Pennsylvania Department of Health
CLEPPER MANOR
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CLEPPER MANOR
Inspection Results For:

There are 126 surveys for this facility. Please select a date to view the survey results.

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


CLEPPER MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on February 27, 2026, it was determined that Clepper Manor 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:

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

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

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

Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan and/or provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 15 residents reviewed (Residents R3, R4, and R41).

Findings include:

A facility policy dated 1/21/26, entitled "Baseline Care Plan" revealed "The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care." Further review revealed "A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident / representative can understand. The summary shall include, at a minimum the following: The initial goals of the resident, a summary of the resident's medications and dietary instructions, and any services and treatments to be administered by the facility and personnel acting on behalf of the facility." And "The person providing the written summary of the baseline care plan shall: Obtain a signature from the resident /representative to verify that the summary was provided and make a copy of the summary for the medical record."

Resident R3's clinical record revealed an admission date of 2/4/26, with diagnoses that included Kidney Failure (kidneys are no longer able to work therefore cannot filter waste and toxins from the blood), Dysphagia (a medical condition characterized by difficulty swallowing solids, liquids, or both, which can lead to choking, coughing, or the sensation of food being stuck in the throat), and High Blood Pressure.

Resident R3's clinical record lacked evidence that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Resident R3 and/or their representative.

Resident R4's clinical record revealed an admission date of 1/21/26, with diagnoses including, fracture of the pubis bone (one of three bones that form the hip bone), muscle wasting (loss of muscle tissue causing reduced size, strength, and movement), muscle weakness, and dysphagia (difficulty swallowing).

Resident R4's clinical record lacked evidence that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Resident R4 and/or their representative.

Resident R41's clinical record revealed an admission date of 7/25/25, with diagnoses that included Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), Chronic Obstructive Pulmonary Disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing), and Lung Cancer.

Resident R41's clinical record lacked evidence that a baseline care plan was initiated, or a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Resident R41 and/or their representative.

During an interview on 2/27/26, at 10:11 a.m. Corporate Registered Nurse confirmed there was no evidence that a baseline care plan was initiated for Resident R41 or that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Residents R3, R4, and R41 and/or their representative.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 04/10/2026

No adverse effects occurred as a result.

Resident 3, resident 4, and resident 41 were provided a copy of orders and baseline care plan by 3.30.26

All residents who admitted in last 30 days will be reviewed to ensure orders and baseline care plans were provided, any identified that were not provided a care plan or orders will be provided to them by 3.30.26

Regional Director of Clinical Operations educated Administrator, Social Services, and Director of nursing on baseline care plan policy and guidelines by 3.26.26

Director of nursing/designee will educate all licensed Registered nurses by 3.26.26 regarding the baseline care plan policy.

Director of Nursing/Designee will audit 3-5 new resident admissions weekly, for four weeks, to ensure policy is being followed. Audit will include validating copy of baseline care plan and orders were given to the resident/responsible party and that a signature was obtained. A copy of the baseline care plan will be retained. Audits will be initiated on 3.30.26

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§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 policy and clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan and failed to review and/or revise resident care plans for three of 15 residents reviewed (Residents R7, R32, and R33).

Findings include:

Review of a facility policy entitled, "Comprehensive Care Plans" with a policy review date of 1/21/26, indicated that "the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment."

Resident R7's clinical record revealed an admission date of 3/17/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure.

Review of Resident R7's comprehensive care plan on 2/25/26, revealed that of the 31 care plans present, 31 had an outstanding target date of 2/8/26. The care plans included the problem categories of: anticoagulant therapy, skin integrity, mood, bladder/bowel incontinence, discharge planning, overactive bladder, diabetes, aspiration, dental, dehydration, anxiety, insomnia, cardiac output, advanced directive, ADL's, leave, allergies, pacemaker, , vision, activities, nutrition, psychotropics, COPD, cognitive process, CHF, respiratory, constipation, hypotension, communication, pain, and falls.

During an interview on 2/25/26, at 1:00 p.m. the Director of Nursing (DON) confirmed that Resident R7's care plans were not reviewed and/or revised as required.

Resident R32's clinical record revealed an admission date of 7/9/24, with diagnoses that included Dementia (loss of memory, language, problem-solving, and other thinking abilities), Chronic Obstructive Pulmonary Disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing), and Anxiety.

Review of Resident R32's comprehensive care plan on 2/26/26, revealed that of the 29 care plans present, 29 had an outstanding target date of 2/16/26. The care plans included the problem categories of: skin integrity, falls, dementia, discharge planning, ADL's, behaviors, bladder/bowels, activities, nutrition, hearing, attention seeking, thyroid, pain, osteoporosis, anticonvulsant use, GERD, allergy, COPD, leave, colitis, antidepressant/antianxiety use, antiplatelet use, advanced directive, weight loss, constipation, skin impairment, narcotics, hyperlipidemia, and dental.

During an interview on 2/26/26, at 11:50 a.m. the DON confirmed that Resident R32's care plans were not reviewed and/or revised as required.

Resident R33's clinical record revealed an admission date of 6/27/25, with diagnoses that included bullous pemphigoid (a skin disorder causing large, itchy, fluid filled blisters), cognitive communication deficit (a loss of language, problem-solving, and other communicating abilities), lack of coordination, and cellulitis (a bacterial skin infection affecting the underlying tissues of the skin).

Review of Resident R33's incontinence care plan on 2/25/26, included goals for toileting needs to be met by staff, with interventions aimed at the prevention of infection and/or skin impairment thru next review. Interventions included be aware of changes in urinary elimination, inspect for skin breakdown and intervene when needed, observe abdomen for distention, complaints of fullness or discomfort, observe or ask resident regarding any burning, pain or itching when urinating, observe or ask resident any burning, pain, or itching when urinating, observe urine for color odor, clarity, frequency, and amount as needed, obtain vital signs, especially temperature if resident becomes symptomatic, and review labs as ordered.

Resident R33's comprehensive care plan on 2/25/26, revealed no evidence that their incontinence care plan was updated with using a urinal then placing it on his/her bedside table that also was used for drinks/meals throughout the day and nighttime.

Observation on 2/25/26, at 8:30 a.m. revealed a urinal full of urine sitting beside his/her breakfast meal on his/her bedside table. Observation on 2/26/26, at 10:30 a.m. revealed a urinal half full of urine sitting beside his/her drink containers on his/her bedside table. During observations, Resident R33 indicated that it was his/her desire to place urinal on bedside table.

During an interview on 2/26/26, at 11:10 a.m. the Assistant Director of Nursing confirmed that the urinal on Resident R33's bedside table should be part of his/her care plan, since he/she desires to keep it there all the time.

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

Plan of Correction - To be completed: 04/10/2026

No adverse effects occurred as a result.

Regional Director of Clinical Operations educated the Interdisciplinary Team (IDT) by 3.26.26 regarding comprehensive care plans and policy. The Interdisciplinary Team consists of the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Therapy, Activities, and Dietary.

R7, R32, R33 had comprehensive care plans developed by 3.26.26

All other residents will have care plans reviewed by 3.26.26 by Director of Nursing/Designee to ensure all have a comprehensive care plan to include revisions and review.

Director of Nursing/Designee will audit 3-5 care plans, three times a week, for four weeks to ensure the care plans are comprehensive to include revisions and review. Audits will be initiated 3.30.26

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning 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.

§483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.

Observations:

Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for two of 15 residents reviewed (Residents R34 and R41).

Findings include:

A facility policy dated 1/21/26, entitled "Care Planning Resident Participation" revealed "The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident / resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan." The policy further revealed "If the participation of the resident and/or resident representative is determined not practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record."

A facility policy dated 1/21/26, entitled "Comprehensive Care Plans" revealed "The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to ....The resident and the resident's representative, to the extent possible ...." The policy further revealed "The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment."

Resident R34's clinical record revealed an admission date of 4/5/24, with diagnoses that included Bipolar Disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), Neurogenic Bladder (when the nerves or the brain cannot communicate effectively to the muscles in the bladder), and Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time).

Resident R34's clinical record revealed the following MDS (Minimum Data Set federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessments with the following Assessment Reference Date (ARD a look back period of time for the MDS assessment): quarterly MDS with ARD of 6/20/25, annual MDS with ARD of 9/19/25, quarterly MDS with ARD 12/12/25, and quarterly MDS with ARD of 1/21/26.

Resident R34's clinical record revealed that a care plan meeting was held with resident representative joining via telephone on 6/4/25, and 12/2/25, which were both prior to the MDS ARD's of 6/20/25, and 12/12/25. Further review of Resident R34's clinical record lacked any evidence that the resident and/or resident representative was invited to or attended a care plan meeting in conjunction with the 9/29/25, annual or 1/21/26, quarterly MDS.

Resident R41's clinical record revealed an admission date of 7/25/25, with diagnoses that included Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), Chronic Obstructive Pulmonary Disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing), and Lung Cancer.

Resident R41's clinical record revealed the following MDS assessments with the following ARDs: admission 7/29/25, quarterly 10/29/25, quarterly 12/31/25, and quarterly 1/21/26.

Resident R41's clinical record revealed that a care plan meeting was held on 8/4/25 with resident representative joining via telephone on 8/4/25. Further review of Resident R41's clinical record lacked any evidence that the resident and/or resident representative was invited to or attended a care plan meeting in conjunction with the 10/29/25, 12/31/25, or 1/21/26, quarterly MDS's.

During an interview on 2/27/26, at 9:53 a.m. Social Worker stated he/she was told to have a care plan meeting four times a year, but when he/she was on leave they don't know if any care plan meetings were held. When asked if the care plan meetings are scheduled in conjunction with the MDS schedule, he/she stated no, and was only told to have one four times a year. Social Worker confirmed that the clinical records lacked evidence of Resident R34 and R41 and/or their representatives being routinely invited to attend care plan meetings.

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 04/10/2026

No adverse effects occurred as a result.

R34 and R41 will have conference scheduled prior to 3.26.26

Regional Director of Clinical Operations educated the Interdisciplinary Team (IDT) on the Care planning resident participation policy by 3.26.26. The Interdisciplinary Team consist of Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Social Services Director, Business office Manager, Therapy Director, and Activities.

Administrator/Designee will coordinate a care conference schedule in conjunction with the Minimum set data schedule. Administrator/designee will send care conference invites to all appropriate parties to include resident and resident representative for quarterly care conferences by 3.26.26

Administrator/Designee will audit 3 resident care conferences scheduled each week for four weeks to ensure compliance, to include appropriate invitations to appropriate parties. Audits will be initiated by 3.30.26

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine need for further compliance.

Results of the audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months and quarterly thereafter to determine the need for further action and ensure ongoing compliance. If noncompliance is identified, additional education and monitoring will be implemented.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§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 review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of three main kitchen freezers (Small Chest Freezer).

Findings include:

Review of facility policy entitled, "Monitoring of Cooler/Freezer Temperature" with a policy review date of 1/21/26, indicated that "Logs for recording temperatures for each freezer will be posted in a visible location outside the freezer unit; temperatures will be checked at least twice per day; thermometers call be placed inside each cooler/freezer and calibrated at least once a week."

Observations on 2/24/26, at 11:15 a.m. of the small kitchen chest freezer containing 6 bags of frozen hotdog buns, 2 bags of frozen zucchini slices with a best buy date of 10/27/26, and 2 bags of frozen cauliflower with a best by date of 9/27/26 did not contain a thermometer to monitor the freezer temperature or log of temperature monitoring.

During an interview on 2/24/26, at the time of observation, the Dietary Manager confirmed that the freezer did not contain a thermometer and that temperature monitoring was not being completed for the small chest freezer. He/she also confirmed that the small freezer should have a thermometer and temperature logs should be completed twice a day.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 04/10/2026

No adverse effects occurred as a result.

The freezer temperature was immediately obtained and within acceptable limits, a thermometer was placed in the freezer, and a temperature log was placed on the freezer. All freezers/coolers were reviewed and thermometers were all validated.

Regional Director of Clinical Operations educated Administrator/Kitchen manager regarding the monitoring of temperature policy by 3.26.26

Kitchen manager will educate all kitchen staff regarding temperature monitoring policy by 3.26.26

Kitchen manager/desginee will audit all coolers/freezers 3 times a week for 4 weeks to ensure policy is followed, temperatures are obtained, and food is stored in accordance to standards. Audits will be initiated 3.30.26

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

483.25 REQUIREMENT Quality of Care:

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

Observations:

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure that physician's orders were followed for one of 15 residents reviewed (Resident R20).

Findings include:

Review of Resident R20's clinical record revealed an admission date of 7/7/21, with diagnoses that included transient ischemic attack (TIA - minor stroke or mini-stroke with noticeable symptoms going away, hyperlipidemia (high cholesterol), and hypertension (high blood pressure).

Review of Resident R20's clinical record revealed a physician's order dated 8/23/24, for left upper extremity elbow brace: don(apply) every morning, doff(remove) in the afternoon. Remove once per shift to inspect skin integrity/circulation.

Observations on 2/24/26, at 11:56 a.m. revealed Resident R20 lying in his/her bed without a brace on their left elbow. He/she stated, "I haven't had my elbow brace on in a long time. I want it on, it helps me."

Observations on 2/25/26 at 9:40 a.m., and again at 10:10 a.m. revealed Resident R20 lying in bed with no brace on their left elbow.

During an interview on 2/25/26, at 10:30 a.m. the Director of Nursing (DON) confirmed that Resident R20 did not have a brace on his/her left elbow. The DON also confirmed that Resident R20 should have a brace applied to their elbow according to physician's orders.

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

Plan of Correction - To be completed: 04/10/2026

No adverse effects occurred as a result.

R20 splint was located, and orders were validated to be accurate. All other residents with splints were reviewed, all splints located and orders validated to be accurate.

Regional Director of Clinical Operations educated Administrator and Director of Nursing by 3.26.26 regarding following physician orders.

Director of Nursing/designee will educate all licensed nurses by 3.26.26 regarding following physician orders.

Director of Nursing/designee will audit 3 residents with splints 3 times a week, for four weeks, to ensure physician orders are being followed. Audits will be initiated on 3.30.26

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

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

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

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

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

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

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

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

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

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

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain a clean homelike environment for one of two units (South).

Findings include:

A facility policy dated 1/21/26, entitled "Routine Cleaning and Disinfection" revealed "It is the policy of this facility to ensure the provisions of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible". Further review revealed "Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to ....Resident chairs, IV poles ....."

Observations on the South Unit on 2/24/26 at 3:38 p.m. and 2/25/26, at 10:35 a.m. revealed Resident R29 sitting in his/her wheelchair with dried dirty substance on the frame of the wheelchair and where the bilateral leg rest attached to the wheelchair.

During an interview on 2/25/26, at 10:37 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R29's wheelchair was unclean with dried debris noted. LPN Employee E1 stated night shift is responsible for cleaning the wheelchairs and the wheelchair should not be dirty.

Observations on the South Unit on 2/24/26 at 9:00 a.m., 2/25/26, at 8:35 a.m. and 2/26/26, at 11:00 a.m., revealed Resident R8's tube feed pole (also known as an IV pole) had splattered dried tube feed formula on the pole and legs of the pole.

During an interview on 2/26/26, at 11:43 a.m. the Director of Nursing (DON) confirmed that Resident R8's tube feed pole was splattered with dried tube feed formula on the pole and legs of the pole and further confirmed that the tube feed pole was not clean or sanitary.

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

Plan of Correction - To be completed: 04/10/2026

No adverse effects occurred as a result.

Regional Director of Clinical Operations educated the Administrator and Director of Nursing regarding a clean homelike environment by 3.26.26, education will include wheelchairs and tube feed poles.

Administrator/Designee will educate housekeeping and direct care nursing by 3.26.26 regarding a clean homelike environment to include wheelchairs and tube feed poles, by 3.26.26

All equipment, to include tubefeed poles and wheelchairs were immediately cleaned.

Administrator/designee will audit 3-5 resident rooms, 3 times a week for 4 weeks to ensure equipment is cleaned, and the clean homelike policy is followed. Audits will be initiated 3.30.26

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for self-administration of medication for one of 15 residents reviewed (Resident R7).

Findings include:

Review of facility policy entitled" Medication Administration" dated 1/21/26, revealed that "Certain medications for self-administration may be kept at the bedside (in a locked cabinet or drawer) with a physician's order and a self-medication assessment showing the resident is competent to self-administer medication."

Resident R7's clinical record revealed an admission date of 3/17/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure.

Observations on 2/24/26, at 12:30 p.m., and again on 2/25/26, at 12:45 p.m. revealed Resident R7 with three vials (small container for holding liquid medication) of Ipratropium-Albuterol Solution (liquid medication for use in a nebulizera machine that converts liquid medication into a fine mist for inhalationto treat shortness of breath, COPD, or wheezing) on the bedside tray table.

During an interview with Resident R7 on 2/24/26 at 12:30 p.m. he/she stated, "I have my nebulizer solution on my bedside table," "I just use it myself when I need it."

Resident R7's clinical record revealed a physician's order dated 12/19/25, for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligrams/milliliters) 3 ml inhale orally every 4 hours as needed for shortness of breath or wheezing via nebulizer; Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligrams/milliliters) 3 ml inhale orally every 8 hours for COPD.

Resident R7's clinical record lacked a self-administration of medication assessment or an order to keep the Ipratropium-Albuterol Solution at the bedside.

During an interview on 2/25/26 at 1:00 p.m., the Director of Nursing confirmed that Resident R7's bedside table contained three vials of Ipratropium-Albuterol Solution for use in a nebulizer and that his/her clinical record lacked a self-administration assessment of medication and self-administration order.

28 Pa. Code 211.5(f)(i)(ii)(iii) Medical records

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

Plan of Correction - To be completed: 04/10/2026

No adverse effects occurred as a result.

R7 was interviewed and assessed and no longer self-administers any medication due to appropriateness.

Regional Director of Clinical Operations educated the Administrator and DON regarding self-administration medication policy and assessment by 3.26.26.

Director of Nursing/Designee will educate all nurses on self-administration medication policy and assessment by 3.26.26

All residents will be re-assessed for medication self-administration by 3.26.26 and any resident deemed appropriate to self-administer will have an assessment and care plan reflective.

Director of Nursing/Designee will audit 3-5 residents, 3 times a week, for four weeks to ensure any resident deemed appropriate to self-administer has an appropriate lock box, assessment and care plan. Audits will be initiated 3.30.26

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

483.70(m),483.70(m)(2)(iii)(iv)(6) REQUIREMENT Binding Arbitration Agreements:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.70(m) Binding Arbitration Agreements.
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

§483.70(m)(2) The facility must ensure that:
(iii) The agreement provides for the selection of a neutral arbitrator agreed upon by both parties; and
(iv) The agreement provides for the selection of a venue that is convenient to both parties.

§483.70(n)( (6) When the facility and a resident resolve a dispute through arbitration, a copy of the signed agreement for binding arbitration and the arbitrator's final decision must be retained by the facility for 5 years after the resolution of that dispute on and be available for inspection upon request by CMS or its designee.

Observations:

Based on review of the facility's arbitration agreement and staff interview, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident and/or resident representative and facility agree on the selection of an arbitrator and venue.

Findings include:

Review of the facility's arbitration agreement, Section C for who will conduct the arbitration, specifies that the arbitration shall be conducted by the National Arbitration Forum (NAF) and if the NAF process is no longer in existence at the time of dispute, or NAF is unwilling or unable to conduct the arbitration, a mutually acceptable neutral third-party alternative will be agreed to by the parties. The arbitration agreement lacked evidence addressing that the selected venue would be convenient to both the resident and/or resident representative and the facility.

During an interview on 2/25/26, at 12:11 p.m. Nursing Home Administrator confirmed the language of the arbitration agreement does not provide for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue that is convenient to both parties.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 04/10/2026

No adverse effects occurred as a result.

Regional Director of Clinical Operations educated Administrator and Social Services, by 3.26.26 regarding Binding Arbitration agreements and components to include ensuring a neutral and fair process by ensuring both resident/representative and facility agree on the selection of both the arbitrator and venue.

Legal team was notified regarding the verbiage in the current arbitration agreement. Legal team updated and revised facility arbitration agreement by 3.26.26.

Administrator/Designee will have all residents/responsible parties sign the updated agreement by 3.30.26
Administrator/Designee will conduct weekly audits for four weeks, 3 admissions will be audited weekly to ensure correct agreement signed.

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

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

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

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

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

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

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

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

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

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for two of two resident units (North and South Units).

Findings include:

A facility policy entitled, "Enhanced Barrier Precautions," dated 1/01/26, revealed it is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms (MDROs). "Enhanced barrier precautions" refer to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds and/or indwelling medical devices (e.g., central line, urinary catheter [a tube inserted into the bladder to drain urine], feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status.

Observations on 2/24/26, 2/25/26, and 2/26/26, revealed no educational signage or PPE maintained for EBP for residents with urinary catheters or wounds throughout the facility.

During an interview on 2/26/26, at 1:00 p.m. the Director of Nursing confirmed the facility lacked signage and PPE readily available when providing care for residents with urinary catheters and chronic wounds, who should have EBP maintained.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 04/10/2026

No adverse effects occurred as a result.

All residents were reviewed by 3.26.26 and any residents that were deemed to need enhanced barrier precautions, had precautions put in place. Residents had orders entered and care plans updated.

Regional Director Clinical Operations educated Director of Nursing on Infection control to include enhanced barrier precautions by 3.26.26

Director of Nursing/designee will educate all nurses and certified nursing assistants on the policy and required recommendations of enhanced barriers by 3.26.26

Director of nursing/designee will audit 3-5 residents, 3 times per week for 4 weeks to ensure those deemed to need enhanced barrier precautions are in enhanced precautions with appropriate signage, supplies and documentation. Audits will be initiated on 3.30.26.

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

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

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

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

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

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:

Based on review of clinical records and Minimum Data Set (MDS federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of one of 15 residents reviewed (Resident R3).

Findings include:

MDs instructions for section K0300 indicated that if weight loss of five percent or more in the last month or loss of 10 percent or more in the last six months to code "yes."

Resident R3's clinical record revealed an admission date of 2/4/26, with diagnoses that included Kidney Failure (kidneys are no longer able to work therefore cannot filter waste and toxins from the blood), Dysphagia (a medical condition characterized by difficulty swallowing solids, liquids, or both, which can lead to choking, coughing, or the sensation of food being stuck in the throat), and High Blood Pressure.

Resident R3's clinical record revealed during a prior admission in December 2025, he/she weighed 96.6 pounds on 12/30/25. At time of admission on 2/4/26, Resident R3 weighed 92 pounds, which is a 4.76 percent weight loss in 36-days.

Resident R3's admission MDS with an ARD of 2/11/26, under section K-Swallowing / Nutrition Status section K0300 Weight loss revealed for "loss of 5% in the last month or loss of 10% or more in last 6 months" was coded as "Yes, not on a prescribed weight loss regimen."

During a telephone interview on 2/26/26, at 11:42 a.m. Registered Nurse Assessment Coordinator Employee E2 confirmed that Resident R3 did not have a significant weight loss and the MDS dated 2/11/26, for Section K0300 Weight Loss was coded incorrectly and should have been coded "no or unknown."

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.5(f)(ix) Medical records

Plan of Correction - To be completed: 03/30/2026

I hereby acknowledge the CMS 2567-A, issued to CLEPPER MANOR for the survey ending 02/27/2026, AND attest that all deficiencies listed on the form was corrected. No adverse effects occurred as a result.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios of one NA per 10 residents on the day shift for 10 of 21 days reviewed (8/26/25, 8/29/25, 12/29/25, 12/30/25, 1/3/26, 2/19/26, 2/21/26, 2/22/26, 2/23/26, and 2/25/26)); failed to meet the NA ratio of one NA per 11 residents on the evening shift for 17 of 21 days reviewed (8/25/25, 8/27/25, 8/28/25, 8/29/25, 12/28/25, 12/29/25, 12/30/25, 12/31/25, 1/1/26, 1/2/26, 1/3/26, 2/19/26, 2/20/26, 2/21/26, 2/22/26, 2/23/26, and 2/24/26); and failed to meet the NA ratio of one NA per 15 residents on the overnight shift for 11 of 21 days reviewed (8/24/25, 8/25/25, 8/29/25, 8/20/25, 12/29/25, 1/1/26, 1/3/26, 2/21/26, 2/22/26, 2/23/26, and 2/25/26).

Findings include:

Review of facility nursing staffing documents for the time periods from 8/24/25, through 8/30/25, 12/28/25, through 1/2/26, and 2/19/26, through 2/25/26 revealed the following NA staffing shortages for the day shift where the NA ratios were not met:

08/26/25 census of 44 3.83 NAs worked and 4.00 were required
08/29/25 census of 43 3.86 NAs worked and 4.30 were required
12/29/25 census of 40 3.96 NAs worked and 4.00 were required
12/30/25 census of 40 3.33 NAs worked and 4.00 were required
01/03/26 census of 41 3.00 NAs worked and 4.10 were required
02/19/25 census of 44 3.50 NAs worked and 4.40 were required
02/21/26 census of 46 4.03 NAs worked and 4.60 were required
02/22/26 census of 46 4.23 NAs worked and 4.60 were required
02/23/26 census of 46 4.03 NAs worked and 4.60 were required
02/25/26 census of 47 4.26 NAs worked and 4.70 were required

Review of facility nursing staffing documents for the time periods from 8/24/25, through 8/30/25, 12/28/25, through 1/2/26, and 2/19/26, through 2/25/26 revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:

08/25/25 census of 44 2.43 NAs worked and 4.00 were required
08/27/25 census of 45 3.06 NAs worked and 4.09 were required
08/28/25 census of 45 3.20 NAs worked and 4.09 were required
08/29/25 census of 43 3.33 NAs worked and 3.91 were required
12/28/25 census of 39 1.80 NAs worked and 3.55 were required
12/29/25 census of 40 1.86 NAs worked and 3.64 were required
12/30/25 census of 40 1.56 NAs worked and 3.64 were required
12/31/25 census of 40 2.10 NAs worked and 3.64 were required
01/01/26 census of 40 1.63 NAs worked and 3.64 were required
01/02/26 census of 41 2.36 NAs worked and 3.73 were required
01/03/26 census of 41 2.96 NAs worked and 3.73 were required
02/19/26 census of 44 2.93 NAs worked and 4.00 were required
02/20/26 census of 45 1.93 NAs worked and 4.09 were required
02/21/26 census of 46 2.10 NAs worked and 4.18 were required
02/22/26 census of 46 2.06 NAs worked and 4.18 were required
02/23/26 census of 46 2.13 NAs worked and 4.18 were required
02/24/26 census of 46 3.88 NAs worked and 4.18 were required

Review of facility nursing staffing documents for the time periods from 8/24/25, through 8/30/25, 12/28/25, through 1/2/26, and 2/19/26, through 2/25/26 revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:

08/24/25 census of 44 2.80 NAs worked and 2.93 were required
08/25/25 census of 44 2.80 NAs worked and 2.93 were required
08/29/25 census of 43 2.83 NAs worked and 2.87 were required
08/30/25 census of 43 1.90 NAs worked and 2.87 were required
12/29/25 census of 40 2.43 NAs worked and 2.67 were required
01/01/26 census of 40 2.06 NAs worked and 2.67 were required
01/03/26 census of 41 2.53 NAs worked and 2.73 were required
02/21/26 census of 46 2.03 NAs worked and 3.07 were required
02/22/26 census of 46 2.13 NAs worked and 3.07 were required
02/23/26 census of 46 2.53 NAs worked and 3.07 were required
02/25/26 census of 47 3.06 NAs worked and 3.13 were required

During an interview on 2/27/26, at 11:05 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the above days and shifts.

Plan of Correction - To be completed: 04/10/2026

Administrator and Director of Nursing, educated by Regional Director of Clinical Operations by 3.30.26 on required state Certified Nursing Assistant ratios.
In an attempt to achieve appropriate staffing ratios, the facility has implemented a daily assignment grid that designates the required Certified Nursing assistant ratios needed to meet state requirements. Assignment grids will be reviewed during labor meetings no less than 3x per week for 3 weeks.
When a call off is received, the nursing supervisor will make every effort to fully replace staff hours. In the event it cannot be covered, the Director of Nursing will be notified so that administrative staff can reach out to employees for coverage. Administrative coverage will be obtained should we not find staff coverage.
The facility will continue with recruitment and retention efforts to include enforcing the attendance policy.
The facility will monitor staffing ratios utilizing the Department of Health Staffing Calculator tool 3x per week for 3 weeks.

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Licensed Practical Nurse (LPN) ratios of one LPN per 30 residents on evening shift for one of 21 days reviewed (8/25/25); and failed to meet the LPN ratio of one LPN per 40 residents on the overnight shift for five of 21 days reviewed (8/24/25, 8/26/25, 8/28/25, 8/29/25, and 2/20/26).

Findings include:

Review of facility nursing staffing ratio documents for the time periods of 8/24/25, through 8/30/25, 12/28/25, through 1/2/26, and 2/19/26, through 2/25/26, revealed the following LPN staff shortage for the day shift where the LPN ratio was not met:

08/25/25 census of 44 residents 1.23 LPNs worked and 1.47 were required

Review of facility nursing staffing documents for the time periods from 8/24/25, through 8/30/25, 12/28/25, through 1/2/26, and 2/19/26, through 2/25/26 revealed the following LPN staffing shortages for the overnight shift where the LPN ratios were not met:

08/24/25 census of 44 residents 1.00 LPNs worked and 1.10 were required
08/26/25 census of 44 residents 1.06 LPNs worked and 1.10 were required
08/28/25 census of 45 residents 1.10 LPNs worked and 1.13 were required
08/29/25 census of 43 residents 1.03 LPNs worked and 1.08 were required
02/20/26 census of 45 residents 1.06 LPNs worked and 1.13 were required

During an interview on 2/27/26, at 11:05 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum LPN ratios for the above days and shifts.

Plan of Correction - To be completed: 04/10/2026

Administrator and Director of Nursing, educated by Regional Director of Clinical Operations by 3.30.26 on required state Licensed Practical Nurse ratios.
In an attempt to achieve appropriate staffing ratios, the facility has implemented a daily assignment grid that designates the required licensed practical nurses ratios needed to meet state requirements. Assignment grids will be reviewed during labor meetings no less than 3x per week for 3 weeks.
When a call off is received, the nursing supervisor will make every effort to fully replace staff hours. In the event it cannot be covered, the Director of Nursing will be notified so that administrative staff can reach out to employees for coverage. Administrative coverage will be obtained should we not find staff coverage.
The facility will continue with recruitment and retention efforts to include enforcing the attendance policy.
The facility will monitor staffing ratios utilizing the Department of Health Staffing Calculator tool 3x per week for 3 weeks.

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits. The Quality Assurance Performance Improvement (QAPI) Committee will review monthly for three months. The QAPI Committee will determine the need for continued monitoring and/or additional education to ensure sustained compliance.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the 3.2 minimum number of general nursing care hours for each 24 hour period for five of 21 days reviewed (8/25/25, 12/29/25, 2/21/26, 2/22/26, and 2/23/26).

Findings include:

Review of facility nursing staffing documents for the time periods from 8/24/25, through 8/30/25, 12/28/25, through 1/2/26, and 2/19/26, through 2/25/26 revealed the following general nursing care hours was below the minimum 3.2 per patient day (PPD) on the following days:

08/25/25 3.07 PPD
12/29/25 3.18 PPD
02/21/26 2.85 PPD
02/22/26 2.93 PPD
02/23/26 2.96 PPD

During an interview on 2/27/26, at 11:05 a.m. the Nursing Home Administrator confirmed the facility did not meet the 3.2 PPD minimum direct nursing care hours on the above dates.

Plan of Correction - To be completed: 04/10/2026

Administrator and Director of Nursing, educated by Regional Director of Clinical Operations by 3.30.26 on required state PPD. The Director of Nursing and Administrator are responsible for scheduling.

In an attempt to achieve appropriate staffing levels, the facility has implemented a daily staffing grid that designates the required staffing hours per patient day (PPD) needed to meet state requirements. Assignment grids will be reviewed during labor meetings no less than 3x per week for 3 weeks. The Nursing Home Administrator and Director of nursing will utilize the staffing grid when creating and adjusting schedules to ensure required staffing hours per patient day (PPD) are met. We do not have a scheduler.

When a call off is received, the nursing supervisor will make every effort to fully replace staff hours. In the event it cannot be covered, the Director of Nursing will be notified so that administrative staff can reach out to employees for coverage. Administrative coverage will be obtained should staffing coverage not be secured to maintain required staffing hours per patient day.

The facility will continue with recruitment and retention efforts to include enforcing the attendance policy.

The facility will monitor staffing hours per patient day utilizing the Department of Health Staffing Calculator tool 3x per week for 3 weeks.

Results of audits will be reviewed by the Quality Assurance Performance Improvement committee to determine further need of audits.

Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee monthly for three months and quarterly thereafter to determine the need for further action and to ensure sustained compliance.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement