Pennsylvania Department of Health
WECARE AT ROLLING MEADOWS REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WECARE AT ROLLING MEADOWS REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 147 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.


WECARE AT ROLLING MEADOWS REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance, and an Abbreviated survey in response to two complaints completed on August 27, 2026, it was determined that We Care at Rolling Meadows Rehab and Nsg 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\~

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§ 483.25 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 facility policy, facility documents, clinical record review, and a staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of ten residents (Resident R18 and R98). Resulting in harm of change in condition without timely intervention (Resident R18) and harm of hospitalization (Resident R98) requiring a blood transfusion.

Findings include:

Review of facility policy "Assisting the Nurse in Examining and Assessing the Resident" reviewed 1/20/26, revealed the primary purpose of assessing the resident is to gather detailed information that will help to develop a plan of care that is appropriate for the resident. The assessment process is continuous. Accurately documenting and reporting your observations provides the interdisciplinary team with information that helps tailor the care plan to the specific needs of the resident.

Review of the facility policy "Change in Resident's Condition or Status" reviewed 1/20/26, indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing. payments, resident rights, etc.). The nurse will notify the resident's Attending Physician or physician on call when there has been a specific instruction to notify the physician of changes in the resident's condition. A "significant change" of condition is a major decline or improvement in the resident's status that:

Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not "self-limiting").Impacts more than one area of the resident's health status.Requires interdisciplinary review and/or revision to the care plan.Ultimately is based on the judgement of the clinical staff and guidelines outlined in the Resident Assessment Instrument.

Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation, Background, Assessment, and Recommendation) Communication form (Nursing tool used to provide detailed report to provider). The nurse will record in the resident's record information relative to changes in the resident's medical/mental condition or status.

Review of facility policy "Charting and Documentation" reviewed 1/20/26, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record:

-Objective observations;
-Medications administered;
-Treatments or services preformed;
-Changes in the resident's condition;
-Events, incidents or accidents involving the resident; and
-Progress toward or changes in the care plan goals and objectives.

The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:

13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment

Review of the clinical record indicated Resident R18 was admitted to the facility on 10/17/22.

Review of Resident R18's Minimum Data Set (MDS-a periodic assessment of care needs) indicated diagnoses of hypertension (high blood pressure), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and polyarthritis (pain and stiffness in five or more joints, swelling, warmth and redness around the joints, decreased range of motion or trouble moving the joints). A review of the MDS Section C: Cognitive Patterns-Brief Interview for Mental Status: Section C0500: BIMS Summary Score-Resident score was 5-severe impairment.

Review of the clinical record revealed:

-7/4/26 06:34 Nursing SBAR: Resident stated she didn't know when it started that she just realized it this morning. Resident eye blood shot. No other complaints r/t her eye. RN assessed. Plan of care continued.

-7/5/26 23:41 Nursing Note: Nurse notified RN that resident has been complaining of Left sided vision loss. Upon assessment RN noted Left pupil is reactive, sclera is red, loss of vision. On Right side, pupil not reactive, pinpoint and vision is normal. Resident is neuro assessed and is at baseline, with the exception of vision loss. Physician notified and RN will add resident to the list to be seen on 7/6/26.

-7/7/26 16:10 Physician Note: Left vision loss, differential includes dry eyes, acute glaucoma, conjunctivitis. Needs seen by Ophthalmology, does not seem to be an ophthalmologic emergency such as a screen coming down on the eye. Urgent ophthalmology referral; that she says this comes and goes is also reassuring; more likely dry eye or a reversible process.

-7/7/26 18:33 Physician Note: Provider into see resident today. Resident continues with complaints of not being able to see out of left eye well. Left eye appears to be red and resident states she is having some discomfort in it. New orders received for Bleph 10, 2 drops QID (Four times a day) x 10 days, resident aware. Message left for Resident Representative

-7/17/26 09:02 Nursing Note: Late Entry (for 7/16/26 at 12:00)-Resident having increased clear drainage to left eye. Sclera remains pink in color. No itching or pain noted. C/O having visual disturbances in that eye.

-7/21/26 09:26 Nursing Note: Residents sclera in left eye increasingly red/irritated. Scant amount of clear drainage noted. Resident c/o visual disturbances in that eye. RN aware/resident on physician list today.

-7/22/26 10:50 Nursing Note: Late Entry (for 7/21/26 at 12:00)- Primary Care Physician (PCP) in to see residents today. Order received for Ophthalmology consult for L eye discomfort and redness. Call made to brother and sister-in-law with update. Detailed message left at this time.

Review of the clinical record on 8/25/26, revealed no progress notes after 7/21/26 to indicate the Ophthalmology appointment was ordered or scheduled until 8/13/26.

Review of the order from 8/13/26 at 20:02 reveals: Schedule Consult: Eye Appointment Name of Provider/Service: Eye Doctor Date/Time: 09/10/2026 at 0825. PICK-UP.

During interview with resident on 8/25/26, revealed that left eye was still bothering her, appeared red and she still could not see.

During an interview on 8/26/26, at 2:10 p.m. the Director of Nursing confirmed that the facility failed to assess resident and notify the physician that change of condition was still present and unchanged.

Review of the clinical record indicated Resident R98 was admitted to the facility on 7/30/26.

Review of Resident R98's Minimum Data Set (MDS-a periodic assessment of care needs) dated 8/3/26, indicated diagnoses of transient ischemic attack (TIA temporary blockage of blood to the brain often called a mini stroke), liver transplant (removal and replacement of a diseased liver for a healthy liver), and renal insufficiency (poor kidney function impacting waste removal, fluid balance, and blood chemistry regulation). Section C0100 Cognitive Patterns: screening score indicated the resident was cognitively intact.

Review of the physicians' order dated 8/6/26, indicated to administer Eliquis (blood thinner) 2.5 MG oral tablet every 12 hours for atrial fibrillation (AFib irregular heart rhythm).

Additional physicians' order dated 8/7/26, included to monitor for unusual bleeding or bruising every shift. Document number of occurrences seen and notify physician.

Review of the Medication and Treatment Record from every shift on 8/7/26, through 8/26/26, this activity had been marked as completed on all days and shifts except for day shift 8/20/26. No evidence of bleeding, interventions, or physician notification appears in the clinical record prior to the surveyor discussing the status with the Director of Nursing.

Review of the anticoagulant therapy pathway initiated on 8/6/26, included "risk for bleeding":
"Resident will show no signs/symptoms of bleeding""Evaluate skin for evidence of impaired coagulation (bruising, petechia, bleeding from orifice)" "Evaluate for hematemesis" (vomiting blood)

Review of the care plan dated 8/5/26, indicated the resident is at risk forcomplications/rejection due to her liver transplant status. The goal is to be free from signs/symptoms of liver complication including abnormal or unexplained bleeding.

Monitor/document/report to physician signs/symptoms of complications including gastrointestinal bleeding (any part of the digestive tract mouth, stomach, colon, and rectum) blood in stool, nosebleeds and bleeding gums.

Review of the care plan dated 8/12/26, indicated anticoagulant therapy, the resident is atrisk for side effects of medication. Monitor each shift blood tinged or red blood in urine or stools. Monitor skin with each encounter.

During an interview and observation of Resident R98 on 8/24/26, at 10:30 a.m., revealed the resident lying in bed with what appeared to be blood on the resident's lips and chin, a small bruise was observed on her face, near the right temple area. The resident stated that this bleeding has been going on for a couple of days. The resident stated she has some pain with her lips though can eat. When asked if the nurses were aware of the bleeding the resident stated yes, they told me to keep my mouth wet, I have water, lifesavers candy, lip balm, and my moistened towel to wipe my face. These items were observed in use by the resident during the interview.

During a subsequent interview and observation of Resident R98 on 8/25/26, at 8:15 a.m., revealed the resident lying in bed with gauze protruding from her mouth. When asked if it was still bleeding the resident nodded yes. A subsequent observation this same date at 11:50 a.m. revealed the resident eating lunch in bed with her spouse at her bedside. Resident confirmed the bleeding continues.

During an interview on 8/25/26, at approximately 1:30 p.m., with the Director of Nursing (DON), the resident's condition was discussed along with the absence of documentation related to the observed bleeding and interventions the resident reported she was doing.

The DON provided an update at approximately 2:30 p.m., this 8/25/26. A call was placed to the physician this afternoon and an order was placed for Aquaphor ointment, apply to the upper and lower lips topically every shift for wound healing. The DON did not have details as to why there was no documentation related to the bleeding or interventions, prior to the surveyor discussing the concern.

Review of the clinical record entry on 8/26/26, at approximately 9:41 a.m., the DON spoke with the resident regarding the resuscitation status of the resident and hospice care. Resident current status is for a full code (all possible life saving measures) as per her choice and physician order. The resident chose to remain a full code status. The resident's family was updated as per the resident request.

At approximately 11:30 a.m., on 8/26/26, the nurse practitioner was notified by the nurse, that the resident continues with red drainage from the lower lip. Orders were received for labs, the resident, is alert and oriented to person, place and time, family notified.

At approximately 2:19 p.m., on 8/26/26the nurse noted labs returned with critical results, all labs were called to the physician and orders received to transfer the resident to the emergency department. The resident is awake and alert, is aware of the critical labs and wishes to remain a full code with full treatment. The resident's family was updated. Resident transferred to the emergency department via ambulance. Labs results revealed: Complete Blood Count (CBC): White Blood Count (WBC)-2.1 (Within Normal Limits (WNL) 4.0-10.7), Red Blood Count (RBC)-1.97 (WNL 3.7-5.2), Hemoglobin (Hgb)-5.6 (WNL 11.9-15.8), Hematocrit (Hct)- 17.4 (WNL 35.9-46.9), Platelets (Plt)- 46 (140-380). Prothrombin Time Test (PT/INR)- PT-17.0 (WNL 9.5-12.5), INR-1.7 (0.8-1.2).

Review of the clinical record dated 8/27/26, at approximately 9:37 a.m., reveals that the resident had been admitted to the hospital for abnormal labs and had received two units of packed red blood cells (PRBC used when there is significant blood loss) and continues to have mouth bleeding.

During an interview on 8/26/26, at 2:00 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to assess Resident R98 and notify the physician with a change of condition.

During exit interview on 8/27/26, at 1:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of ten residents (Resident R18 and R98), resulting in harm of change in condition without timely intervention (Resident R18) and harm of hospitalization (Resident R98) requiring a blood transfusion.

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

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

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

Plan of Correction - To be completed: 10/08/2026

The Facility submits this plan of correction under the procedures established by the Department of Health in order to comply with the department's directive to change conditions which the department alleges are deficient under date and/or federal long term care regulations. This plan of correction should not be construed as either a waiver or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of state or federal regulatory requirements.

Residents R18 and R98 were immediately assessed and MD notified of condition.
R18 had an eye appointment on 9/10/26 and was ordered Cosopt drops for pressure in her right eye and follow up on 9/24/26.
R 98 returned from the hospital 9/7/26 and passed away on 9/10/26 due to a previous diagnosis of liver failure.
Whole house audit of residents was reviewed for a 2 week period to identify any change in condition documentation and follow up.
Lewis Ligation Support and Clinical Consulting Group will provide Directed Inservice "F684 Quality of Care" education on 9/17/26 for licensed nurses on assessing residents, change in condition, and documentation.
DON or designee will educate licensed nurses on the Assisting the nurse in examining and assessing the resident, change in residents condition or status, and charting and documentation policies.
DON or designee will audit 24 hour report daily for 4 weeks to ensure any change in condition is documented and MD notified.
Audits will be taken to QAPI for review.

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

This is a less serious (but not lowest level) 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 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.

§483.60(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 policy, observations, and staff interview, it was determined that the facility failed to properly verify sanitation levels for three-compartment sink in the Main Kitchen which created the potential for foodborne illness.

Findings include:

Review of the facility policy, "Manual Dishwashing" dated 1/20/26, indicated, "All eating and drinking utensils, as well as food contact surfaces of equipment will be thoroughly washed, rinsed, and sanitized as indicated." "Sanitizer test strips will be used to validate the appropriate concentration of sanitizer, 200 ppm (parts per million) for quaternary ammonia."

During an observation of the three-compartment dishwashing sink in the Main Kitchen on 8/24/26, at 12:39 p.m. the "Pot Sink Sanitation Record" for August 2026, indicated that 100 ppm was documented for breakfast and lunch warewashing on:
8/01/26: 7:40 a.m., 11:50 a.m.
8/02/26: 8:20 a.m., 10:46 a.m.
8/03/26: 7:50 a.m., 10:21 a.m.
8/04/26: 8:15 a.m., 11:45 a.m.
8/07/26: 7:40 a.m., 11:16 a.m.
8/08/26: 8:30 a.m., 10:49 a.m.
8/09/26: 7:45 a.m., 10:12 a.m.
8/10/26: 8:26 a.m., 11:45 a.m.
8/11/26: 7:40 a.m., 10:39 a.m.
8/13/26: 7:40 a.m., 10:39 a.m
8/14/26: 6:48 a.m., 11:06 a.m
8/15/26: 7:21 a.m., 11:09 a.m

No documentation for parts per million was present for:
8/05/26: 12:30 p.m.
8/06/26: 12:40 p.m
8/16/26: No times or measurements
8/17/26: 12:00 p.m
8/22/26: 12:30 p.m
8/23/26: 12:50 p.m

Review of all dates for the dinner-hour warewashing from 8/1/26, through 8/23/26, indicated the letters "DW" in place of the PPM amount.

During an interview and observation on 8/27/26, at approximately 10:00 a.m. Regional Dietary Manager Employee E7 confirmed the facility uses quaternary ammonia, and that 200 PPM is the required sanitation level.

During an interview on 8/27/26, at approximately 11:30 a.m. the Director of Nursing confirmed the facility failed to properly verify sanitation levels for three-compartment sink in the Main Kitchen which created the potential for foodborne illness.

28 Pa. Code: 211.6(f) Dietary Services.

Plan of Correction - To be completed: 10/08/2026

The 3 compartment sink was tested to verify sanitation level at 200 ppm was obtained and documented.
Dietary Manager or designee will educate dietary staff on the sanitation level of the 3 compartment sink and log.
Dietary Manager or designee will observe the staff performing the test for proper procedure and then document the result on the sanitation log of the 3 compartment sink 5x for 2 weeks to ensure the correct sanitation level is recorded.
Audits will be taken to QAPI for review.

§483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:

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.

§483.35 Nursing Services.

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a) Sufficient Staff.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:

(i) Except when waived under paragraph (e) of this section, licensed nurses; and

(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Plan of Correction - To be completed: 10/08/2026

Residents ADL will be provided per Plan of care

House review was completed of interviewable residents to ensure resident call bells are answered to meet resident requests and needs evidenced by resident interviews and observations

DON or designee will educate all staff on Answering the Call Light policy for call bell response times to meet resident requests and needs focusing on identified peak times.

When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff and agency is utilized. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assist with recruiting and hiring new nursing staff. CNA instructor on staff to conduct CNA classes.

DON or designee will audit 5 residents for 2 weeks to ensure their call bell is answered timely to respond to their requests and needs based on resident interviews and observations

Audits will be taken to QAPI for review

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to document delay in treatment as recommended by consult for skin infection for one of eight residents (Resident R83) failed to document skin assessments after diagnosis of fungal infection for one of eight residents (Resident R93) and failed to document assessments while administering an opioid (Resident 112) for pain/air hunger for one of eight residents.

Findings include:
Review of facility policy, "Charting and Documentation" dated 1/20/26, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident's medical record: objective observations, medications administered, treatments or services performed, changes in resident's condition, events, incidents or accidents involving the resident, and progress toward or changes in the car plan goal or objectives.

Review of facility policy "Administering Medications" dated 1/20/26, indicated medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who are administering medications and/or have related services. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Review of facility policy "Administering Pain Medication" reviewed 1/20/26, indicated to administer pain medications as ordered. If there are signs of serious adverse consequences related to narcotic (opioid) analgesics (including somnolence [state of strong or persistent drowsiness or a heavy desire to sleep during normal waking hours], delirium [change in brain function that causes severe confusion, trouble focusing, and rapid shifts in awareness], respiratory depression [breathing becomes too slow or too shallow to keep proper oxygen and carbon dioxide levels in the body], notify the practitioner prior to administering. Report other information in accordance with facility policy and professional standards of practice.

The Kaiser Permanente 0-to-10 pain scale uses numbers from 0 (zero) to 10 (ten) to help measure and share your level of discomfort with your care team.
0 (zero): no pain
1 (one) to 3 (three) = mild: annoying or noticeable pain that does not stop you from doing normal daily tasks.
4 (four) to 6 (six) = moderate: distracting pain that begins to get in the way of your activities and makes it hard to concentrate.
7 (seven) to 10 (ten) = severe: strong to worst possible pain that keeps you from doing normal activities, talking, or functioning.

Review of the clinical record indicated Resident R83 was admitted to the facility on 4/7/25.

Review of the Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 7/2/26, included diagnoses of hypertension (high blood pressure), anxiety (natural response to stress or a perceived which can become excessive and impaired daily living), adult failure to thrive (multi-factor syndrome of physical, mental, and functional decline most common in older adults).

Review of Resident R83's care plan initiated on 4/8/25, revised on 5/19/26 and 6/9/26, for skin integrity indicated to remain free from skin breakdown daily through next review. Resident R83 will have weekly skin assessment to be performed during regularly scheduled bath/shower per facility policy. Administer treatments as ordered and monitor effectiveness. Assess/record/monitor wound healing per facility policy. Inform resident of any new skin breakdown. Revision from 6/9/26, indicated Resident R83 will have no complications from rash through the review date. Resident R83 will avoid scratching and keep hands and body parts from excessive moisture, increase out of bed activity as tolerated, and monitor skin rashes for increased spread or signs of infection.

Review of Resident R83's clinical record revealed a consult with a dermatologist on 8/12/26, resident returned with recommendations for Clindamycin 1% Ointment to be applied to the back once a day after bathing. In review of orders the order was not placed until 8/20/26, no documentation noted to state that consult paperwork was reviewed and recommendation was related to facility physician.

Review of the clinical record indicated Resident R93 was admitted to the facility on 4/20/25.

Review of the MDS dated 8/3/26, included diagnoses of hypertension, muscle weakness, diabetes (a metabolic disorder ub which the body has high sugar levels for prolonged periods of time), end-stage renal disease (final permanent stage of chronic kidney disease requiring either dialysis or kidney transplant).

Review of Resident R93's care plan initiated on 4/20/25, revised on 2/12/26, for skin integrity indicated Resident R93 will remain free from skin breakdown daily through next review date. Resident R93 will have house barrier cream to buttocks, moisturizing lotions with AM and PM care, encourage/remind/assist to turn/reposition as needed or required, support surface to bed: pressure reducing mattress, support surface to chair, pressure reducing cushion for wheelchair. On 6/4/26, care plan initiated for actual impairment to skin integrity of the axilla r/t fungal rash with potential for complications. Resident R93 will have treatment applied per order, avoid scratching and keep hands and body parts from excessive moisture, and encourage good nutrition and hydration in order to promote healthier skin. On 6/7/26, care plan initiated for Resident R93 has a fungal rash under bilateral breasts with an antifungal cream. Goal is to have rash healed by review date. Resident R93 will avoid scratching and keep hands and body parts from excessive moisture, monitor skin rashes for increased spread or signs of infection, seek medical attention if skin becomes bloody or infected.

Review of the clinical record revealed resident seen on 5/23/26 for "Right axilla with red fungal rash. [Medical] on-call notified and new order received. Resident made aware of new orders." Further review of the clinical record-order summary revealed no new orders for this date range, care plan not updated for thirteen days regarding new issue, no further documentation regarding skin assessments after initial date of diagnosis.

Review of the clinical record indicated Resident R112 was admitted to the facility on 7/2/26, with diagnoses that included urinary tract infection (UTI), anxiety, and difficulty in walking.

Review of physician orders revealed the following:
-On 7/5/26, Lorazepam (Ativan prescription benzodiazepine used to treat anxiety disorders) one mg (milligram), give one (1) tablet by mouth one time only for agitation.
-On 7/5/26, Morphine Sulfate (strong opioid pain medication) oral solution 20mg/ml (milliliter), give 0.5 ml by mouth every one (1) hour as needed for moderate to severe pain/air hunger.

Review of the vital signs, and Medication Administration Record (MAR) for July 2026, revealed Resident R112 received the following:
-On 7/5/26, at 2:04 a.m. Vital signs (VS): Blood pressure (BP) was 128/98; Pulse (P) 73; Oxygen (O2) level 98%; Respirations (R)18; Pain level 4/10.
-On 7/5/26, at 11:18 a.m. Pain level 4/10.
-On 7/5/26, at 2:03 p.m. VS: BP 118/87; P 72; O2 98%; R 18; Pain level 6/10.
-On 7/5/26, at 4:50 p.m. Pain level 5/10.
-On 7/5/26, at 5:25 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.
-On 7/5/26, at 6:35 p.m. Morphine Sulfate 20 mg/ml, 0.5ml.
-On 7/5/26, at 7:35 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.
-On 7/5/26, at 8:35 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.
-On 7/5/26, at 9:21 p.m. Lorazepam one mg tablet, one tablet was given.
-On 7/5/26, at 9:35 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.
-On 7/5/26, at 10:09 p.m. VS: BP 105/66; O2 96%; R 16; pain level 5/10.
-On 7/5/26, at 11:37 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml. BP 102/68: P 64; R 20; O2 94%; Pain level 3/10.
-On 7/6/26, at 1:51 a.m. Morphine Sulfate 20 mg/ml, 0.5 ml.
-On 7/6/26, at 6:17 a.m. Morphine Sulfate 20 mg/ml, 0.5 ml.
-On 7/6/26, at 6:50 a.m. VS: BP 84/68; P 112; R 14; O2 88%.
-On 7/6/26, at 9:55 a.m. VS: BP 85/58; P 58; R 24; O2 91%; pain level 0/10.
-On 7/6/26, at 10:55 a.m. pain level 0/10.
-On 7/6/26, at 5:21 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.
-On 7/6/26, at 5:39 p.m. pain level 0/10.
-On 7/6/26, at 8:21 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.

Review of the progress notes failed to reveal an assessment of Resident R112's condition, side effects of medications administered, and/or behaviors observed (agitation, respiratory distress, air hunger) relating to Resident R112 receiving pain medication and lorazepam. Further review of a progress note dated 7/7/26, at 1:45 a.m. indicated Resident R112 ceased to breathe at 12:22 a.m.

During an interview on 8/26/26, at approximately 9:45 a.m. the Director of Nursing confirmed that the clinical record failed to reveal further skin assessments, follow-up care, review of orders, and review of consultation documentation for Resident R83 and R93.

During an interview on 8/27/26, at 11:15 a.m. the Director of Nursing confirmed the medical record failed to include documentation and assessments for Resident R112 receiving morphine sulfate and lorazepam.

28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 211.10 (c)(d) Resident care policies
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 10/08/2026

Resident R83 and R93 have orders in place per MD. R112 discharged 7/7/26.
whole house audit of documentation and assessment for pain medication, review consults upon return from appointments related to skin, skin assessments completed for an identified skin infection.
DON or designee will educate licensed nurses on charting and documentation, administering pain medications, administering medication policies and pain and skin assessment completion and the process of reviewing consultations upon return from an appointment.
DON or designee will audit 5 residents for 2 weeks to ensure that documentation and assessments related to pain medication, skin assessment complete when a skin infection is identified, recommendation reviewed and order placed upon return from an appointment is reflected in the clinical record.
Audit will be taken to QAPI for review.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on a review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to serve food that was palatable for nineteen of thirty-two residents (Residents R9, R90, R500, R501, R502, R503, R504, R505, R506, R507, R508, R509, R510, R511, R512, R513, R514, R515, and R516).

Findings include:

Review of the facility policy "Meal Service Line" last reviewed on 1/20/26, indicated food will be prepared by methods that conserve nutritive value. Flavor and appearance. And will be placed on tray in an attractive manner as near to the time of actual tray service as possible. This is done to ensure acceptable temperatures of food when the tray is served to the resident.

Review of a resident grievance filed on 5/27/26 revealed concerns related to food palatability. The resident noted "the food is repulsive! I've had six or more hot dogs this week more water than oatmeal, blackened pizza, and hard grilled cheese. I've asked at food meetings for some changes that don't happen! Today we had chicken and noodles. Mine had zero chicken. Come on, the kitchen would not eat what they serve! Its's all disgusting."

During an interview on 8/24/26 at approximately 11:15 a.m., Resident R90 laughed when I asked her how the meals tasted like the facility provided. The resident stated I have photos that I send to my friends so they can see what the meals look like. She stated her friends didn't believe her until they had seen the photos. The food is terrible, just terrible, thankfully I am going home. Sometimes it is not always hot when you get it, sometimes it's overcooked, sometimes it is not even what you ordered. Sometimes it's mashed up just like her roommate's mechanical soft diet like everyone gets the same thing on those days.

During an interview on 8/24/26 at approximately 11:30 a.m., Resident R9 stated she has been asking to speak with someone about the food and stated I have nothing good to say about it at all. I have not been here very long, and I don't think I'll be able to tolerate the food here too much longer.

During a group interview, on 8/24/26 at approximately 1:30 p.m., the residents shared their dissatisfaction with the palatability of the food served at the facility. Residents statements included it's not good, every morning your toast gets steamed sitting under the dome with your food, it's always soggy, often the cheeseburgers don't have cheese, the pepperoni pizza doesn't always have pepperoni, the pizza is often over cooked and you can only eat the center of the slice as the edges are too hard, you are to get two pieces of toast and you only get one. The residents state they bring up concerns at food committee however nothing changes, it's like our food concerns go in one ear and out the other. At times, we go to bed hungry because the food is not good. It's like whoever is making and plating the food has never done this before, often it's hard like its overcooked. On occasion it is not hot when you get it. You don't get condiments all the time. Thank God most of us have family who bring in food for us.

Review of six months of facility provided "Resident Dining Committee Notes" indicated:
Most of the minutes were dedicated to attendees' individual food preferences. None of the minutes were signed by the staff.

-3/18/26: Concerns the ham is too hard and individual preferences discussed.
-4/15/26: Concerns individual preferences only,
-5/20/26: Concerns sometimes breakfast is cold and individual preferences discussed.
-6/17/26: Concerns were not visible on the document as another document had been copied over this section and individual preferences discussed.
-7/15/26: Concerns related Food is under or over cooked, eggs and burned cheese. Soggy fries and individual preferences discussed.
-8/19/26: Concerns related to condiments are missing, and not receiving the slices of bread as ordered. Food temperatures are not appropriate and individual preferences discussed.

During an interview on 8/27/26, at 10:00 a.m. the Nursing Home Administrator confirmed that the facility failed to serve food that was palatable.

28 Pa Code: 211.6(b)(c) Dietary services.

Plan of Correction - To be completed: 10/08/2026

Residents R 9 will be interviewed for her specific concerns. Resident R 90 was discharged from the facility.
Food will be prepared and served based on the menus.
Food Committee will be held for the residents to address concerns regarding food palatability including under/over cooked food and food preferences from a group perspective and then individualized based on the responses.
Dietary Manager or designee will educate dietary staff on the Meal Service Line policy.
Dietary Manager or designee will audit 5 residents weekly for 2 weeks by conducting interviews to ensure that food that is being served is palatable by monitoring test tray for temperatures, food preferences honored and observations of tray pass to ensure timely distribution. Dietary Manager or designee will conduct Food Committee specifically addressing food palatability.
Audits will be taken to QAPI for review.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Plan of Correction - To be completed: 10/08/2026

A calendar has been created to accommodate various resident activities based on the activity assessments throughout the day on the dementia unit.
A staff member transferred into the activities department effective 8/30/26 in a FT capacity.
In a previous POC it was implemented that activities assist residents with meal choices based on the alternate menu as a way to promote one on one interactions.
The NHA will educate the activities department on the Activities - cognitively impaired policy and the calendar.
The NHA will audit the calendar and observe activities to ensure they are occurring 3x week for 2 weeks.
Audits will be taken to QAPI for review.

483.25(l) REQUIREMENT Dialysis:

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

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents reviewed. (Resident R5 and R93).

Findings include:

Review of the facility policy "Dialysis Management (Hemodialysis)" dated 1/20/26. The policy indicates that the facility will develop a binder/folder to send to dialysis with the resident. A communication form is placed in the binder after completion of the pre-dialysis assessment. The facility is to complete the pre-dialysis information on the communication form and send with resident on treatment days, to ensure communication of resident information and coordinate care between dialysis center and facility. Dialysis center personnel to complete dialysis communication form and return to facility. The dialysis center may provide their EHR documentation versus manual documentation of treatment on communication form. Upon return from dialysis center, review information provided on dialysis communication form/EHR. Communicate and address as appropriate. Facility to complete post-dialysis information/data and place in resident's medical record and assess and manage post-dialysis complications.

Review of the clinical record indicated Resident R5 was admitted to the facility on 12/5/25.

Review of Resident R5's Minimum Data Set (MDS-a periodic assessment of care needs) dated 6/13/26, indicated diagnoses of hypertension (high blood pressure), diabetes (body does not use insulin effectively), and end-stage renal disease (kidneys fail to filter waste and balance fluids).

Review of Resident R5's physician order dated 6/12/26, indicated dialysis: Monday-Wednesday-Friday at [dialysis center]. Transport time scheduled for 10:45 a.m. for a chair time of 11:00 a.m.

Review of Resident R5's current care plan indicated dialysis three times a week, treatments as scheduled: Monday, Wednesday, and Friday at [dialysis center].

Review of Resident R5's dialysis communication forms from 7/3/26 through 8/24/26 revealed incomplete communication on the following dates:

-Pre-dialysis information incomplete: Weight, Blood Sugar, Assessment (Medication changes, Appetite Problems, Adherence to fluid restrictions, newly developed physical symptoms, food accompanied resident) on 7/3/26, 7/6/26,7/10/26, 7/20/26, 7/22/26, 7/24/26, 7/29/26, 7/31/26, 8/3/26, 8/7/26, 8/24/26.

-Post-dialysis information incomplete: Post-dialysis weight, vitals, dialysis staff signature noted on 7/6/26, 7/10/26, 7/20/26, 7/24/26, 7/29/26, 7/31/26, 8/5/26, 8/12/26, 8/17/26.

Review of the dialysis sheets for Resident R5 does not show an area where the facility does an assessment upon arrival back to the facility.

Review of the clinical record indicated Resident R93 was admitted to the facility on 4/20/23.

Review of Resident R93's MDS dated 8/3/26, indicated diagnoses of hypertension, muscle weakness, diabetes, and end-stage renal disease.

Review of Resident R93's physician order dated 10/28/25, indicated dialysis: Tuesday-Thursday-Saturday at [dialysis center]. Transport time scheduled for 6:00 a.m. for a chair time of 7:00 a.m.

Review of dialysis communication forms from 7/3/26, through 8/24/26 revealed incomplete communication on the following dates:

-Pre-dialysis information incomplete: Weight, Blood Sugar, Assessment (Medication changes, Appetite Problems, Adherence to fluid restrictions, newly developed physical symptoms, food accompanied resident) on 7/8/26, 7/13/26, 7/15/26, 7/22/26, 8/7/26, 8/14/26, 8/24/26.

-Post-dialysis information incomplete: Post-dialysis weight, vitals, dialysis staff signature noted on 7/17/26.

During an interview on 8/26/26, at 9:39 a.m. the Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained in two of three residents.

28 Pa. Code 211.15(f) Clinical Records
28 Pa. Code 211.12(d)(2)(3) Nursing Services.

Plan of Correction - To be completed: 10/08/2026

Resident R5 and R93 dialysis communication form was reviewed for prior non completion.
Whole house dialysis residents dialysis communication forms were reviewed for prior non completion.
DON or designee will educate licensed nurses and Medical Records on the dialysis management policy and dialysis communication form. DON or designee will educate Dialysis Center staff on the regulatory requirements related to completing the dialysis communication form.
DON or designee will audit dialysis residents communication form 3x week for 2 weeks to ensure completion.
Audits will be taken to QAPI for review.

483.70(m)(1)(2)(i)(ii)(3)-(5) REQUIREMENT Entering into Binding Arbitration Agreements:

§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)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(m)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;

§483.70(m)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

§483.70(m)(4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(m)(5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k).

Plan of Correction - To be completed: 10/08/2026

The arbitration agreement in the admissions agreement was revised to reflect an accept or decline option and signature of acknowledgement.
The NHA will educate Admissions and Social Service on completing the arbitration agreement in the admissions agreement.
The NHA will audit the next 10 admissions to ensure that the accept or decline has been chosen and a signature is present.
The audit will be taken to QAPI for review.

§ 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 nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per ten residents during the day shift for 10 of 21 days (8/9/26, 8/13/26, 8/16/26, 8/18/26, 8/20/26, 8/21/26, 8/22/26, 8/23/26, 8/24/26, 8/25/26). One nurse aide per 11 residents on evening shift for 4 of 21 days (8/10/26, 8/16/26, 8/20/26, 8/22/26), and one nurse aide per 15 residents on night shift for 8 of 21 days (8/9/26, 8/15/26, 8/16/26, 8/18/26, 8/18/26, 8/21/26, 8/22/26, 8/23/26).

Findings include:

Review of facility census data and nursing time schedules from 8/9/26, through 8/15/26, 8/16/26 through 8/22/26, and 8/23/26 through 8/29/26 revealed the following nurse aide staffing shortages:

Day Shift:

Date- Census- Full Time Equivalent (FTE)- Present FTE Required
8/9/26- 108 -10.80- 9.69
8/13/26- 108- 10.80- 9.89
8/16/26- 110 -11.00- 10.87
8/18/26- 111- 11.10 -10.94
8/20/26- 112 -11.20- 10.83
8/21/26- 112- 11.20- 8.81
8/22/26- 110- 11.00- 10.80
8/23/26- 109- 10.90 -9.75
8/24/26- 108- 10.80- 10.07
8/25/26- 111- 11.10- 10.87

Evening Shift:
Date- Census- FTE Present- FTE Required
8/10/26- 110- 10.00- 7.93
8/16/26 -110 -10.00 -8.47
8/20/26- 112 -10.18- 9.91
8/22/26- 110- 10.00- 9.97

Night Shift:
Date- Census- FTE Present FTE Required
8/9/26- 108- 7.20- 5.85
8/15/26- 111- 7.40- 7.21
8/16/26- 110- 7.33- 6.55
8/18/26- 111- 7.40- 6.51
8/19/26- 111- 7.40- 6.56
8/21/26- 112- 7.47- 7.16
8/22/26- 110- 7.33- 6.62
8/23/26- 109- 7.77- 6.30

During an interview on 8/26/26, at approximately 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift as required with no additional excess higher-level staff to compensate this deficiency.

Plan of Correction - To be completed: 10/08/2026

The Nursing schedule is created to ensure CNA staffing ratios reflects the current census per shift. Each shifts CNA staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts when needed. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assist with recruiting and hiring new nursing staff.
The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing ratios and PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Daily recruiting calls with the NHA, HR, and recruiter occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.

§ 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 nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse per 25 residents during the day shift for 13 of 21 days (8/9/26, 8/10/26, 8/11/26, 8/12/26, 8/13/26, 8/14/26, 8/15/26, 8/16/26, 8/17/26, 8/18/26, 8/19/26, 8/22/26, 8/23/26). One licensed practical nurse per 30 residents on evening shift for 2 of 21 days (8/12/26, 8/12/26), and one licensed practical nurse per 40 residents on night shift for zero of 21 days.

Findings include:

Review of facility census data and nursing time schedules from 8/9/26, through 8/15/26, 8/16/26, through 8/22/26, and 8/23/26, through 8/29/26, revealed the following licensed practical nurse staffing shortages:

Day Shift:

Date -Census- Full Time Equivalent (FTE)- Present FTE Required
8/9/26- 108- 4.32- 4.04
8/10/26- 110- 4.40- 4.13
8/11/26- 109- 4.36- 4.04
8/12/26- 109- 4.36- 3.51
8/13/26- 108- 4.32- 3.00
8/14/26- 110- 4.40- 3.33
8/15/26- 111- 4.44- 3.17
8/16/26- 110- 4.40- 3.05
8/17/26- 111- 4.44- 2.55
8/18/26- 111- 4.44 -4.04
8/19/26- 111- 4.44- 4.11
8/22/26- 110- 4.40- 3.84
8/23/26- 109- 4.36- 4.04

Evening Shift:

Date- Census- FTE Present -FTE Required
8/10/26- 110- 10.00- 7.93
8/12/26- 109- 10.18- 9.91
8/22/26- 110- 10.00- 9.97

During an interview on 8/26/26, at approximately 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one licensed practical nurse per 25 residents during the day shift, one licensed practical nurse per 30 residents on evening shift, and one licensed practical nurse per 40 residents on night shift as required with no additional excess higher-level staff to compensate this deficiency.

Plan of Correction - To be completed: 10/08/2026

The Nursing schedule is created to ensure LPN staffing ratios reflects the current census per shift. Each shifts LPN staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts when needed. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assist with recruiting and hiring new nursing staff.
The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing rations and PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Daily recruiting calls with the NHA, HR, and recruiter occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.

§ 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 nursing time schedule and staff interviews it was determined that the facility administration staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 19 of 21 days (8/9/26, 8/10/26, 8/12/26, 8/13/26, 8/14/26, 8/15/26, 8/16/26, 8/17/26, 8/18/26, 8/19/26, 8/20/26, 8/21/26, 8/22/26, 8/23/26, 8/25/26, 8/26/26, 8/27/26, 8/28/26, 8/29/26).

Findings include:

Review of the nursing schedule and census information for 8/9/26 through 8/15/26, 8/16/26 through 8/22/26, and 8/23/26 through 8/29/26, revealed that the facility failed to maintain 3.20 hours of general nursing care (PPD) to each resident in a 24-hour period on the following dates:

8/9/26 Census 108 PPD: 2.95
8/10/26 Census 110 PPD: 3.02
8/12/26 Census 109 PPD: 3.16
8/13/26 Census 108 PPD: 3.05
8/14/26 Census 110 PPD: 3.13
8/15/26 Census 111 PPD: 2.95
8/16/26 Census 110 PPD: 2.79
8/17/26 Census 111 PPD: 2.96
8/18/26 Census 111 PPD: 3.04
8/19/26 Census 111 PPD: 3.05
8/20/26 Census 112 PPD: 3.02
8/21/26 Census 112 PPD: 3.00
8/22/26 Census 110 PPD: 2.87
8/23/26 Census 110 PPD: 3.10
8/25/26 Census 111 PPD: 3.08
8/26/26 Census 111 PPD: 3.12
8/27/26 Census 111 PPD: 3.12
8/28/26 Census 110 PPD: 3.15
8/29/26 Census 110 PPD: 3.15

During an interview on 8/26/26, at approximately 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 19 of 21 days as required.

Plan of Correction - To be completed: 10/08/2026

The Nursing schedule is created to ensure staffing PPD reflects the current census per shift. Each shifts staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assisting us with recruiting and hiring new nursing staff.
The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing ratios and PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Daily recruiting calls with the NHA, HR, and recruiter occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.

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