Pennsylvania Department of Health
NEW EASTWOOD HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NEW EASTWOOD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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NEW EASTWOOD HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a State Licensure survey and an Abbreviated survey in response to a complaint completed on October 31, 2025, it was determined that New Eastwood Healthcare 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.

Plan of Correction:

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations:

Based on clinical record, observation, and staff interview, it was determined that the facility failed to ensure that call bells were accessible for one of 22 sampled residents. (Resident 63)

Findings include:

Clinical record review revealed that Resident 63 had diagnoses that included dementia and chronic pain. The Minimum Data Set assessment, dated September 23, 2025, indicated that the resident was cognitively impaired and required extensive assistance from staff for activities of daily living such as toilet use and bathing. A review of the care plan revealed that the resident was at risk for falls and that staff was to keep her call bell within reach. Observation on October 28, 2025, at 10:15 a.m., revealed that the call bell was on the floor behind the bed. On October 29, 2025, at 10:19 a.m., 12:30 p.m., and 1:30 p.m. the call bell was on the floor and out of the resident's reach.

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

Plan of Correction - To be completed: 11/25/2025

1. The call bell for resident 63 was placed within reach immediately to ensure it was assessable.
2. Current patients calls bells were audited to ensure they were placed in reach and assessable.
3. Department Heads or Designee to complete and education with facility staff to ensure calls bells are within reach of patients.
4.Department Heads or Designee to complete random audits weekly x4 weeks. Audits will be reviewed by the QAPI Committee, monthly, for further follow-up as indicated.

483.25 REQUIREMENT Quality of Care:

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

Observations:

Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to implement physicians' orders for five of 22 sampled residents. (Residents 4, 7, 16, 56, 81)

Findings include:

Clinical record review revealed that Resident 4 had diagnoses that included a recent joint replacement, chronic hypertensive kidney disease, and diabetes. Resident 4 had a total left knee replacement on October 20, 2025, and was admitted to the facility on October 22, 2025. Review of the Minimum Data Set (MDS) assessment dated October 27, 2025, indicated the resident had no cognitive impairment and required substantial to maximum assistance with bathing and lower body care. According to the surgeon's instructions after discharge from the hospital, staff was to leave the dressing in place for seven days after surgery, to keep the incision dry for the first two weeks after surgery, to use a watertight wrap or barrier when bathing, and that the incision was not to be saturated until approved by the surgeon. Review of a nursing note indicated that Resident 4 received a shower on October 28, 2025. On October 30, 2025, at 10:45 a.m., Resident 4 was observed in bed with the dressing on her left knee wound which was loose and lifting on its left side. In an interview at that time, Resident 4 stated it was the original dressing from the hospital, that she had been receiving showers, and that they were washing the dressing. In an interview on October 31, 2025, at 12:40 p.m., Resident 4 said the dressing was removed during a shower earlier that day and the incision was washed thoroughly.

On October 26, 2025, at 8:36 p.m., a nurse noted that Resident 4 was tearful, was having difficulty falling asleep, and stated she had not slept in days. The physician gave a verbal order for two sleep aid medications (trazadone and melatonin) and staff were to monitor the resident's outcome. Review of the Medication Administration Record (MAR) for October 2025, indicated that no order was placed for these medications. In an interview on October 31, 2025, at 12:40 p.m., Resident 4 stated that she had difficulty sleeping at night while in the facility.

In an interview on October 31, 2025, at 12:50 p.m., the first floor unit manager confirmed the resident had a shower that morning, the surgical dressing was removed, and the incision cleaned. In an interview a that time the Administrator and Assistant Director of Nursing (ADON) confirmed the verbal orders for the sleep aids were never entered into the system, the surgical dressing was not removed after seven days, and the incision was not kept dry and should have been.

Clinical record review revealed that Resident 7 had diagnoses that included diabetes mellitus and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). A physician's order dated August 18, 2025, directed staff to inject insulin Lispro three units with meals for blood glucose greater than 180 milligrams per deciliter (mg/dL). On October 13, 2025, the physician changed the insulin order and further directed staff to inject insulin aspart three units with meals for blood glucose greater than 180 mg/dL. Review of Resident 7's MAR revealed that staff administered the medication 18 times in August, 25 times in September, and 25 times in October 2025 when the resident's blood glucose was less than 180 mg/dL.

In an interview on October 31, 2025, at 9:29 a.m., the ADON confirmed that the medication was administered outside of the established parameters for Resident 7.

Clinical record review revealed that Resident 16 had diagnoses that included acute bacterial endocarditis (serious inflammation of the inner lining of the heart), pneumonia, and chronic obstructive pulmonary disease. Review of the MDS assessment, dated October 11, 2025, indicated that the resident had no cognitive impairments and was receiving intravenous medications during her stay. A physician's order dated October 8, 2025, directed staff to administer an antibiotic medication (daptomycin) intravenously one time a day for acute bacterial endocarditis. Observation on October 30, 2025, at 9:50 a.m., revealed that Licensed Practical Nurse (LPN) 1 was preparing a 50 milliliter (ml) bag of the intravenous (IV) antibiotic medication by priming the IV tubing (sending a small portion of fluid through the tubing to remove air from the tubing) and was observed dripping ten ml of the medication out into a medicine cup that was discarded. At 10:10 a.m., the medication infusion was started by LPN 1. At 11:00 a.m., the resident was observed unhooked from the IV medication. The medication bag was observed hanging from the IV pole and was not completely empty.

In an interview on October 31, 2025, at 9:30 a.m., the ADON confirmed the medication was not fully administered to Resident 16 as ordered.

Clinical record review revealed that Resident 56 had diagnoses that included heart failure and high blood pressure. A physician's order dated March 30, 2024, directed staff to administer a medication (midodrine hydrochloride) three times a day for blood pressure support before meals. Staff was not to administer the medication if the resident's systolic blood pressure (SBP) was 135 millimeters mercury (mm/Hg) or higher. Review of Resident 56's MAR revealed that staff administered the medication when the resident's SBP was above 135 mm/Hg on 26 occasions in August 2025, 17 occasions in September 2025, and seven occasions in October 2025.

Clinical record review revealed that Resident 81 had diagnoses that included sepsis, heart failure, and hypertension. Review of the MDS assessment, dated October 13, 2025, indicated the resident had no cognitive impairment and was receiving IV medications during her stay. A physician's order dated October 15, 2025, directed staff to change the peripherally inserted central catheter (PICC) line dressing and IV tubing caps on admission then every seven days. Observations on October 30, 2025, at 2:00 p.m., revealed the resident's PICC dressing was dated October 14, 2025. In an interview with Resident 81 at that time the resident confirmed that staff never changed the dressing.

In an interview on October 31, 2025, at 9:30 a.m., the ADON confirmed the medication was given outside of parameters and the PICC line dressing was not changed as ordered.

CFR 483.25 Quality of care
Previously Cited 9/5/24

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

Plan of Correction - To be completed: 11/25/2025

R4 remained approximated and there were no ill effects from dressing removal. R4 was ordered melatonin and trazodone upon discovery. R7 is receiving the insulin as ordered. R16 completed course of IV antibiotics per order and is successfully discharged home. R56 is no longer receiving midodrine. R81 is receiving the PICC line dressing as ordered.
2. Current patients who are receiving insulin, who are on midodrine, who have PICC line dressings and those with special instructions for post-surgical/wound dressings will be reviewed to ensure physician orders are being as followed. Variances to be addressed.
3. DON or Designee to complete an in-service with license nursing staff to ensure surgical dressings orders are being followed as ordered, verbal orders are placed timely in medical record, parameters are being followed as ordered, IV medication are being hung as ordered, and PICC line dressing are being followed as ordered. Physician orders will be printed daily to ensure they are transcribed appropriately and followed accordingly.
4. DON or Designee to complete random audits for medication parameters, PICC line dressings, and orders special instructions for postsurgical/wound dressings weekly x4 weeks audits will be reviewed by the QAPI Committee, monthly, for further follow-up as indicated.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

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

Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for two of 22 sampled residents. (Residents 9, 63)

Findings include:

Clinical record review revealed that Resident 9 had diagnoses that included multiple sclerosis, pressure ulcer of sacral region (bed sore), and dementia. A physician's order dated June 4, 2025, directed staff to apply heel boots (a device to prevent and treat pressure sores) while in bed. Multiple observations on October 28 through October 30, 2025, between 10:00 a.m. and 2:30 p.m., revealed Resident 9 in bed, and the heel boots was not applied. In addition, a physician's order dated August 30, 2025, directed staff to get Resident 9 out of bed on dayshift, and if resident refuses staff was to document. Multiple observations on October 28 through October 30, 2025, between 10:00 a.m., and 2:30 p.m., revealed that staff did not get Resident 9 out of bed and there was no documented evidence that the resident refused.

Clinical record review revealed that Resident 63 had diagnoses that included dementia and chronic pain. A physician's order dated May 16, 2025, directed staff to apply protective boots (devices to protect the skin of the feet) while in bed. Review of the comprehensive care plan revealed that the resident was at risk for skin breakdown. Multiple observations on October 28 through October 30, 2025, between 10:00 a.m., and 3:00 p.m., revealed Resident 63 in bed and the protective boots were not applied.

In an interview on October 31, 2025, at 9:30 a.m., the Director of Nursing confirmed that staff did not follow the physician's orders for Resident's 9 and 63.

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

Plan of Correction - To be completed: 11/25/2025

1. R9 continues to be encouraged to get out of bed daily and her heels are being elevated by utilizing a positioning device. R63 currently has protective boots ordered as residents allow.
2. Current patients who have protective and positioning devices, to prevent worsening wounds, will be reviewed to ensure they are in place. Variances to be addressed.
3. DON or Designee to complete in-service with Licensed Nursing staff and Nurse Aids to ensure protective and positioning devices are within place as ordered.
4 DON or Designee will complete random audits weekly x4 weeks to ensure protective and positioning devices are in place as ordered. Audits will be reviewed by the QAPI committee, monthly, for further follow-up as indicated.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for two of eight sampled residents with limited range of motion. (Residents 3 and 90)

Findings include:

Clinical record review revealed that Resident 3 had diagnoses that included anoxic brain damage and quadriplegia. The Minimum Data Set (MDS) assessment dated September 24, 2025, indicated that the resident was cognitively impaired, dependent on staff for dressing and personal hygiene, and had limitations in range of motion in both upper and lower extremities. Review of the occupational therapy discharge summary from October 21, 2025, revealed a restorative splint and brace program with a left palm grip (a device applied to prevent the permanent tightening of muscles and tendons) to be applied with morning care and removed with evening care. On October 21, 2025, the physician ordered that staff apply a palm grip to Resident 3's left hand with morning care and remove with evening care. Observations on October 28, 2025, between 10:05 a.m. and 1:45 p.m., and October 29, 2025, between 9:30 a.m. and 2:00 p.m., revealed that Resident 3 was lying in bed without the left palm grip in place.

Clinical record review revealed that Resident 90 had a diagnosis that included contracture of the left hand and left wrist due to effects of a stroke, and muscle weakness. The MDS
assessment, dated August 19, 2025, indicated that the resident had memory impairment and required extensive assistance for most activities of daily living including dressing and had limited range of motion on one side of her upper extremities. Review of the occupational therapy discharge summary, dated May 19, 2025, revealed that staff was to ensure that the resident had a blue therapy carrot (a device used as a splint for severely contracted fingers) on her left hand at morning care and off after evening care. A review of a physician's order dated May 21, 2025, directed staff to apply left blue therapy carrot at morning care and remove at evening care to deter worsening contracture and compromising skin integrity. Observation on October 28, 2025, at 10:15 a.m. and 12:40 p.m., revealed that the resident had received morning care, and the blue carrot was not applied on her left hand. Observation on October 29, 2025, at 10:30 a.m. and 1:00 p.m., revealed that the resident had received morning care, and the blue carrot was not applied on her left hand. Observation on October 30, 2025, at 10:00 a.m., 11:00 a.m., and 12:30 p.m., revealed that the resident had received morning care, and the blue carrot was not applied on her left hand.

In an interview on October 31, 2025, at 9:29 a.m., the Assistant Director of Nursing confirmed that the interventions were not in place for Residents 3 and 90 per physician's order.

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

Plan of Correction - To be completed: 11/25/2025

1. R3 is receiving her left palm grip as ordered. R90is receiving her blue therapy carrot as ordered.
2. Current patients who have splinting devices will be reviewed to ensure they are in place. Variances to be addressed.
3. DON or Designee will complete an in-service with Licensed Nursing staff and Nursing Aids to ensure splint devised are in place as ordered.
4. DON or Designee will complete random audits weekly x4 weeks to ensure splint devices are in place. Audits will be reviewed by the QAPI committee, monthly, for further follow up as indicated.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Observations:

Based on clinical record, observation, and staff interview, it was determined that the facility failed to ensure that a resident was provided with adequate supervision to prevent accident hazards for one of 22 sampled residents. (Resident 56)

Findings include:

Clinical record review revealed that Resident 56 had diagnoses that included heart failure and atrial fibrillation (an irregular and rapid heart rhythm). The Minimum Data Set assessment dated October 1, 2025, indicated that the resident was on a blood thinner medication and required supervision from staff for personal hygiene. Multiple observations on October 28 through 30, 2025, between 10:15 a.m. and 2:15 p.m., revealed that Resident 56 had five disposable razors inside a wash bin on top of his tray table.

In an interview on October 31, 2025, at 9:30 a.m., the Director of Nursing confirmed that the disposal razors should've been properly secured for safety.

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

Plan of Correction - To be completed: 11/25/2025

1. R56 razors were removed from resident room immediately when discovered.
2. Current resident rooms were audited to ensure no razors were found at bedside in residents rooms. Variances to be addressed.
3. DON or Designee to in-service Nurse Aids to ensure that no razors are kept at bed side.
4. DON or Designee will complete random room audits weekly x4 weeks to ensure razors are found at bedside in patient rooms. Audits will be reviewed by the QAPI committee, monthly, for further follow up as indicated.

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 review of facility policy, clinical record review, and resident and staff interview, it was determined that the facility failed to provide adequate treatment and services for respiratory therapy for one of five sampled residents who utilized respiratory equipment. (Residents 32)

Findings include:

Review of the facility policy entitled, "Oxygen Administration," last reviewed January 24, 2025, revealed that a humidifier bottle was a necessary supply needed for oxygen administration.

Clinical record review revealed that Resident 32 had diagnoses that included chronic respiratory failure, chronic obstructed pulmonary disease, and was dependent on supplemental oxygen. Review of the Minimum Data Set assessment dated October 21, 2025, indicated the resident had moderately impaired cognition and received oxygen during her stay. Review of Resident 32's medication and task administration report for October, 2025, revealed that the resident consistently used two to three liters of oxygen to maintain adequate oxygen levels in the body. A physician's order dated August 28, 2025, directed staff to change the resident's oxygen humidifier bottle weekly and as needed and to date and label the new bottle. Observations on October 28, 2025, at 12:20 p.m., October 29, 2025, at 12:05 p.m., and on October 30, 2025, at 8:35 a.m., revealed that Resident 32 received three liters of oxygen through a nasal cannula with no humidifier bottle connected. An unopened, undated humidifier bottle was observed on the windowsill each day the resident was observed. In an interview on October 30, 2025, at 8:35 a.m., the resident stated she felt like her mouth and nose were very dry.

In an interview on October 31, 2025, at 9:31 a.m.., the Assistant Director of Nursing confirmed that the resident's humidifier bottle should have been connected between the oxygen concentrator and the tubing.

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

Plan of Correction - To be completed: 11/25/2025

1.R32 is receiving humidified oxygen therapy.
2. Current residents will be reviewed to ensure residents who are on oxygen therapy will be reviewed to determine appropriate use of humidification. Variances to be addressed.
3. DON or Designee will complete an in-service with Licensed Nursing staff on appropriate use of humidified oxygen.
4. DON or Designee will complete random weekly audits x4 week to ensure residents are receiving humidified oxygen as ordered. Audits will be reviewed by the QAPI committee, monthly, for further follow up as indicated.

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

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

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

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

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

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

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

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

Observations:

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for one of 22 sampled residents. (Resident 16)

Findings include:

Review of the facility policy entitled, "Isolation- Categories of Transmission-Based Precautions," last reviewed on January 24, 2025, revealed that staff were to place appropriate signage on the room entrance door alerting staff and visitors of the need for precautions that included the equipment and instructions for use of personal protective equipment. For contact precautions, the sign would require sanitized hands, gloves, and a disposable gown.

Review of Resident 16's clinical record revealed that the resident was admitted to the facility on October 5, 2025, with diagnoses of infective endocarditis (a serious inflammation of the inner lining of the heart) and was recently treated for pneumonia due to methicillin resistant staphylococcus aureus (MRSA) infection. Review of the care plan revealed that Resident 16 required contact precautions for MRSA.

Observations on October 30, 2025, at 9:50 a.m., revealed a sign outside of Resident 16's room that directed staff to follow contact precautions by wearing a gown and gloves when entering the room. During the same observation period, Licensed Practical Nurse (LPN) 1 entered Resident 16's room and administered an intravenous medication through the resident's peripherally inserted central catheter. LPN 1 did not wear a gown.

In an interview on October 31, 2025, at 9:30 a.m., the Assistant Director of Nursing confirmed that staff should have worn a gown when providing care.

28 Pa Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 11/25/2025

1. R16 is discharged.
2. Current residents on Enhanced Barrier and Transition Based Precautions were reviewed to ensure appropriate precautions are maintained. Variances to be addressed.
3. The Infection Preventionist or Designee will complete an in-service with facility staff to ensure appropriate precautions are maintained.
4. The Infection Preventionist or Designee will complete random audits weekly ensure appropriate precautions are maintained x4 weeks. Audits will be reviewed by the QAPI committee, monthly, for further follow up as indicated.

§ 201.19(4) LICENSURE Personnel policies and procedures.:

(4) A determination by a health care practitioner that the employee, as of the employee's start date, is free from the communicable diseases or conditions listed in § 27.155 (relating to restrictions on health care practitioners).

Observations:

Based on a review of employee personnel files, facility policy, and staff interview, it was determined that the facility failed to adhered to facility policy for new employee screening and the Centers for Disease Control and Prevention (CDC) recommendations for baseline tuberculosis (TB) screening and testing for one of five sampled newly hired employees. (Employee 5)

Findings include:

According to the CDC's recommendations entitled, "Baseline Tuberculosis Screening and Testing for Health Care Personnel," last updated December 19, 2023, all United States health care personnel should be screened for TB upon hire. This process includes a risk assessment, symptom evaluation, and either a one-step interferon-gamma release assays (IGRA) blood test or two-step Mantoux tuberculin skin test. Per facility policy, entitled "Tuberculosis, Employee Screening", last reviewed January 24, 2025, an employee may submit documentation of a previous negative TB test result completed less than 12 months prior to their start date.

A review of Employee 5's personnel file revealed that Employee 5 started work at the facility as a nurse aide on October 16, 2025. A one-step IGRA test result dated May 17, 2024, was the only documentation provided of a TB screen for Employee 5.

In an interview on October 31, 2025, at 9:25 a.m., the Administrator confirmed that a current negative TB test had not been collected and documented in the file for Employee 5 before their start date.

Plan of Correction - To be completed: 11/25/2025

1. The TB test was completed for the cited employee on 10/30/2025.
2. New employee files for the past 60 days will be reviewed to identify issues with TB testing.
3. The NHA will educate the Human Resources Director to ensure all new hires will receive PPD prior to start date.
4. NHA or Designee will complete weekly audits for all new hires to ensure they are completed prior to start date x4 weeks. Audits will be reviewed by the QAPI committee, monthly, for further follow-up as indicated.

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