Pennsylvania Department of Health
CANTERBURY PLACE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CANTERBURY PLACE
Inspection Results For:

There are 143 surveys for this facility. Please select a date to view the survey results.

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


CANTERBURY PLACE - 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 a complaint completed on January 16, 2026, it was determined that Canterbury Place 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:

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

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

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

Observations:

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents' care plans were updated and revised to reflect the resident's specific care needs for three of six residents (Resident R22, R29, and R31).

Findings include:

Review of the facility policy "Goals and Objectives, Care Plans" dated 12/9/25, indicated care plan goals and objectives are defined as the desired outcomes for a specific resident problem. Care plans will be modified accordingly.

Review of clinical record indicated Resident R29 was admitted to the facility on 6/9/25, with diagnoses that included pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart), glaucoma and dysphagia (difficulty swallowing).

Review of Resident R29's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 11/6/25, indicated the diagnoses remain current.

Physician orders dated 9/1/25 indicated regular diet, regular texture, regular thin consistency.

Review of Resident R29's progress note dated 12/12/25 indicated that resident was choking. Resident was in her bed. Her daughter was in the room with her. her daughter responded resident had a bite of the hamburger, this time around she was having more difficulty coughing the piece of hamburger up. When I got there resident had already recovered from the choking and was at her baseline.

Resident was assessed and was offered a pureed diet and she refused. Her daughter who was present with her responded "That will never happen."

Review of Resident R29's car

Plan of Correction - To be completed: 02/23/2026

The care plans of the affected residents (R31, R29, R22) were updated to include fluid restriction, anticoagulant monitoring and diet order.
Care plans of residents having either a fluid restriction, anticoagulant monitoring and diet order. were reviewed by DON or designee and updated to ensure compliance.
RNs, and LPNs, will be educated by the Director of Nursing or designee that care plans should be created and/or updated timely to reflect the current condition of the resident.
The DON or designee will audit the care plans of residents with fluid restrictions, anticoagulant monitoring, and diet order 1X weekly for 4 weeks to ensure that the care plans reflect the current needs of the residents.

483.70(n)(1)-(4) REQUIREMENT Hospice Services:

§483.70(n) Hospice services.
§483.70(n)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(n)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(n)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(n)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.

Observations:

Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for five of seven residents (Resident R21, R30, R33, R36, and R50) and failed to have a current hospice agreement that included the vendors name.

Findings include:

Review of the facility "Hospice Program" last reviewed 12/9/25, indicated Hospice services are available to residents at the end of life. Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. Hospice providers who contract with this facility must have a written agreement with the facility outlining the responsibilities of the facility and the hospice agency. It is the responsibility of the hospice to manage the residents' care as it relates to terminal illness and related conditions including determining the appropriate hospice plan of care. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care.

Review of the admission record indicated Resident R21 was admitted to the facility on 7/25/23.

Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/10/25, indicated the diagnosis of diabetes (high sugar in the blood), dementia (a group of symptoms affecting memory, thinking and social abilities) and osteoarthritis (joint pain).

Review of Resident R21's current physician orders indicated admission to an outside vendor's Hospice Services on 10/16/25.

Review of Resident R 21's hos

Plan of Correction - To be completed: 02/23/2026

The hospice binders for all residents currently receiving hospice services were immediately audited. For residents identified without hospice care plans in the hospice binder, the hospice agency was contacted and current hospice care plans were obtained and placed in the appropriate hospice binders. The hospice contract, including the hospice agency name, was obtained and placed in the designated administrative contract file.
An audit of all current hospice residents was completed by the NHA or designee to identify any additional residents whose hospice care plans were not present in the hospice binders or whose hospice documentation was incomplete. The audit included contract availability.
Staff have been re-educated by the director of nursing or designee on hospice documentation requirements and the location of hospice binders to ensure compliance and accessibility.
The Director of Nursing or designee will conduct 1X weekly audits of hospice binders for four weeks to ensure hospice care plans are present and current and that hospice agency identification is clearly documented. Findings will be documented, and any deficiencies will be corrected and reported to QAPI committee for further review and consideration until compliance is maintained.

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

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

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

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

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

Observations:

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide an Assessment Involuntary Movement Scale (AIMS- a widely used tool designed to measure the severity of tardive dyskinesia (TD- a disorder characterized by involuntary movements that can occur as a side effect of long term use of antipsychotic medication) assessment at least quarterly for three of five residents (Resident R30, R36, R102).

Findings include:

Review of the facility policy "Assessment Involuntary Movement Scale" last reviewed 12/9/25, indicated to ensure early identification, monitoring, and appropriate clinical response to involuntary movements particularly those associated with antipsychotic medication use, through consistent use of the AIMIS scale for residents receiving nursing services. AIMS must be completed prior to initiation of any antipsychotic medication, must be completed every three months (quarterly) for all residents receiving antipsychotic medications.

Review of the admission record indicated Resident R30 was admitted to the facility on 12/2/22.

Review of Resident R30's MDS (MDS - a periodic assessment of care needs) dated 12/31/25, indicated the diagnosis of hypertension (high blood pressure), atrial fibrillation (A-fib-irregular and often rapid heartbeat) and dementia. Section N0415 indicated antipsychotic use.

Review of Resident R30's AIMS evaluation indicated last completion date of 7/8/25.

Review of the admission record indicated Resident R36 was admitted to the facility on 8/18/25.

Review of Resident R36's MDS dated 10/23/25, indicated the diagnosis of heart failure (heart doesn't pump the way it should), hypertension and dementia. Section N

Plan of Correction - To be completed: 02/23/2026

Resident (R30, R36, R102) prescribed antipsychotic medications were identified, and AIMS assessments were completed by licensed nursing staff for each applicable resident. No adverse outcomes were identified related to the delay in assessments.
An audit of residents currently prescribed antipsychotic medications to be conducted by DON or designee to ensure AIMS assessments were completed as required. New admissions and medication changes will be monitored to ensure timely initiation and ongoing completion of AIMS assessments.
The DON or designee will reeducate licensed nursing staff on policy regarding AIMS monitoring for residents on antipsychotic medications.
The Director of Nursing or designee will conduct weekly audits on residents on antipsychotics, new admissions/residents that newly initiated antipsychotic medications weekly for 30 days to ensure AIMS assessments are completed and documented appropriately. Audits will be reviewed through the QAPI process. Any deficiencies identified will be addressed immediately.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of five residents (Resident R64).

Findings include:

Review of facility policy "Dignity" dated 12/9/25, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered.
Review of the clinical record indicated Resident R64 was admitted to the facility on 12/23/25.

Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/28/25, indicated diagnoses of benign prostatic hyperplasia (BPH- a common enlargement of the prostate gland in aging men that squeezes the urethra), obstructive uropathy (a blockage in the urinary tract that prevents normal urine flow), and depression. Section H0100 indicated an indwelling catheter was present.

Review of a physician order dated 1/1/26, indicated catheter care for indwelling catheter (a flexible tube inserted into the bladder for continuous urine drainage) every shift for catheter care. Cleanse area every shift.

Review of Resident R64's care plan dated 12/29/25, indicated the resident has an indwelling catheter due to obstructive uropathy.

During an observation on 1/12/26, at 1:11 p.m. Resident R64 was walking with Therapy Employee E2 in the foyer at the top of the public stairwell with the uri

Plan of Correction - To be completed: 02/23/2026

The resident identified (R64) as having a urinary catheter bag without a dignity bag in place was immediately assessed by nursing staff. A dignity bag was applied promptly to ensure the urinary catheter bag was properly covered and the resident's dignity was maintained. Staff provided immediate re-education regarding resident rights and the importance of maintaining dignity during care. No adverse outcomes were identified.
Residents with urinary catheters audited by DON or designee to ensure dignity bags were in place and utilized appropriately. Any additional instances of noncompliance were corrected immediately at the time of observation.
Clinical staff will be re-educated by DON or designee on resident rights and dignity, specifically regarding the proper use of dignity bags for urinary catheter bags.
The DON or designee will conduct audits 2 X per week for 2 weeks and 1 X per week for 2 weeks, to ensure dignity bags are consistently used for residents with urinary catheters. Audit results will be documented and reviewed by the QAPI committee. Any identified deficiencies will be addressed immediately.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on the review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for one of four residents reviewed (Resident R48).

Findings include:

Review of the facility policy "Advanced Directives" dated 12/9/25, indicated prior to or upon admission of a resident, the social services director or designee inquires of his/her family members and/or their legal representative, about the existence of any written advanced directives. If the resident indicates that they have not established an advanced directive the facility staff will offer assistance in establishing advanced directives. Staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.
Review of the admission record indicated Resident R48 admitted to the facility on 12/27/25.
Review of Resident R48's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/6/26, indicated the diagnoses of high blood pressure, end stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and anemia (the blood doesn't have enough healthy red blood cells).

Review Resident R48's Social Service Initial Assessment and Social History dated 1/6/26, failed to reveal an advanced directive or documentation that Resident R48 was given the opportunity to formulate an Advanced Directive.

Interview on 1/13/26, at 2:55 p.m

Plan of Correction - To be completed: 02/23/2026

The resident identified (R48) without documentation reflecting the opportunity to formulate an advance directive was reviewed by nursing. The resident and/or responsible party was re-approached and provided education regarding advance directives, including the right to formulate, revise, or decline an advance directive. Documentation was completed in the medical record to reflect that the opportunity was offered and the resident's decision was obtained. No adverse outcomes were identified as a result of the missing documentation.
Resident admission records were audited by DON or designee to ensure documentation was present indicating that residents were offered the opportunity to formulate an advance directive. Any missing or incomplete documentation identified during the audit was corrected immediately.
Nursing staff to be re-educated by DON or designee on resident rights related to advance directives and the requirement for accurate and timely documentation.
The Director of Nursing or designee will conduct 1X weekly audits of new admissions for 30 days to ensure advance directive documentation is complete. Audit findings will be reviewed through the QAPI process. Any deficiencies identified will be addressed immediately.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of five residents (Resident R41).

Findings include:

Review of the clinical record indicated Resident R41 was admitted to the facility on 10/19/20, with diagnoses that included polyneuropathy (nerve disease caused by damage to many nerves), edema and obesity.

Review of Resident 's Medicare 5-day MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 12/29/25, indicated the diagnosis remained current.

Review of Resident R41's physician orders dated 12/29/25 Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro)

Inject as per sliding scale: if 0 - 140 = 0 units; 141 - 180 = 1 unit; 181 - 220 = 2 units; 221 - 260 = 3 units; 261 - 300 = 4 units; 301 - 340 = 5 units; 341 - 1000 = 6 units

Call provider if CBG >340, subcutaneously with meals for IDDM

Review of blood sugar summary indicated:

12/31/2025 22:05 423.0 mg/dL

1/5/2026 16:52 424.0 mg/dL

1/8/2026 10:56 399.0 mg/dL

1/8/2026 12:37 388.0 mg/dL

Review of Resident R41 progress notes dated 12/1/2025- 1/8/2026 revealed there was no indication it was reported to the physician.

During an interview on 1/14/26, at 1:40 p.m. Director of Nursing confirmed there was no physician notification for elevated blood sugar as required.

28 Pa. Code: 211. 12(d)(1) Nursing services.

Plan of Correction - To be completed: 02/23/2026

The MD was notified of the resident's (R41) blood sugar per MD order.
RNs, LPNs, and Unit Managers will be educated by the Director of Nursing or designee on the necessity of timely provider notification of the resident's blood glucose level pursuant to the provider's order.
The DON or designee will audit five random residents' blood glucose levels 1 X weekly for three weeks and compare these levels with the provider's order to ensure compliance and 5 random residents' blood glucose levels for one week to ensure notifications if needed.
Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.

483.10(j)(1)-(4) REQUIREMENT Grievances:

§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations:

Based on observations, resident and staff interviews it was determined that the facility failed to display (for the residents and family members) the required information on the grievance process for the building.

Findings include:

Review of facility policy "Resident Grievance/Complaint Procedures" dated? 12/9/25, indicated: " Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at this facility. Grievances also may be voiced or filed regarding care that has not been furnished. "

Review of facility policy "Grievance Program (Concern and Comment)" dated 12/9/25, indicated: " Purpose: To help guide our communities in the Grievance Process and ensure that a thorough, complete, and accurate investigation has been completed to the best of our knowledge in accordance with F585 483.10 (j)(1)(2)(3) and (4).
The facility will post in prominent locations throughout the facility The Right to File Grievances orally (meaning spoken) or in writing: the right to file anonymously. This will include a. The contact information of the Grievance Officer with whom a grievance can be filed, that is, his , or her name, business address (mail and email) and business phone number. B. a reasonable expected time frame for completing the review of the grievance is usually 5 days but no longer than 10 days. C. The right to obtain a written decision regarding his or her grievance. D. The contact information of independent entities with whom grievances may be filed, that is, the pertinent State Agency, Quality Improvement Organization, State Survey Agency and

Plan of Correction - To be completed: 02/23/2026

The facility immediately identified and designated a Grievance Officer. Signage was developed and posted in visible common areas outlining the grievance process, including the name or title of the Grievance Officer and instructions on how residents, families, file a grievance. No residents were found to have been harmed as a result of this deficiency.
Residents and responsible parties will be notified of the grievance process through admission packets and resident council meetings.
Education will be provided to the social service director, activity director and other managers by the NHA or designee on grievance policy and proper posting of grievance process displayed.
The NHA or designee will conduct monthly audits for 2 months, of resident rights postings to ensure grievance information remains visible, accurate, and current. Audit results will be documented and reviewed through the QAPI process. Any deficiencies identified will be corrected immediately.

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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers/injuries (PU/PI's - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of four residents (Resident R11, and R93).

Findings include:

Review of the facility wound policy "Pressure Ulcers/Skin Breakdown - Clinical Protocol", dated 12/9/25, indicated In addition, the nurse shall describe and document/report the following - a full assessment of pressure sore including location, stage, length, width, and depth presence of exudates or necrotic tissue.
Review of Resident R11's admission record indicated she was originally admitted on 11/29/21, and re-admitted on 11/30/24.

Review of Resident R11's MDS dated 11/27/25, indicated diagnoses of non-Alzheimer's dementia with behavioral disturbance (brain diseases that mainly affect frontal and temporal lobes of the brain. These areas of the brain are associated with personality, behavior, and language, depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation).

Review of Resident R11's clinical progress notes indicated:
10/19/2025: Skin/Wound Note Text: Resident has an open area on the Sacrum/Coccyx.

Review of the clinical progress notes failed to include a stage, measurements or description of the wound.

No description of Resident R11 wound was noted until 11/4/25 in the wound notes indicating: a Pressure Injury Stage 4.\par

Plan of Correction - To be completed: 02/23/2026

Residents identified with pressure wounds (R11, R93) were immediately assessed by licensed nursing staff and wounds were measured and documented. Wound care treatments were reviewed and updated per physician orders and current wound care protocols. No additional adverse outcomes were identified.
Residents identified as at risk or with existing pressure wounds were reviewed by DON or designee to ensure appropriate treatment plans; measurements and interventions were in place. Any concerns identified were addressed immediately.
Licensed nursing staff will be re-educated by DON or designee on pressure ulcers and skin protocol policies. Routine wound rounds have been implemented involving nursing leadership and wound care designees to ensure consistent and appropriate treatment.
The Director of Nursing or designee will conduct weekly wound audits for 30 days. Audits will include review of wound assessments, measurements, treatment administration, documentation, and adherence to physician orders. Findings will be reviewed through the QAPI process, and any deficiencies identified will be corrected immediately.

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

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

Observations:

Based on observation, review of clinical record, review of facility policy, interview with staff and resident, it was determined the facility failed to provide tracheostomy care consistent with professional standards of practice for one of two residents receiving oxygen (Resident R39).

Findings include:

Review of the facility policy "Tracheostomy Care" dated 12/9/25, indicated a replacement tracheostomy tube (a hollow tube inserted into a surgical opening in the neck (stoma) directly into the windpipe to provide long-term ventilation) must be available at the bedside at all times.

Review of the admission record indicated R39 was admitted to the facility on 12/27/25.

Review of Resident R39's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/31/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Section O - E1 indicated that resident received tracheostomy care.

Review of Resident R39's current physician orders indicated trach care daily and as needed . Monitor trach site for signs and symptoms of infection, increased secretions, and dislodgement: Trach size 6.0 cuffless every shift. Oxygen at 4 liters via trach mask.

Review of Resident R39's care plan dated 12/30/25, indicated resident has a trach. Resident will have no abnormal drainage around trach site through the review date. Intervention - trach - Shiley, uncuffed #6.

Review of Resident R39's clinical admission assessment dated 12/27/25, at 5:18 p.m.

Plan of Correction - To be completed: 02/23/2026

Resident (R39) identified without a replacement tracheostomy tube at the bedside, a replacement tracheostomy tube of the appropriate size, a was placed at the bedside in accordance with facility policy. No adverse outcomes were identified as a result of this deficiency.
No other residents with tracheostomy were identified to ensure replacement of tracheostomy tubes and required emergency supplies were present and readily available at the bedside.
Licensed nursing staff to be re-educated by DON or designee on facility policy regarding tracheostomy care, including the requirement to maintain a replacement tracheostomy tube and emergency equipment at the bedside at all times.
The Director of Nursing or designee will conduct audits on all residents with a tracheostomy 3 X weekly for 2 weeks and 1 X weekly for 2 weeks, to ensure compliance with tracheostomy care policy. Audit results will be documented and reviewed through the QAPI process. Any noncompliance identified will be addressed immediately with re-education and corrective action as needed.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R36).

Findings include:

Review of the facility policy "Goals and Objectives, Care Plans" last reviewed 12/9/25, indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence.

Review of the admission record indicated Resident R36 was admitted to the facility on 8/18/25.

Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs)dated 10/23/25, indicated the diagnosis of heart failure (heart doesn't pump the way it should), hypertension and dementia.

Review of Resident R36's physician progress notes dated 8/19/25, indicated past medical history that included but not inclusive to CAD, hypertension, hyperlipidemia, Post Traumatic Stress Disorder (PTSD).

Review of Resident R36's care plan with revision on 10/20/25, indicated that Resident R36 had trauma but failed to identify what the triggers were and how to avoid them.

During an interview on 1/15/25, at 2:39 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R36).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management

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Plan of Correction - To be completed: 02/23/2026

The care plan of Resident ( R36) was updated to include trauma history, known triggers, preferred approaches, and specific interventions to avoid triggering behaviors. No adverse outcomes were identified as a result of this deficiency.
To protect residents who may be in a similar situation, the facility will conduct random audits of eight (8) resident care plans to identify any and all current residents with comparable clinical, psychosocial, or care needs. Residents identified through this process will have their care plans reviewed and updated as necessary to ensure appropriate interventions, safety measures, and individualized approaches are in place. Any deficiencies identified will be corrected immediately.
The facility will implement enhanced interdisciplinary review processes to ensure residents with similar needs are proactively identified and protected. Staff will be re-educated on recognizing resident-specific needs and implementing appropriate, individualized care plan interventions. Care planning will emphasize prevention, resident safety, and consistent application of interventions for residents with similar conditions or risk factors.
The Director of Nursing or designee will conduct random audits for 5 residents per week, of care plans for 30 days to ensure trauma-informed care components are present. Observations and documentation will be reviewed through the QAPI process. Any deficiencies identified will be addressed immediately through re-education and corrective action.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications properly and securely in one of two medication rooms ( Renaissance unit), four of four medication carts (First Floor Carts A and B, and Renaissance Hall front and back), and failed to ensure medication carts were secured when not in presence of the nurse.

Findings include:

Review of the facility policy "Storage of Medications" dated 12/9/25, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner.

During an observation on 1/13/26, at 11:14 a.m. theRenaissance unit medication room refrigeration contained an ice pack.

During an interview completed on 1/13/26, at 11:19 a.m. Licensed Practical Nurse (LPN) Employee E10 confirmed the ice pack was stored in the refrigerator and stated, "the ice pack is used for the laboratory and should be stored in the laboratory refrigerator".

During an observation on 1/13/26, at 1:24 p.m. the First Floor Cart A contained the undated medication of albuterol nebulizers (respiratory medication to help in breathing).

Interview on 1/13/26, at 1:25 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the albuterol was not dated when opened as required.

During an observation on 1/13/26, at 1:30 p.m. the First Floor Cart B contained the following:

-moxifloxacin eye drops (eye drop to treat infection) not stored in a box or bag. Opened and undated.

During an interview on 1/13/26, at 1:31 p.m. Registered Nurse (RN) Employee E7 confirmed the medications were opened and not dated as required and the eye drops were not stored in a box or bag.

Duri

Plan of Correction - To be completed: 02/23/2026

Employee E5 and E8 were educated on facility policy of Storage of Medications. Inhalation medications were dated immediately when noted with date of delivery. Medication cart was immediately locked when notified.
Licensed nurses will be educated by Director of Nursing/Designee on Medication Administration policy and Medication Storage.
Director of Nursing/Designee will randomly audit 1 medication cart, 5 times weekly for 2 weeks and then 3 times weekly for 2 weeks.
Audits will be reported to the QAPI committee for further review and consideration until compliance is maintained.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarters (January 2025, through March 2025 and July 2025, through September 2025).

Findings include:

Review of facility policy "Quality Assurance and Performance Improvement Program Guidelines" last reviewed 12/9/25, indicated the facility shall develop, implement, and maintain an ongoing, facility wide data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents.

Review of the facility policy "Quality Assurance and Performance Improvement" last reviewed 12/9/25, indicated the following individuals serve on the committee: Administrator, Director of Nursing, Medical Director, Infection Preventionist, Pharmacy, Social Services, Activity Service, Environmental Services, Human Resources, Medical Records and Diagnostics.

A review of the QAPI Committee meeting sign-in sheets from the period of January 2025, through December 2025, revealed that Medical Director was not in attendance for two of the four quarters (January 2025, through March 2025 and July 2025, through September 2025).

During an interview on 1/16/25, at 11:20 a..m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarters (January 2025, through March 2025 and July 2025, through September 2025).

28 Pa Code: 201.18(e )(1)(2)(3)(4) Management.
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Plan of Correction - To be completed: 02/23/2026

The Medical Director was notified of the requirement to participate in QAPI meetings in accordance with facility policy and regulatory requirements. The Medical Director reviewed QAPI data.
Residents are included in the facility's QAPI program through ongoing monitoring of clinical outcomes, incident reports, grievances, and quality measures. QAPI data will continue to be reviewed for trends or concerns that may affect residents, with Medical Director involvement to ensure medical oversight and timely intervention for any identified issues.
The facility has established a scheduled QAPI meeting calendar with standing meeting dates communicated to the Medical Director in advance. The Medical Director will attend QAPI meetings. Attendance will be documented in QAPI meeting minutes. The facility policy has been reviewed with the Medical Director, by the NHA to reinforce expectations regarding participation in the QAPI program.
The Administrator or designee will monitor QAPI meeting attendance by the Medical Director through review of QAPI meeting minutes on a monthly basis for three months. Monitoring results will be documented and reviewed as part of the QAPI program.

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, clinical record review, observation, and staff interview, it was determined that the facility failed to manage airborne isolation for Covid positive infections in one of seven rooms (Resident R37).

Findings include:

Review of the facility policy "Coronavirus Disease (Covid-19) - Identification and Management of Ill Residents" dated 12/9/25, indicated newly identified Covid-19 infection in resident; symptomatic residents regardless of vaccination status, are restricted to their rooms and cared for staff using a NIOSH (National Institute for Occupational Safety and Health) approved N95 or equivalent or higher level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and a gown.

Review of Resident R37's admission record indicated admission to the facility on 8/11/25.

Review of Resident R37's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/25, indicated diagnosis of hypertension (high blood pressure), renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), and depression.

Review of Resident R37's physician order dated 1/8/25, indicated assess lungs and apical heart rate every shift for Covid for ten days. Covid isolation - contact and airborne precautions in private room due to positive Covid. Care and services to be provided in the resident's room for ten days.

Review of Resident R37's care plan dated 1/8/26, indicated the resident has a respiratory infection of Covid related to exposure. The resident will be free from signs and symptoms of infection by review date. Airborne contact isolation.

Observation on 1/12/26, at 1

Plan of Correction - To be completed: 02/23/2026

Staff involved were re-educated at the time of observation on required personal protective equipment (PPE), including the mandatory use of protective eyewear when entering a COVID-positive resident's room. Appropriate PPE, including eye protection, was made readily available outside the resident's room and utilized immediately.
All residents on isolation precautions were reviewed to ensure appropriate PPE signage and supplies were present outside each room.
Staff have been re-educated by Infection Control Preventionist or designee on the facility's infection prevention and control policies, specifically regarding required PPE for COVID-positive residents, including protective eyewear. PPE requirements have been reinforced during shift reports and infection control education.
The Infection Preventionist or designee will conduct 2X weekly PPE compliance audits for 30 days. Observations will be documented and reviewed through the QAPI process. Any staff found non-compliant will receive immediate re-education.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview and review of the facility's Infection Control Committee attendance records, the facility failed to ensure that the nine required multidisciplinary members were present at the Infection Control meetings for one of four quarters (Quarter one - January - March 2025).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility. "A review of the applicable members at infection control meetings includes medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member, and a member of the infection control team.

Review of the facility's infection control attendance records for Quarter one of 2025, failed to reveal documented evidence of an Infection Control Committee Meeting for February 2025, missing all nine of the required multidisciplinary members.

Interview with Infection Preventionist Employee E5 on 1/16/26, at 1:00 p.m. confirmed the facility could not locate the signature sheet for the month of February 2025, and could not provide documented evidence of the nine required multidisciplinary members.

Plan of Correction - To be completed: 02/23/2026

Current and future Infection Control meetings now include a standardized agenda with an attached signature sheet to ensure attendance is documented. No residents were harmed as a result of the missing documentation.
All Infection Control meeting records for the prior review period were audited to ensure signature sheets were present and complete.
A standardized Infection Control meeting packet has been implemented, including a required signature sheet for all meetings. Infection Preventionist was re-educated by the NHA on documentation requirements. The responsibility for ensuring completion of the signature sheet has been assigned to the Infection Preventionist or designee.
The Administrator or designee will review Infection Control meeting documentation monthly for 3 months to ensure agendas and signature sheets are completed and filed appropriately. Findings will be reviewed through the QAPI process. Any deficiencies identified will be corrected immediately.

§ 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 10 residents during the day shift for one of 21 days (12/6/25) and one nurse aide per 15 residents on midnight shift for two of 21 days (1/1/26 and 1/2/26).

Findings include:

Review of facility census data and nursing time schedules from 12/5/25, through 12/10/25, and 12/29/25, through 1/11/26, revealed the following nurse assistant (NA) staffing shortages:

Day shift:
Date: Census: Hours required: Actual hours:
12/6/25 113 90.40 68.60

Night Shift:
Date: Census: Hours required: Actual hours:
1/1/26 113 60.27 51.50
1/2/26 112 59.73 52.70

During an interview on 1/16/26, at 11:20 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 for one of 21 days (12/6/25) and one nurse aide per 15 residents on midnight shift for two of 21 days (1/1/26 and 1/2/26).

Plan of Correction - To be completed: 02/23/2026

NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers and Nursing Supervisors on the minimum state ratio requirements for CNAs.
NHA or designee will conduct daily staffing meetings five times per week for the next 1 month to ensure the state minimum ratio of CNAs are met.
NHA or designee will review staffing sheets 2 X per week for the next month to ensure adequate CNA coverage is scheduled to meet the minimum ratio of CNAs.
Facility recruitment/retention efforts include utilizing job postings on company's career website, Indeed and LinkedIn. Company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program.
Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met.

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

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

Observations:

Based on review of facility documentation and staff interview it was determined that the facility failed to meet state minimum staffing levels that could affect resident health and safety on 1 of the 21 days reviewed (12/6/25).

Findings include:

A review of the facility "Nursing Care Hours" for dates 12/4/25, to 12/10/25, indicated that the facility failed to meet the minimum required hours of 3.20.

Findings include:

Date Required Actual
12/6/25 3.20 3.04

During an interview on 1/16/26, at 11:20 a.m. the Nursing Home Administrator confirmed that the facility failed to meet state minimum staffing levels that could affect resident health and safety on 1 of the 21 days reviewed (12/6/25).

Plan of Correction - To be completed: 02/23/2026

NHA or designee educated staffing coordinator, DON, ADON, Unit Managers and Nursing Supervisors on the state required minimum staffing levels of 3.2 hours per patient day.
NHA or designee will conduct daily staffing meetings 5X times per week for the next two months to ensure the state minimum number of general nursing care hours are met.
NHA or designee will review staffing sheets 1X per week for the next month to ensure adequate nursing coverage is scheduled to meet the minimum number of general nursing care hours.
Facility recruitment/retention efforts include utilizing job postings on company's career website, Indeed and LinkedIn. Company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program.
Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met.

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