all injuries/incidents are required to be reported through risk management in the electronic medical record. This includes abrasions, bruises, skin tears, falls, elopement, and acts of aggression toward other residents. The risk management report is the actual investigation into the cause of the injury or incident and to rule out abuse.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 17, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, had a diagnosis of ends stage renal disease and was receiving dialysis (medical treatment that filters waste, toxins, and excess fluid from the blood when the kidneys have failed).

A nurse's note for Resident 61 dated February 13, 2026, revealed that the resident was given a shower, and the nurse aide noticed a bruise on his right knee. There was no documented evidence that an investigation was initiated to identify the cause of the bruise or to rule out abuse.

Interview with the Nursing Home Administrator on February 26, 2026, at 12:00 p.m. confirmed that she was unable to find an incident report or investigation for Resident 61's bruise that occurred on February 13, 2026.

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

28 Pa. Code 211.10(d) Resident Care Policies.

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





 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 61 Right knee discoloration is resolved, and a progress note was entered into the electronic medical record by the Director of Nursing.
2. Identifying other residents
- Residents with newly observed skin conditions or discolorations have the potential to be affected.

3. Systemic Changes
- The Director of Nursing (DON)/designee shall in-service nursing staff including agency staff regarding F610 including:
- Risk Management and Abuse reporting policy with increased focus to include that all skin impairments such as abrasions, bruises, skin tears, and open areas will be entered into the risk management reporting system so an assessment is completed by a Registered Nurse and an investigation into the cause of the injury or accident is completed to rule out abuse.
- DON/Assistant Director of Nursing/Wound nurse shall review nursing progress notes in clinical meeting to ensure new bruises observed have been addressed in Risk Management and investigated to rule out abuse.

4. Monitoring
- DON/ADON/Wound Nurse or designee shall audit residents electronic medical record to ensure new bruises observed have been addressed in Risk Management and investigated Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement (QAPI) for analysis and to be addressed as appropriate.


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for five of 33 residents reviewed (Residents 1, 5, 68, 92, 97).

Findings include:

A facility policy for Comprehensive Care Planning, dated December 18, 2025, indicated that an interdisciplinary plan of care be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The care plan is reviewed on an ongoing basis and revised as indicated by the residents' needs, wishes, or a change in condition.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 22, 2025, revealed that the resident was cognitively intact, received oxygen therapy and had diagnoses that included respiratory failure, congestive heart failure and pneumonia. A care plan for the resident, dated November 16, 2025, indicated that the resident had pneumonia. There was no documented evidence in the resident's clinical record that indicated the resident had an active diagnosis of pneumonia.

Interview with the Assistant Director of Nursing on February 26, 2026, at 10:48 a.m. confirmed that Resident 1 did not have an active diagnosis of pneumonia and was not currently being treated for it, and that the care plan should have been resolved.

An admission MDS assessment for Resident 5, dated January 30, 2026, indicated that the resident had cognitive impairment, required assistance with daily care needs, and had diagnoses that included cognitive communication deficit. A care plan dated January 24, 2026, revealed that Resident 5 had an indwelling catheter.

A nurse's note for Resident 5, dated February 7, 2026, at 11:59 a.m. indicated that the resident was incontinent of a large amount of urine this morning since her indwelling urinary catheter (a tube inserted in the bladder) was discontinued.

An interview with Licensed Practical Nurse 1 on February 25, 2026, at 9:52 a.m. confirmed that Resident 5 did not have an indwelling catheter.

Interview with the Administrator on February 25, 2026, at 10:25 a.m. confirmed that Resident 5 did not have an indwelling catheter and her care plan should have been revised to reflect that.

A quarterly MDS assessment for Resident 68, dated February 13, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, and had a diagnosis of cancer.

A nursing note for Resident 68, dated September 10, 2025, at 12:35 a.m. revealed that the resident returned from the hospital on September 9, 2025, and had a dry dressing to her port site from her mediport (a small medical device surgically implanted under the skin, usually in the chest, providing long-term, easy access to a vein for chemotherapy, medication, fluids, or blood draws) being de-accessed (removing the specializedneedle from the port device under your skin). A care plan for the resident, dated April 21, 2025, indicated that she had a mediport to her right chest and was receiving Heparin flushes and saline flushes intravenously to her accessed mediport every evening shift, and that staff may access her mediport for blood draws one time a day every seven days and as needed. There was no documented evidence that the resident had orders to flush her mediport.

Interview with the Assistant Director of Nursing on February 26, 2026, at 11:28 a.m., revealed that Resident 68 does not currently have orders to flush her mediport due to it being de-accessed and that they do not do anything with her port at this time. She also revealed that currently they do not draw labs from the mediport and confirmed that the care plan should have been revised to reflect that they were not flushing the mediport.

Interview with the Nursing Home Administrator on February 27, 2026, at 10:15 a.m. revealed that Resident 68 has her blood draws at the cancer center and if they use her mediport, they do the flushes there. She indicated that if she did not get the flushes at the cancer center, they would flush them every 30 days to keep the port open, but since the cancer center flushes it so frequently, they no longer do the flushes at the facility. She confirmed that the care plan should have been revised to reflect that they no longer do the flushes to her mediport.

A quarterly MDS assessment for Resident 92, dated November 19, 2025, indicated that the resident was cognitively impaired, had no behavioral symptoms, received psychotropic medications including antianxiety medications, and had diagnoses that included anxiety and depression. A care plan for the resident, dated February 1, 2026, indicated that the resident was receiving Ativan (an antianxiety medication); however, there was no documented evidence in the resident's clinical record that she was ordered Ativan.

Interview with the Director of Nursing on February 26, 2026, at 3:46 p.m. confirmed that Resident 92's care plan should have been revised to reflect that the Ativan was discontinued.

A quarterly MDS assessment for Resident 97, dated January 9, 2026, revealed that the resident was cognitively intact and was moderately dependent on staff for daily care needs. The current care plan for Resident 97 indicated that she had actual skin impairment from necrotizing fasciitis (a bacteria that destroys skin and soft tissue) and surgical wounds on her back. There was no documented evidence in the resident's clinical record that indicated the resident had an active diagnosis of necrotizing fasciitis or surgical back wounds.

Interview with the Nursing Home Administrator on February 26, 2026, at 12:47 p.m. confirmed that Resident 97 was not currently receiving treatment for necrotizing fasciitis and surgical wounds and the care plan should have been resolved.

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







 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 1 No longer resides in the home.
- Resident 5 No longer resides in the home.
- Resident 68 mediport access care plan has been resolved to reflect staff not required to flush port at the facility and flushes to be completed at the cancer center.
- Resident 92 psychotropic use for Ativan care plan has been resolved.
- Resident 97 necrotizing fasciitis and surgical wounds care plans have been resolved.


2. Identifying other residents
- Residents with previous diagnosis of Pneumonia have the potential to be affected.
- Residents with previous orders for indwelling catheters have the potential to be affected.
- Residents with mediport access have the potential to be affected.
- Residents with discontinued psychotropic Ativan orders have the potential to be affected.
- Residents with resolved necrotizing fasciitis and surgical wounds diagnosis have the potential to be affected.
- The Registered Nurse Assessment Coordinators (RNAC's) audited current residents with above findings to ensure care plans are updated to reflect current resident status.

3. Systemic Changes
- Director of Nursing (DON)/designee shall in-service nurses including agency staff and RNAC's regarding F657 including:
- Comprehensive Care Planning policy
- Ensure care plans are updated timely to reflect current resident status and plan of care.
- DON/RNAC's or designee will review residents' comprehensive care plans to ensure each completed Minimum Data Set (MDS) assessment captures current plans of care when submitting MDS assessments.

4. Monitoring
- DON/RNAC or designee shall audit resident care plans to ensure current resident status is reflected and captured accurately and timely Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance (QAPI) for analysis and to be addressed as appropriate.


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 review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for two of 33 residents reviewed (Resident 61 and 95).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 17, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, had a diagnosis of ends stage renal disease and was receiving dialysis (medical treatment that filters waste, toxins, and excess fluid from the blood when the kidneys have failed).

A nurse's note for Resident 61 dated February 13, 2026, revealed that the resident was given a shower, and the nurse aide noticed a bruise on his right knee. There was no documented evidence that registered nurse assessment of the bruise was completed.

Interview with the Nursing Home Administrator on February 26, 2026, at 12:00 p.m. confirmed that there was no documented evidence that a registered nurse assessment was completed for the bruise that was identified on Resident 61's right knee on February 13, 2026.

A quarterly MDS assessment for Resident 95 dated January 17, 2026, indicated that the resident had severe cognitive impairment, was dependent on staff for most daily care needs, and had diagnosis that included dementia.

Physician's orders for Resident 95 dated January 25, 2026, included for the resident to have he left shin wound cleansed with wound cleanser, dry with gauze, apply a small amount of bacitracin, cover with nonadherent dressing, and secure with kerlix and tape every day.

A nurse's note for Resident 95 dated January 25, 2026, indicated that the resident had an old bruise/blood collection that opened on her left shin area. As of February 26, 2026, there was no documented evidence of any further assessments of the resident's change in skin condition to her left shin that was identified on January 25, 2026.

An interview with the Director of Nursing on February 27, 2026, at 3:13 p.m. revealed Resident 95 had a previous blood blister that opened on her left shin, and that there was no documented evidence of any assessments of the change in skin condition since it was identified on January 25, 2026, and there should have been.

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





 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 61 right knee bruise was assessed by a Registered Nurse (RN) and currently resolved without adverse effects, A progress note was entered into the Electronic Medical Record (EMR).
- Resident 95 change of condition to the left shin was assessed by RN, the area is resolved and a note was entered into the EMR.
2. Identifying other residents
- Residents with newly observed skin conditions have the potential to be affected.

3. Systemic Changes
- Director of Nursing (DON)/designee shall in-service nurses including agency staff regarding F658 including:
- Licensed Practical Nurses are instructed to document any change in skin condition in the progress note section of the EMR
- Notifying RN immediately upon new skin condition observation
- RN shall conduct a thorough skin assessment, obtain orders, notify family and wound nurse for further evaluation
- DON or designee shall review daily progress notes to ensure all new skin conditions are addressed, assessed by RN and orders for treatment are obtained if necessary.

4. Monitoring
- DON/designee shall audit residents body check sheets to ensure all new skin conditions are addressed and assessed by RN daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.


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

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders and clarify physician's orders for four of 33 residents reviewed (Resident 2, 5, 8, 68).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated December 10, 2025, revealed that the resident was cognitively impaired, requires assistance from staff for daily care needs, and had medical diagnosis that included dementia.

A Pharmacist recommendation review dated January 16, 2026, revealed that the pharmacist recommendation was to change Resident 2's multivitamin to a multivitamin-M and discontinue vitamin B12, vitamin D, magnesium oxide and folic acid. On January 30, 2026, the physician agreed to the pharmacist recommendation.

A review of Resident 2's January 2026 and February 2026 Medication Administration record revealed that the multivitamin was not changed to multivitamin M and that Vitamin B12, Vitamin D, Magnesium oxide, and folic acid were administered to the resident.

Interview with the Director of Nursing on February 26, 2025, at 12:55 p.m. confirmed that there was no documented evidence that Resident 2's multivitamin was changed to multivitamin M and that Vitamin B12, Vitamin D, Magnesium oxide, and folic acid were discontinued per pharmacy recommendations.

An admission MDS assessment for Resident 5, dated January 30, 2026, indicated that the resident had cognitive impairment, required assistance with daily care needs, and had diagnosis that included cognitive communication deficit.

A nurse's note dated February 7, 2026, at 11:59 a.m. revealed Resident 5 had a large amount incontinent urine this morning since her indwelling catheter (a tube inserted in the bladder) was discontinued.

An interview with Licensed Practical Nurse 1 on February 25, 2026, at 9:52 a.m. confirmed that Resident 5 did not have an indwelling catheter.

Physician's orders for Resident 5 dated January 23, 2026, included an order to change foley catheter as needed for leakage or blockage.

An interview with the Nursing Home Administrator on February 25, 2026, at 10:25 a.m. confirmed that Resident 5 does not have an indwelling catheter and that the physician's order to change foley catheter for blockage and leakage as needed should have been discontinued.

A quarterly MDS assessment for Resident 8, dated December 23, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had a diagnosis of hypertension (high blood pressure).

Physician's orders for Resident 8, dated May 4, 2025, indicated that the resident was to receive 25mg carvedilol (a medication to treat high blood pressure) and to hold the medication if her pulse was less than 60 beats per minute (bpm) or her systolic blood pressure (the top number of the blood pressure) was less than 100.

Review of resident 8's Medical Administration Records (MAR) for January and February 2026 revealed that she received 25mg Carvedilol on January 10 with a pulse of 58 bpm, January 19 with a pulse of 58bpm, January 23 with a pulse of 56, January 30 with a pulse of 50, and February 8 with a pulse of 58.

Interview with the Director of Nursing on February 25, 2026, at 3:10 p.m. confirmed that Resident 8's carvedilol should have been administered on the above times and dates and should have been held according to the parameters on the physician's orders.

A quarterly MDS assessment for Resident 68, dated February 13, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, received an anticoagulant medication (medication that thins the blood) and had a diagnosis of cancer.

A nursing note for Resident 68, dated February 2, 2026, at 7:48 a.m. revealed that the resident was seen by the physician and orders were obtained to hold her Eliquis (an anticoagulant medication) three days prior to her upcoming breast biopsy.

A physician's order for Resident 68, dated February 3, 2026, indicated that staff was to hold her Eliquis three days prior to her breast biopsy.

A nursing note for Resident 68, dated February 3, 2026, at 3:33 p.m. revealed that the resident's biopsy was scheduled for February 18, 2026, at 10:00 a.m.

Review of resident 68's clinical records revealed that she was hospitalized on February 8, 2026, and returned to the facility on February 11, 2026. There was no documented evidence that the facility clarified the order to hold the Eliquis three days prior to her biopsy when she returned from the hospital.

A nursing note for Resident 68, dated February 17, 2026, at 10:21 a.m. revealed that the facility received a phone call from the Breast Care Center regarding holding the resident's Eliquis three days prior to her appointment and the Eliquis was given. Her biopsy was rescheduled for March 4, 2026.

Interview with the Nursing Home Administrator on February 25, 2026, at 1:37 p.m. confirmed that Resident 68's Eliquis should have been clarified when she returned from the hospital to hold it prior to her biopsy and it was not, resulting in her biopsy having to be rescheduled.

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


.





 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 2 multivitamin order was clarified and changed to MVI M. Vitamin B12, Vitamin D, Magnesium oxide and folic acid were discontinued per physician order.
- Resident 5 No longer resides in the home.
- Resident 8 Carvedilol order remains appropriate with parameter orders to hold for pulse less than 60 and systolic blood pressure less than 100.
- Resident 68 Eliquis order was held three days prior to appointment on March 4, 2026.


2. Identifying other residents
- Residents with pharmacy consultant recommendations have the potential to be affected.
- Residents with foley catheter orders have the potential to be affected.
- Residents with blood pressure parameter orders have the potential to be affected.
- Residents with upcoming appointments and orders to hold specific medications have the potential to be affected.
- The Director of Nursing (DON) completed audits of the above deficient practices and no other residents were affected.

3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F684 including:
- Completion of Pharmacy recommendations
- Following physician orders related to foley catheters and hold orders
- Blood pressure parameters
- Registered Nurse Unit Managers shall review monthly pharmacy recommendations and report to Director of Nursing (DON)/Assistant Director of Nursing (ADON) upon completion.
- Medication hold orders for upcoming appointments shall be included in the appointment order for visual reminder.

4. Monitoring
- DON/ADON shall or designee shall audit pharmacy recommendations for completion to ensure approved orders from physician are carried out monthly x 3 months or until sustained compliance is achieved.
- DON/ADON or designee shall audit foley catheter orders to ensure orders remain appropriate daily x 7 days, then weekly x 3 weeks then monthly x 3 months or until sustained compliance is achieved.
- DON/ADON or designee shall audit blood pressure medication orders to ensure parameters are being followed and held as appropriate daily x 7 days, then weekly x 3 weeks then monthly x 3 months or until sustained compliance is achieved.
- DON/ADON or designee shall audit resident appointments to ensure hold orders for specific medications are carried out daily x 7 days, then weekly x 3 weeks then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.


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, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for one of 33 residents reviewed (Resident 3).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 17, 2026, revealed that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, and had medical diagnosis that included stroke, hemiplegia and dementia.c

Care plan for Resident 3 dated August 5, 2025, indicated that the resident has the potential for pressure ulcer development and required extensive-total assist with bed mobility. An intervention dated January 23, 2026, indicated that the resident was to have B Prevalon boots ( medical devices designed to prevent heel pressure injuries in non-ambulatory, bedridden patients) on all times when in bed, and her skin integrity checked with application and removal.

Physician's orders for Resident 3, dated January 22, 2026, included an order for the resident to have B Prevalon boots on all times when in bed. Check skin integrity with application and removal.

Observations of Resident 3 on February 24, 2026, at 11:00 a.m. and on February 26, 2026, at 10:15 a.m. revealed the resident lying in bed without the presence of B Prevalon boots.

Interview with Nurse Aide 2 on February 26, 2026, at 10:15 a.m. revealed that Resident 3 did not have B Prevalon boots in place, and that she did not have any B prevalon boots available in her room to put in place as ordered.

Interview with the Nursing Home Administrator on February 26, 2026, at 12:49 p.m. revealed that B prevalon boots were not added to Resident 3's task list to alert nurse aides to apply them, they should have been available in her room, and there was no documented evidence that they were being applied as ordered.

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


















 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 3 B Prevalon boots order remain appropriate and are currently available in the resident room.

2. Identifying other residents
- Residents with orders for pressure ulcer prevention/treatment: Prevalon Boots have the potential to be affected.
- Wound nurse audited current residents with skin conditions and orders for preventative treatment: Prevalon boots to ensure availability and use as ordered. The audit revealed that no other resident was affected by the deficient practice.

3. Systemic Changes
- Director of Nursing (DON)/designee shall in-service nurses including agency staff regarding F686 including:
- Use of/availability of Pressure ulcer preventative devices: Prevalon boots
- Wound nurse/designee shall create an inventory list of pressure ulcer preventative treatment/equipment/devices to ensure availability and use, and report to DON weekly.

4. Monitoring
- Wound Nurse/designee shall audit residents with skin conditions and orders for preventative measures: Prevalon boots to ensure availability and use Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.



483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place for one of 33 residents reviewed (Resident 14).

Findings include:

The facility's policy regarding falls, dated December 18, 2025, indicated that residents identified as fall risks will have interventions in place to prevent further falls.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14 dated February 27, 2026, indicated that the resident was cognitively impaired, and required assistance for daily care. Resident 8's current care plan, indicated that the resident was at risk for falls. Fall interventions included keeping her personal belongings within reach, and that she would have a reacher tool (used to grab objects that are beyond your reach).

Observations of Resident 14 on February 24, 2026, at 10:45 a.m. revealed that the resident was in her wheelchair and did not have her reacher available in her room. Observations on February 26, 2025, at 1:15p.m. revealed that the resident was in her wheelchair in her bedroom reaching for items on her stand and did not have her reacher available to her.

Interview with Nurse Aide 3 on February 26, 2026, at 1:16 p.m. confirmed that Resident 14's reacher was not in her room and was missing.

Interview with the Nursing Home Administrator and Director of Therapy on February 26, 2026 at 2:52 p.m. confirmed that Resident 14's reacher tool should have been available to her.

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

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

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

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 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 14 reacher device was provided in the room and currently being used.

2. Identifying other residents
- Residents with fall intervention equipment: Reacher devices have the potential to be affected.
- Director of Nursing (DON)/Assistant Director of Nursing (ADON) reviewed residents' fall intervention equipment: Reacher Devices to ensure items are available and in place to minimize fall incidents and no other deficient practices were identified.

3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F689 including:
- Fall policy
- Ensure Fall interventions and equipment: Reacher devices availability
- Restorative nursing or designee will create an inventory for fall intervention equipment to ensure items are available, in use and functioning, and submit to DON weekly.

4. Monitoring
- DON/designee shall audit residents fall intervention equipment: Reacher devices to ensure items are available, in use and functioning Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.


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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for one of 33 residents reviewed (Resident 1).

Findings include:

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 22, 2025, revealed that the resident was cognitively intact, received oxygen therapy and had diagnoses that included respiratory failure, congestive heart failure and pneumonia.

Physician's orders for Resident 1, dated November 13, 2025, included orders for the resident to receive oxygen at a flow rate of 1-5 liters per minute (LPM) via nasal cannula (a small tube that delivers oxygen through the nasal passages) to keep her pulse oximetry (measures blood oxygen levels) greater than 90 percent. May titrate as needed for pulse oximetry less than 90 percent and/or shortness of breath.

Observations of Resident 1on February 24, 2026, at 10:42 a.m., February 25, 2026, at 12:44 p.m. and February 26, 2026, at 8:45 a.m. revealed that the resident was lying in bed with oxygen being supplied via nasal cannula at a flow rate of 3 LPM. There was no documented evidence in the resident's clinical record that the facility was documenting her use of oxygen and that they were checking her pulse oximeter to ensure she was getting the appropriate liter flow.

Interview with the Assistant Director of Nursing on February 26, 2026, at 10:48 a.m. confirmed that there was no documented evidence in Resident 1's clinical record that the facility was documenting her use of oxygen and that they were checking her pulse oximeter to ensure she was getting the appropriate liter flow.

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





 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 1 no longer resides in the home

2. Identifying other residents
- Residents with current orders for oxygen therapy have the potential to be affected.
- Director of Nursing (DON)/Assistant Director of Nursing (ADON) audited current orders for oxygen use to ensure monitoring of pulse oximetry is included and documented every shift. The Medication Administration Record was updated to capture documentation of oxygen use every shift to prevent other like residents from being affected by the deficient practice.

3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F695 including:
- oxygen therapy
- Checking pulse oximetry every shift to ensure appropriate liter flow is provided to maintain oxygen levels as ordered.

4. Monitoring
- DON/ADON shall audit residents with oxygen therapy to include checking pulse oximetry to ensure appropriate liter flow is provided to maintain oxygen levels Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.


483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive 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 policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to follow facility policy for the care and monitoring of residents receiving dialysis for one of 33 residents reviewed (Resident 61).

Findings include:

Review of the facility's dialysis policy, dated December 18, 2025, revealed that when a resident is requiring dialysis an order will be written for the dialysis, place of treatment, port check every shift and as needed, medications to be held prior to dialysis, and any specific orders from dialysis including dietary restrictions, fluid restrictions and intake and output and laboratory studies. The Licensed Practical Nurse/Registered Nurse will monitor the dialysis port or catheter every shift and as needed. The nurse will report any bleeding, redness, inflammation, drainage or catheter dysfunction.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 17, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, had a diagnosis of ends stage renal disease and was receiving dialysis (medical treatment that filters waste, toxins, and excess fluid from the blood when the kidneys have failed).

Care plan for Resident 61 dated February 11, 2026, indicated that the resident had end stage renal failure and required hemodialysis, and staff were to monitor his fistula (a surgically created connection between an artery and a vein designed to provide long-term access for hemodialysis) and watch for signs or symptoms of infection and monitor the bruit and thrill (the audible "whooshing" and palpable "buzzing" sensations felt over a functioning hemodialysis fistula or graft, confirming adequate blood flow) as per orders.

Review of Resident 61's clinical records that included medication and treatment administration records dated February 2026, revealed no documented evidence that the resident had orders for dialysis that included when and where it was scheduled, and there was no documented evidence that staff were monitoring the resident's dialysis fistula site.

Interview with the Nursing Home Administrator on February 26, 2026, at 12:00 p.m. confirmed that there was no documented evidence that the resident's clinical record included orders for dialysis treatments, or that the resident's fistula was being monitored per the resident's care plan.

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





 Plan of Correction - To be completed: 04/27/2026

1. Corrective Action
- Resident 61 Dialysis orders have been clarified to include the location of dialysis center, dialysis days and time, and monitoring fistula site to confirm adequate flow and functionality.

2. Identifying other residents
- Residents currently receiving dialysis have the potential to be affected.
- Director of Nursing (DON)/Assistant Director of Nursing (ADON) audited current residents to ensure dialysis orders include the location of dialysis center, dialysis days and time, and monitoring fistula site to confirm adequate flow and functionality.

3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F698 including:
- Dialysis policy
- Required dialysis orders:
1. location of dialysis center,
2. dialysis days and time,
3. monitoring fistula site for signs/symptoms of infection and
4. monitoring Hemodialysis (HD) site for bruit/thrill to confirm adequate flow and functionality.

4. Monitoring
- DON/ADON shall audit residents receiving Dialysis to ensure dialysis orders include the location of dialysis center, dialysis days and time, and monitoring fistula site to confirm adequate flow and functionality Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.



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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 12). Findings include: The facility's policy regarding medication administration, dated December 18, 2025, indicated that documentation of narcotic administration will be done in accordance with applicable law including documenting necessary medication administration treatment information on appropriate forms, and removal of fentanyl patches (a narcotic medication) will require two signatures to ensure proper disposal of the patch. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 12, dated January 8, 2026, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnoses that included Parkinson's (a progressive neurological disease that affects movement). Physician's orders for Resident 12 dated October 27, 2025, included an order for the resident to receive one 25 microgram (mcg) per hour fentanyl transdermal (through the skin) patch, applied every 72 hours for pain management and to remove per schedule. Review of the controlled drug record (tracks each dose of a controlled medication) and Medication Administration Record (MAR) for Resident 12 for December, 2025 and January, 2026, revealed that there were not two signatures for the removal and disposal of the 25 mcg/hour fentanyl patch for December 26, 2025 and January 5, 8, 11, and 14, 2026. Interview with the Director of Nursing on February 26, 2026, at 12:53 p.m. confirmed that there was not two signatures for the removal and disposal of the fentanyl patches for Resident 12 on the above dates. Current physician's orders for Resident 12 included an order for the resident to receive one 37.5mcg/hour fentanyl transdermal patch applied every 72 hours and to remove the patch per schedule. Review of the controlled drug record for Resident 12 revealed that a 37.5mcg/hr fentanyl transdermal patch was signed out on February 23, 2026, however a review of Resident 12's MAR for February, 2026 revealed no documented evidence the patch was administered on the above date. Interview with the Nursing Home Administrator on February 27, 2026 at 8:35 a.m. confirmed that there was no documented evidence that the fentanyl patch that was signed out on February 23, 2026, was administered to Resident 12. 28 Pa. Code 211.9(a)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 12 No longer resides at the home
2. Identifying other residents
- Residents with current orders for Fentanyl patches have the potential to be affected.
- Director of Nursing (DON) audited current residents with orders for Fentanyl patches to ensure proper documentation during application and removal/disposal is signed off by two nurses and no other resident was ordered a Fentanyl patch.

3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F755 including:
- Medication Administration policy
- Fentanyl patches require two signatures to ensure proper removal and disposal
- DON/Assistant Director of Nursing (ADON) or designee shall review controlled drug record weekly to ensure proper disposal of fentanyl patches are completed and signed by two nurses.

4. Monitoring
- DON/designee shall audit residents receiving Fentanyl patches to ensure proper documentation during application and removal/disposal is signed off by two nurses Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations: Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent. Findings include: Observations during medication administration on February 26, 2026, and February 27, 2026, revealed that three medication administration errors were made during 38 opportunities for error, resulting in a medication administration error rate of 7.89 percent. Manufacturer's directions for Trelegy Ellipta (medication that reduces inflammation in the airways)100-62.5-25 micrograms/activation (mcg/act), dated January 2019, indicated to advise patients to rinse his/her mouth with water without swallowing after inhalation to reduce the risk of candida albicans, an infection of the mouth and pharynx (throat). Physician's orders for Resident 68, dated February 11, 2026, included an order for the resident to receive one puff (inhalation) of 100-62.5-25 mcg/act of Trelegy Ellipta daily in the morning for chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult). Observations during medication administration on February 26, 2026, at 8:18 a.m. revealed thatLicensed Practical Nurse 4 administered one puff of Resident 68's Trelegy Ellipta then proceeded to give her a drink of iced tea. Interview withLicensed Practical Nurse 4at 8:40 a.m. revealed that she was not sure if she needed to have Resident 68 rinse her mouth out with water without swallowing after administering Trelegy Ellipta. Interview with the Nursing Home Administrator on February 26, 2026, at 4:33 p.m. confirmed thatLicensed Practical Nurse 4should have had Resident 68 rinse her mouth out with water and spit after administering her Trelegy Ellipta. Manufacturer's directions for use of Xtandi (used to treat prostate cancer), dated January 2025, revealed that tablets should be taken whole and should not be cut, crushed or chewed. Instructions on the bottle indicated that the medication should be swallowed whole and should not be cut, crushed, or chewed. Manufacturer's directions for use of Ferrous Sulfate (an iron supplement), dated March 2020, revealed that tablets should be taken whole and should not be chewed or crushed. Physician's orders for Resident 31, dated January 5, 2026, included an order for the resident to receive 160 milligram (mg) of Xtandi daily for prostate cancer. Physician's orders for Resident 31, dated January 5, 2026, included an order for the resident to receive 325 mg of Ferrous Sulfate daily. Observations during the medication administration on February 27, 2026, at 8:14 a.m. revealed thatLicensed Practical Nurse 5 crushed Resident 31's Ferrous sulfate tablet and crushed one 40 mg tablet of Xtandi, and then administered the crushed medications to the resident. Observations during the medication administration on February 27, 2026, at 8:14 a.m. revealed thatLicensed Practical Nurse 5prepared and administered one 40 mg table of Xtandi to Resident 31. The physician's order indicated that the resident was to receive 160 mg of Xtandi daily. The medication was supplied in a bottle containing 40 mg tablets. Interview withLicensed Practical Nurse 5 on February 27, 2026, at 8:45 a.m. confirmed that Resident 31's Ferrous Sulfate and Xtandi should not have been crushed, and confirmed that she should have administered Resident 31 a total of four 40 mg tablets of Xtandi to equal the ordered dose of 160 mg and she did not. Interview with the Nursing Home Administrator and Director of Nursing on February 27, 2026, at 10:35 a.m. confirmed that Resident 31's Ferrous Sulfate and Xtandi should not have been crushed, and that Resident 31 received the incorrect dose of Xtandi. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 68 continues to receive Trelegy Ellipta and mouth is rinsed with water and spit out after administration.
- Licensed Practical Nurse (LPN) 4 was educated regarding proper mouth rinsing after Trelegy administration.
- Resdient 31 continues to receive Xtandi and Ferrous sulfate and administered in whole tablets
- LPN 5 was educated regarding proper administration of Xtandi and Ferrous sulfate and to follow physician orders to meet dosage requirements.

2. Identifying other residents
- Residents currently receiving Trelegy Ellipta, Xtandi, Ferrous sulfate have the potential to be affected.
- Director of Nursing (DON)/Assistant Director of Nursing (ADON) shall review above medications to ensure residents have the ability to swallow medications without crushing or chewing.

3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F 759 including:
- Medication administration policy
- Trelegy Ellipta—advise to rinse mouth without swallowing to reduce fungal infections
- Xtandi-should not be cut, crushed or chewed
- Ferrous Sulfate—should be taken whole, should not be crushed or chewed
- Follow correct dosage administration as ordered
- Follow manufacturer's directions

4. Monitoring
- DON/ADON shall conduct Med Pass competencies for nurses to ensure proper medication administration per policy and following manufacturer's directions Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.



483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results: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.
§483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 33 residents reviewed (Resident 4).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 12, 2026, revealed that the resident was cognitively intact and had diagnoses that included a urinary tract infection.

Physician's orders for Resident 4, dated June 24, 2025 included an order for staff to obtain a urine specimen to rule out a urinary tract infection.

A progress note for Resident 4, dated June 24, 2025, revealed that the writer performed a straight catheterization (the manual insertion of a plastic tube into the bladder to drain urine) on the resident at this time to obtain a urinalysis and culture and sensitivity (UA C&;S - urine tests to check for the presence of bacteria and determine which antibiotics the bacteria is sensitive to).

There was no documented evidence that staff obtained a physician's order to obtain Resident 4's urine specimen via catheterization.

Interview with the Nursing Home Administrator on February 25, 2026, at 2:05 p.m. confirmed that there was no evidence that a physician's order was obtained for Resident 4 to be catheterized to obtain the urine specimen on June 24, 2025 and there should have been.

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








 Plan of Correction - To be completed: 04/27/2026


1. Corrective Action
- Resident 4 continues to reside in the facility and Physician will be notified when a urine specimen is needed to include an order to collect specimen via straight catheterization as needed.

2.Identifying other residents
- Residents with orders to collect urine specimen have the potential to be affected.
- Director of Nursing (DON)/Assistant Director of Nursing (ADON) audited current orders for urine specimen collection to ensure that instructions to collect via straight catheterization is included in the order and no other deficient practices were identified.

3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F773 including:
- Obtaining urine specimens via clean catch and straight catheterization
- Obtain orders to collect urine specimen via clean catch and/or via straight catheterization

4. Monitoring
- DON/designee shall audit residents urine specimen orders to ensure collection via straight catheterization is obtained Daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate

483.75(c)(1)-(4)d)(1)(2)(e)(1)-(3)(g)(2)(ii)(iii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations: Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending March 27, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 27, 2026, identified repeated deficiencies related to failure to correct deficient practices related to care plan revision, quality of care, services to prevent/heal pressure ulcers, safe environment that is free of accident hazards, laboratory services, complete and accurate accounting of controlled medications and infection control. The facility's plan of correction for a deficiency regarding a failure to revise residents' care plans, cited during the survey ending March 27, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding care plan revisions. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending March 27, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending March 27, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F686, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding services to prevent/heal pressure ulcers. The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending March 27, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards. The facility's plans of correction for deficiencies regarding laboratory services, cited during the survey ending March 27, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F773, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding laboratory services. The facility's plan of correction for a deficiency regarding complete and accurate accounting of controlled medications, cited during the survey ending March 27, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding complete and accurate accounting of controlled medications. The facility's plans of correction for deficiencies regarding infection control, cited during the surveys ending March 27, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding infection control. Refer to F657, F684, F686, F689, F773, F755, F880 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.
 Plan of Correction - To be completed: 04/27/2026

1. Corrective Action
- F657—care plan revisions
- F684—quality of care
- F686—prevent/heal pressure ulcers
- F689—safe environment/free of hazards
- F773—lab services
- F755—accurate accounting of controlled meds
- F880—infection control
- Refer to individualized plan of correction for each above item.

2. Identifying other residents
- Residents currently residing in the facility have the potential to be affected.

3. Systemic Changes
- Director of Nursing (DON)/designee shall in-service all staff including agency staff regarding F867 including:
- Quality Assurance Performance Improvement (QAPI) policy
- F657, F684, F686, F689, F773, F755 and F880
1. These in-services were either in-person, in a classroom setting or 1:1 either in person or by telephone. Any staff missing in-services will not work until they receive training. Any staff who fail to comply with the points of the in-services will be further educated and/or progressive discipline will begin as indicated.
- DON/designee shall submit Plan of Correction (POC) audits to Quality Assurance Performance Improvement (QAPI) committee and governing body monthly to ensure identified issues are properly addressed.

4. Monitoring
- DON/designee shall review POC audits for completion and addressed appropriately to ensure compliance is maintained daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to QAPI for analysis and to be addressed as appropriate.


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 guidance from the Centers for Disease Control (CDC - the national health protection agency) and clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to Clostridioides difficile (C-diff-a bacteria that can cause severe diarrhea and inflammation of the colon) infection for one of 33 residents reviewed (Resident 11).

Findings include:

The Facility's policy regarding isolation and transmission-based precautions dated December 18, 2025, indicated that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Residents with diarrhea and suspected clostridium difficile will be placed on contact precautions while awaiting laboratory results.
A quarterly Minimum Data Set (MDS) assessment (required assessment of a resident's abilities and care needs) for Resident 11, dated February 10, 2026, revealed that the resident was cognitively impaired, was always incontinent of bowel, required assistance for staff with daily care needs, and had diagnosis that included high blood pressure and a stroke.

A nurses note dated February 23, 2026, at 2:43 p.m. stated that Resident 11 had tested positive for clostridium difficile.

A laboratory test dated February 23, 2026, revealed that Resident 11 was positive for clostridium difficile.

Observations on February 25, 2026, at 9:54 a.m. revealed that Resident 11 was lying in his bed and did not have contact isolation signs on his door.

Interview with Licensed Practical Nurse 1 on February 25, 2026, at 9:54 a.m. confirmed that Resident 11 did not have contact isolation on door and he should have.

Interview with the Nursing Home Administrator on February 25, 2026, at 10:48 a.m. confirmed that Resident 11 did not have contact isolation signs on door and that he should have had them.

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





 Plan of Correction - To be completed: 04/27/2026

1. Corrective Action
- Resident 11 isolation sign for Enteric precaution was placed on the door immediately after speaking with surveyor on 2/25/26.

2. Identifying other residents
- Residents currently residing in the facility on Enteric isolation precautions have the potential to be affected.
- Director of Nursing (DON)/Assistant Director of Nursing (ADON) audited residents with current isolation orders to ensure that the appropriate visual sign is placed on the residents' doors and no other deficient practices were identified.

3. Systemic Changes
- DON/designee shall in-service nurses including agency staff regarding F880 including:
- Isolation and Transmission-based policy
- different types of isolation door signs

4. Monitoring
- DON/ADON shall audit residents on isolation precautions to ensure door signs are placed and accurate for the type of infection daily x 7 days, then weekly x 3 weeks, then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.



§ 201.14(c) LICENSURE Responsibility of licensee.:State only Deficiency.
(c) The licensee through the administrator shall report as soon as possible, or, at the latest, within 24 hours to the appropriate Division of Nursing Care Facilities field office serious incidents involving residents as set forth in § 51.3 (relating to notification). For purposes of this subpart, references to patients in § 51.3 include references to residents.

Observations:

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the Department of Health of resident incidents involving hot coffee burns for two of 33 residents reviewed (Residents 14 and 95).

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated November 25, 2025 revealed that the resident was cognitively impaired and required moderate assistance from staff for daily care needs.

Nurse's note for Resident 14, dated February 6, 2026, at 11:35 a.m., revealed that the resident spilled hot tea from her lunch tray on her right chest area.

Incident report for Resident 14 dated January 25, 2026, revealed that the resident received a reddened area to her chest from hot tea.

There was no documented evidence to indicate that this coffee burn incident was reported to the Department of Health.

Interview with the Director of Nursing February 27, 2026, at 12:15 p.m. confirmed that the Department of Health was not notified of Resident 14 receiving a burn from hot coffee.

A quarterly MDS assessment for Resident 95, dated January 26, 2026, revealed that the resident had severe cognitive impairment, required set up or clean up assistance with meals and had diagnosis that included dementia.

Nurse's note for Resident 95, dated January 25, 2026, revealed that on January 25, 2026, at 6:30 p.m. the registered nurse went into the resident's room to take her dinner tray and observed that she had spilled her coffee onto her chest. The resident was unable to give a description of the incident due to her advanced dementia. The registered nurse did observe an area of pink skin to the resident's chest measuring approximately 12 centimeters (cm) by 12 cm.

Incident report for Resident 95 dated January 25, 2026, revealed that the resident received a pink area to her chest from hot coffee.

There was no documented evidence to indicate that this coffee burn incident was reported to the Department of Health.

Interview with the Director of Nursing February 27, 2026, at 2:15 p.m. confirmed that the Department of Health was not notified of Resident 95 receiving a burn from hot coffee.






 Plan of Correction - To be completed: 04/27/2026

1. Corrective Action
- Resident 14 reportable event was submitted to State agency on 2-27-26 by the Director of Nursing (DON)
- Resident 95 reportable event was submitted to State agency on 3-1-26 by the Director of Nursing


2.Identifying other residents
- Residents with recent hot liquid spills have the potential to be affected.
- DON/Assistant Director of Nursing (ADON) audited Risk Management reports related to hot liquid spills for the past 3 months to ensure similar incidents are reported to the state agency and no other deficient practices were identified.

3. Systemic Changes
- Administrator shall in-service DON/ADON/Clinical leadership regarding State Tag 1040 including:
- Reportable events and hot liquid spill incidents

4. Monitoring
- DON/designee shall audit risk management reports related to hot liquid spills to ensure timely reportable event was submitted weekly x 3 weeks then monthly x 3 months or until sustained compliance is achieved.
- Audit results shall be submitted to Quality Assurance Performance Improvement for analysis and to be addressed as appropriate.


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