Pennsylvania Department of Health
BRINTON MANOR NURSING AND REHABILITATION
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

BRINTON MANOR NURSING AND REHABILITATION
Inspection Results For:

There are 143 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.


BRINTON MANOR NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State licensure, Civil Rights Compliance Survey and an abbreviated survey for two complaints completed on June 5, 2026, it was determined that Brinton Manor Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.\~

Plan of Correction:

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

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

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

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

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

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

Observations:

Based on clinical record reviews, resident interviews and staff interviews, it was determined that the facility failed to properly assess two of twenty-three residents reviewed (Resident 3 and Resident 66).

Findings Include:

Review of Resident 3's quarterly MDS assessment (MDS - periodic assessment of resident care needs) dated April 22, 2026, Section H0100 Bowel and Bladder indicated that the resident had an indwelling foley catheter (a flexible tube inserted into the bladder to continuously drain urine.)

No current, discharged, or completed orders for an indwelling foley catheter were observed in Resident 3's physician orders.

Review of resident 3's care plan revealed no care plan or interventions for an indwelling foley catheter.

During interview conducted with Resident 3 on June 3, 2026, at 1:04 p.m., Resident 3 denied ever requiring the use of an indwelling foley catheter.

Interview conducted with Director of Nursing (DON) on June 4, 2026, when the above was presented, the DON confirmed Resident 3 did not require use of an indwelling foley catheter and the MDS was inaccurately documented.

Review of Resident 66's medical diagnoses revealed a diagnosis for Diabetic Retinopathy (a serious eye condition caused by damage to the blood vessels in the retina due to Diabetes Mellitus (- a condition that occurs when the body can't properly use blood sugars, leading to high sugar levels) .)

Resident 66's care plan revealed a focus dated April 14, 2025, indicating the resident has impaired visual function related to Diabetes Mellitus (DM- with bilateral DM retinopathy.
During interview conducted with Resident 66 on June 2, 2026, at 11:35 p.m., Resident 66 stated that he/she had a visual deficit and was only able to see shadows.

Review of Resident 66's May 7, 2026, Quarterly MDS, Section B1000 indicates the resident has adequate ability to see in adequate light.

Interview conducted with Director of Nursing (DON) on June 4, 2026, at 10:15 a.m. when the above was presented, the DON confirmed Resident 66 had a visual deficit and the MDS was incorrectly documented.

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

Plan of Correction - To be completed: 07/22/2026

1 Inaccurate MDS coding was identified for Resident 3's catheter status and Resident 66's visual status, and corrections have been made to both assessments
2 The RNAC reviewed and corrected other affected MDS as appropriate and verified consistency with the clinical record, physician orders, care plan, and supporting documentation.

3 The MDS coordinator re-educated the RNAC and licensed nursing staff on accurate MDS coding requirements, including validation of Section H0100 and Section B1000 against the applicable look-back period and supporting documentation prior to submission of the assessment.

4 The RNAC will audit 5 random completed MDS assessments weekly x4 weeks, then monthly x2 months, with findings reported to QAPI and additional corrective action/education provided as needed.

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

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

Observations:

Based on observation review of facility's policy and clinical records, and interview with resident and staff, it was determined that the facility failed to follow a respiratory order and provide sanitary measures for handling, cleaning and storage of respiratory equipment for two out of eight residents reviewed (Resident 34, and 37).

Findings include:

Review of facility policy "Administering Medications through a Small Volume (Handheld) Nebulizer (a medical device that coverts liquid medication into a fine mist for inhalation directly into the lungs for the treatment of breathing difficulty. It consists of a mask or mouthpiece, a medicine cup, tubing and a machine that converts the liquid medication into a mist", dated

2001, revealed: "Rinse and disinfect the nebulizer equipment according to facility protocol; or a. wash pieces in warm, soapy water; b. allow to air dry on a paper towel. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it."

Observation of Resident 34's bedside table on June 4, 2026, at approximately 9:30 a.m. revealed a nebulizer mask attached to a medicine cup and tubing laying on top of various belongings on Resident 34's bedside table. The tubing was unlabeled and there was a small amount of clear liquid in the medication cup.

Observation of Resident 34's bedside table on June 5, 2026, at approximately 1:05 p.m. revealed a nebulizer kit laying on top of various belongings on Resident 34's bedside table. There was no label on the tubing, indicating when it had last been changed, and there was a

small amount of clear liquid in the medication cup.

The observation was witnessed by E9 on June 5, 2026, at approximately 1:10 p.m.

A review of Resident 37's diagnosis list revealed that the resident was admitted to the facility on March 19, 2026, with diagnoses including acute and chronic respiratory failure with hypoxia (meaning your lungs aren't getting enough oxygen, both long-term and suddenly, causing dangerously low oxygen levels in the blood), and chronic respiratory failure with hypercapnia (meaning your lungs aren't getting enough oxygen and they cannot get rid of carbon dioxide, both long-term and suddenly).

A review of Resident 37's physician's order dated March 20, 2026, at 7:00 p.m., revealed and active order for "0xygen at 2L/min continuously via nasal canula every shift for COPD. Baseline o2 saturation is 90%".

An observation conducted on June 2, 2026, at 11:00 a.m., revealed an oxygen concentrator set at 4-5 L/min, with the flowmeter ball fluctuating between 4 and 5 L/min.

An observation conducted on June 2, 2026, at 1:00 p.m., revealed an oxygen concentrator set at 4-5 L/min, with the flowmeter ball fluctuating between 4 and 5 L/min.

An observation conducted on June 3, 2026, at 12:45 p.m., revealed an oxygen concentrator set at 4-5 L/min, with the flowmeter ball fluctuating between 4 and 5 L/min.

An interview with the Director of Nursing (DON) conducted on June 5, 2026, at 10:00 a.m., confirmed Resident 37's oxygen concentrator was not set according to the physician's order. The DON stated the resident should have been receiving 2L/min as ordered.

The facility failed to ensure Resident 37's oxygen was administered in accordance with the physician's order.

A review of Resident 37's physician's order dated June 20, 2026, revealed an order "Resident to use [their] own AVAP (Average Volume-Assured Pressure Support a noninvasive ventilator with automatic mode that adjusts pressure to deliver a consistent targeted volume of air, q HS (every bedtime) setting in accordance with pre-set up".

An observation conducted on June 2, 2026, at 1:00 p.m., June 3, 2026, at 9:00 a.m., and June 4, 2026, at 10:00 a.m., revealed a bedside machine that was labeled "CPAP" (Continuous Positive Airway Pressure- This delivers a steady stream of pressurized air through a tube and mask to keep your throat open as you sleep) The machine was set up at "6.0 cm H2o".

An interview was conducted with Resident 37 on June 4, 2026, at 2:00 p.m. Resident 37, who was alert and oriented, confirmed that they have been using the CPAP machine since the machine that they brought from home broke a few weeks ago. The residents reported that the facility provided the current machine that they have been using.

A review of the nursing progress notes dated April 16, 2026, at 10:23 p.m., revealed "Called to [respiratory company name] therapist to set up a new BIPAP (A non-invasive ventilation device that delivers two distinct levels of air pressure to assist breathing) machine because the resident's own has malfunctioned. Awaiting call back."

An interview with the Director of Nursing (DON) was conducted on June 5, 2026, at 10:00 a.m. The DON confirmed that the residents' order for an AVAP was not followed.

The facility failed to ensure Resident 37's order for an AVAP at bedtime was followed.

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

28 Pa Code 211.5(f) Clinical Records

Plan of Correction - To be completed: 07/22/2026

1 Resident 34's nebulizer mask is dated, cleaned, and stored properly.
Resident 37's oxygen is set per physician orders.
Resident 37 is using the correct respiratory equipment as ordered by physician.
2 Current residents with respiratory treatments were reviewed to ensure nebulizer equipment is dated, cleaned and stored appropriately.
Current residents with oxygen orders were reviewed to ensure that oxygen is set to physician orders.
Current residents with orders for AVAPS, CPAP's and BiPAP's were reviewed to ensure correct equipment is being used per MD order

3 Licensed Nurses were re-educated on Administering medications through a small volume (handheld) nebulizer with emphasis on cleaning, dating and storing equipment
Licensed Nurses were re-educated on oxygen administration policy with emphasis on following physician orders
Licensed Nurses were re-educated on following physician orders for residents requiring respiratory pressure support

4
DON/designee will audit random residents with orders for hand held nebulizer treatments weekly x4, then monthly x2 to ensure that equipment is clean, dated and stores appropriately and report findings to QAPI Committee.
DON/designee will audit random residents weekly x4, then monthly x2 with physician orders for oxygen to ensure that oxygen is being administered per order and report findings to QAPI Committee.
DON/designee will audit random residents weekly x4, then monthly 2 to ensure residents with orders for respiratory pressure support have the appropriate equipment and report findings to QAPI committee.

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.

Plan of Correction - To be completed: 07/22/2026

1 Per-shift fluid intake monitoring were reviewed for Residents 1, 7, and 37 and excess fluids removed from their rooms. Resident 53's fall mat was placed on the window side per order and care plan.
2 The DON or designee will audit and educate current residents for fluid restriction orders, per-shift documentation, bedside fluids match order and residents with fall mat orders for placement matches order and care plan.
3 Nursing staff will be re-educated on encouraging a restricting fluid policy with emphasis on documenting fluid intake by shift, controlling bedside fluids for restricted residents, and verifying ordered interventions against the care plan. Nursing staff were reeducated on making sure fall mats are placed appropriately for residents requiring them.
4 The DON or designee will audit fluid-restriction documentation/bedside compliance and fall mat placement for affected residents weekly x4, then monthly x2. Results reported to QAPI.

483.10(e)(1),483.12(a)(2),483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

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

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

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

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

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

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

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

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

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

Observations:

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to monitor the resident's behaviors, medication side effects, and document indications for a resident receiving a psychotropic medication for one of the five residents reviewed (Resident 13).

Findings:

A review of the facility's policy titled "Psychotropic Medication Use", undated, revealed that psychotropic medication management is an interdisciplinary process that involves determining adequate indication for use, and adequate monitoring for efficacy and adverse consequences. The same policy revealed that residents receiving psychotropic medications are monitored, and the response to treatment is documented. In addition, residents are monitored for adverse consequences associated with psychotropic medications, including anticholinergic effects, cardiovascular effects, metabolic effects, neurologic effects, and psychosocial effects.

A review of Resident 13's diagnosis list includes bipolar disorder (A Disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).

A review of Resident 13's physician's order dated November 5, 2025, revealed an order for Olanzapine (An anti-psychotic medication) oral tablet 20 mg one tablet at bedtime for Bipolar.

A review of Resident 13's physician's order revealed an order for Lorazepam 1 mg, one tablet every 12 hours as needed for anxiety. The order was renewed every 14 days.

A review of Resident 13's May 2026 Medication Administration records revealed that from May 1 until May 31, 2026, the resident was administered as-needed Lorazepam 41 times without an appropriate indication. In addition, residents' behaviors and psychotropic side effects monitoring were not documented.

An interview conducted with the Director of Nursing (DON) on June 5, 2026, at 9:28 a.m., confirmed that Resident 13 was administered as-needed Lorazepam without appropriate indications. The DON further confirmed that behavior and side effects monitoring for the use of anti-psychotic medication was not done.

The facility failed to ensure Resident 13 had an appropriate indication before administering an as-needed anti-anxiety medication, and their behaviors and medication side effects were monitored.

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

28 Pa Code 211.5(f) Clinical Records

28 PA Code 211.10(a) Resident care policies

Plan of Correction - To be completed: 07/22/2026

1 Resident 13's PRN Lorazepam order was reviewed by the attending physician for continued appropriateness and documented indication, and behavior monitoring was initiated.
Residents 13 olanzapine was reviewed by attending physician and behavior/side effect monitoring was initiated.
2 — The DON or designee will audit current residents on PRN anti-anxiety. Current residents with anti-psychotic medications were reviewed to confirm a documented indication at administration and active behavior/side-effect monitoring; identified gaps will be corrected.
3 — Licensed nursing staff will be re-educated on the Psychotropic medication use policy with emphasis on documenting indication at each PRN psychotropic administration and completing behavior monitoring. And complete side-effect monitoring for anti-Psychotics.
4 — The DON or designee will audit random residents with psychotropic medication orders weekly x4, then monthly x2. Results reported to QAPI.

483.20(e)(1)(2) REQUIREMENT Coordination of PASARR and Assessments:

§483.20(e) Coordination.
A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes:

§483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

§483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Observations:

Based on interview and record review, the facility failed to incorporate PASSAR level 2 recommendations into the resident's care plan for one out of eight residents reviewed (Resident 9).

Findings include:

Review of Resident 9's annual Minimum Data Set (MDS - a mandatory assessment of a resident's care needs and medical condition) dated December 5, 2025 revealed that Resident 9 was completely dependent on facility staff for the completion of activities of daily living and required substantial assistance for mobility. Resident 9 had diagnoses that included anxiety disorder, bipolar disorder (a severe mood disorder) and schizophrenia (severe mental disorder affecting how a person thinks, feels, and behaves). Resident 9 received antipsychotic (for the treatment of bipolar disorder and schizophrenia) medication, anti-platelet (for the prevention ofblood clots) medication, hypoglycemic (for the treatment of increased blood sugar) medication and anti-seizure medication.

The facility failed to indicate on the MDS that the resident qualified for a Level II Preadmission Screening and Resident Review (PASARR - a mandatory screen of all residents entering long term care for severe mental illness or disability that determines if a resident qualifies for a higher level of care while in the facility due to that severe mental illness or disability) determination.

Review of Resident 9's PASARR dated June 25, 2019, revealed that Resident 9 "requires a further Level II (indicating that a resident may require certain care and services provided by the nursing home, and/or specialized services provided by the State) evaluation"

Review of Resident 9's facility care plan revealed that Resident 9 "meets the criteria PASARR II level of determination secondary of serious mental illness." Review of Resident 9's care plan interventions revealed "Consult MCO (managed care organization - a contracted service provider)."

Review of Resident 9's facility care plan specified the name of the MCO and the name of a contact but did not specify the specialized services the resident was to receive or the frequency with which they were to be provided.

Review of the Person-Centered Service Plan provided by the MCO dated June 17, 202, revealed that Resident 9 was to receive specialized services thorough the MCO weekly for 90 days between January 13, 2025, and June 16, 2026, a total number of two times.

Interview with Employee E4 on June 4, 2026 at approximately 11:00 a.m. with the Director of Nursing in attendance revealed that the resident was to receive specialized services but could not indicate what those specialized services entailed. Further interview revealed that the facility failed to maintain any documentation of these services in the resident's record.

Plan of Correction - To be completed: 07/22/2026

1 Resident 9's care plan was reviewed and level II recommendations were added to the care plan and MCO was contacted to see if resident is still eligible for specialized services.
2 The Social Services Director or designee will review current residents with a PASARR Level II determination to confirm services and frequency, if recommended in the care plan and delivery is documented.
3 Social Services staff will re-educate random residents on incorporating PASARR Level II recommendations—specific services, frequency, and tracking of delivery—into the care plan.
4 The Social Services Director or designee will audit random residents with PASARR Level II records for care plan specificity and service documentation weekly x4 monthly x2. Results reported to QAPI.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based on record review, the facility failed to ensure that the attending physician documented their rationale for not addressing a medication irregularity documented by the pharmacist during their monthly review of medications for three of 16 residents reviewed (Residents 3, 9,and 18).

Findings include:

Review of Resident 3's monthly Pharmacist Medication Regime Reviews (MRR) revealed a regime review dated June 1. 2026, noting a recommendation for the resident's Voltaren gel (a topical anti-inflammatory drug used for relief of joint pain) order, indicating "on for 12 hours and off 12 hours". A recommendation was made to please remove these instructions since the gel can be applied up to four times daily.

The physician signed and disagreed with the recommendation on June 1. 2026, but did not provide a rational as to why he/she disagreed with the recommendation.

Review of Resident 3's physician orders revealed the changes were not made.

Review of Resident 9's physician order summary revealed an order dated March 28, 2025, for Protonix Tablet Delayed Release 40MG (milligrams). Give 1 tablet by mouth in the morning for GERD (gastro-esophageal reflux disease where stomach acid flows back up the tube connecting the mouth to the stomach).

Review of Resident 9's Medication Reconciliation Review dated June 1, 2026 revealed the following: "Currently receiving Protonix (pantoprazole) since 3/2023. Long term use of PPIs has been associated with increased risk of pneumonia, c. Difficult, hypomagnesemia fractures, and both B12 and iron deficiencies. Please consider a reduction to 20mg daily."
The physician checked "disagree" on the Medication Reconciliation Review form and provided no rationale for the disagreement.

Review of Resident 18's monthly Pharmacist Medication Regime Reviews revealed a regime review dated January 4, 2026, indicating the resident has been receiving Loratadine routinely since December 2024. A recommendation was made to please evaluate current need and consider PRN (as needed) use if appropriate.

The physician signed and disagreed with the recommendation on January 6. 2026, but did not provide a rationale as to why he/she disagreed with the recommendation.

Review of Resident 18's physician orders revealed the changes were not made.

Review of Resident 18's monthly Pharmacist Medication Regime Reviews revealed a recommendation dated June 1, 2026, indicating the resident has been receiving Loratadine routinely since December 2024. Please evaluate current need and consider PRN use if appropriate.

The physician signed and disagreed with the recommendation on June 1. 2026, but did not provide a rationale as to why he/she disagreed with the recommendation.

Review of Resident 18's physician orders revealed the changes were not made.

28 Pa. Code 211.10(c) Resident care policies

Pa Code 211.12 (c) Nursing Services

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

Plan of Correction - To be completed: 07/22/2026

1 -Residents 3,9,18 pharmacy recommendations were reviewed with physician and rational documented for reason for declination of recommendation.
2 - Pharmacy recommendations for past 30 days reviewed for documented rational if recommendation was refused and if rational, physician was contacted to review and document rational for refusal.
3 -Unit managers and Physicians were reeducated on completion of pharmacy review declinations to include rational as to why it is being declined.
4 -DON/designee will audit random pharmacy recommendations weekly x4 then monthly x2 for rational on recommendations that are declined by physician

483.65(a)(1)(2) REQUIREMENT Provide/Obtain Specialized Rehab Services:

§483.65 Specialized rehabilitative services.
§483.65(a) Provision of services.
If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident's comprehensive plan of care, the facility must-

§483.65(a)(1) Provide the required services; or

§483.65(a)(2) In accordance with §483.70(f), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act.

Observations:

Based on interview, observation, and record review, the facility failed to deliver rehab servicesfor one out of eight residents reviewed (Resident 34).

Findings include:

Review of facility policy "Therapy Services Policy" (undated) revealed "Services will be designed to assist residents in attaining and maintaining their highest practicable level of physical ...well-being."

Review of Resident 34's annual Minimum Data Set (MDS - a mandatory assessment of a resident's care needs and medical condition) dated March 20, 2026, revealed that Resident 34 was cognitively intact, dependent on facility staff for the completion of activities of daily living and mobility. Resident 34's diagnoses included traumatic brain injury (TBI - a disruption of normal brain function caused by an external force ranging from mild concussions to severe, life-threatening injuries), multiple sclerosis (a disease that causes breakdown of the protective covering of the nerves), muscle wasting and atrophy (thinning of muscle mass due to diseases
or lack of use), and muscle weakness (generalized). Resident 34 was not receiving therapy services at the time of the annual assessment.

Interview with Resident 34 on June 2, 2026, at approximately 9:30 a.m. revealed that they had been evaluated for therapy "a couple of weeks ago and they came to my room a couple of times, but they stopped, and I don't know why."

Review of Physical Therapy Evaluation &; Plan of Treatment dated May 13, 2026, revealed that Resident 34 was certified for physical therapy for 12 times within the 30-day period between May 13, 2026, and Jun 11, 2026. The evaluation revealed "Pt (patient) is a 35 y.o. (year old) female, history of TBI s/p (status post - after) MVA (motor vehicle accident). Pt was referred to PT (physical therapy) per pt's request." The evaluation revealed: "patient demonstrates good rehab potential."

Review of Physical Therapy Treatment Encounter Notes revealed that Resident 34 received therapy services on May 13, 2026, May 14, 2026, May 21, 2026, and May 23, 2026. Review of the Summary of Daily Skilled Services dated May 23, 2026, revealed "actively participates with skilled interventions" and "Complexities/Barriers Impacting Session: None Present."

Interview with E6 on June 5, 2026, at approximately 12:30 p.m. revealed that the resident was receiving therapy, but had been discharged on June 3, 2026. No discharge summary had been entered into Resident 34's chart.

Interview with the E7 on June 5, 2026, at approximately 1:30 p.m., with the Director of Nursing and Nursing Home Administrator present, confirmed that Resident 34had been discharged from therapy on June 3, 2026, but could not provide the discharge summary. E7 confirmed thatResident 34 could continue therapy services by asking for them. The facility failed to provide evidence documenting why Resident 34 was discharged from therapy after only 4 sessions or why Resident 34 went 11 days without therapy services without notification of discharge. E7 confirmed that Resident 34could resume therapy services by asking for them.

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

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

Plan of Correction - To be completed: 07/22/2026

1 -Unable to retroactively correct the alleged deficient practice.

2 - Like Residents:
A. Residents currently receiving Physical Therapy will be audited to ensure that Physical Therapy is provided in accordance with the resident's comprehensive plan of care.
B. Residents DC's from Physical Therapy in the past 14 days were audited to ensure they or their responsible parties were informed of the reason for discharge.
3 - A. Physical Therapists were educated by the Regional Rehabilitation Director/designee on providing care in accordance with the resident's comprehensive plan of care.
B. Physical Therapists will be educated by Regional Rehabilitation Director/designee on informing the residents or their rps on the reason(s) for pt discharge.
4 -
The DOR/designee will audit random residents receiving physical therapy services weekly x4, then monthly x2, to ensure visits are conducted per the comprehensive plan of care; findings reported to the QAPI committee.
The DOR/designee will audit random residents discharged from physical therapy weekly x4, then monthly x2, for documentation of notification of discharge; findings reported to the QAPI committee.

§ 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 of facility staffing data, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents on day shift, one licensed practical nurse per 30 residents on evening shift, and one licensed practical nurse per 40 residents on night shift, for three of three weeks of facility staffing reviewed (Weeks of May 1. 2026, May 22, 2026, and June 1, 2026).

Findings include:

Review of the weeks of May 1. 2026, May 22, 2026, and June 1, 2026, revealed the following dates on dayshift did not meet the requirement of one licensed practical nurse (LPN) per 25 residents during day shift:

May 24, 2026

Review of the weeks of May 1. 2026, May 22, 2026, and June 1, 2026, revealed the following dates on dayshift did not meet the requirement of one licensed practical nurse (LPN) per 30 residents during evening shift:

May 5, 2026

Review of the weeks of May 1. 2026, May 22, 2026, and June 1, 2026, revealed the following dates on dayshift did not meet the requirement of one licensed practical nurse (LPN) per 40 residents during night shift:

May 4, 2026, May 6, 2026, May 24, 2026, May 27, 2026, May 28, 2026, June 3, 2026, June 4, 2026

Interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 5, 2026, at 2:00 p.m. when the NHA and DON confirmed that the LPN staffing ratios were not met on the above days.

Plan of Correction - To be completed: 08/06/2026

1 - Upon review, there were no grievances or negative resident care outcomes identified related to resident related to staffing ratios on the dates reviewed. Current staffing schedules were reviewed to ensure compliance with required nurse aide ratios.
2 - Scheduler and or designee will continue to continue to contact the multiple agencies under contract and in- house staff to fill callouts and meet ratios. All resources to meet staffing regulations will be utilized.
3 - Nursing administration and scheduler will be reeducated on nurse staffing and ratio requirements.
4 - Audits of nurse aide ratios will be conducted weekly x4 weeks by NHA/designee to ensure nurse aide ratio is met. Audits will be reported to QAPI for review and further recommendations as
needed.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on review of facility staffing data, it was determined that the facility failed to ensure a minimum of one registered nurse per 250 residents for day shift two of twenty-one days of facility staffing reviewed (Weeks of May 1. 2026, May 22, 2026, and June 1, 2026).

Findings include:

Review of the weeks of May 1. 2026, May 22, 2026, and June 1, 2026, revealed the following dates on day shift did not meet the requirement of one Registered Nurse (RN) per 250 residents:

May 24, 2026, and May 25, 2026

Interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 5, 2026, at 2:00 p.m. when the NHA and DON confirmed that the RN staffing ratios were not met on the above days.

§ 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.

Plan of Correction - To be completed: 08/06/2026

1 - Findings of PPD cannot be retroactively corrected.
2 - The facility will continue to hold daily staff meetings to review staffing levels and make the necessary adjustments as possible to meet the state minimum requirement of 3.2. All resources to meet staffing levels will be utilized.
3 - NHA or designee will re-educate nursing administration and scheduling that staffing levels must be 3.2 or above with the appropriate staff to perform care in the facility.
4 - Audits will be conducted weekly x4 weeks and then monthly x2 months by facility leadership/designee to ensure the facility maintained a PPD of 3.2 or above. Audits will be reported to QAPI for review and further recommendations as needed.

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