Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT HARMONY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT HARMONY
Inspection Results For:

There are 136 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT HARMONY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to three complaints, and an incident completed on September 5, 2026, it was determined that Kadima Rehabilitation and Nursing at Harmony was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Plan of Correction - To be completed: 10/13/2026

The facility will ensure that all residents are protected from sexual abuse and inappropriate sexual interactions and that effective policies and procedures are in place to identify, prevent, report, investigate, and respond to allegations of sexual abuse.
The facility completed a 30 day look back of all resident progress notes and incident and accident reports as well as resident interviews were completed if BIMS was 8 or higher to ensure all potential sexual abuse allegations and/or sexual interactions were identified, thoroughly investigated and reported. No additional sexual abuse allegations or sexual interactions were identified in the look back or resident interviews.
The facility developed and implemented a process to assess residents for abuse and neglect vulnerability. All residents were assessed on 9/3/26 and all new admissions will continue to be assessed. Any resident identified as being at an increased vulnerability will have a care plan implemented to monitor behaviors and the potential for increased risk of sexual abuse. Individualized interventions will be incorporated as indicated.
All staff has been educated including agency and new hires on prohibiting and prevention of abuse, what constitutes abuse, recognizing signs of abuse and reporting abuse.
All licensed staff has been educated including agency and new hires on updating resident care plan needs to prevent sexual abuse.
AAE Consulting Services will provide Directed In-Service training on F600: Free from Abuse and Neglect and the steps/process to follow when sexual abuse is seen or suspected for all staff members, including agency personnel, on September 29, 2026. A copy of the educational presentation will be given and completion will be required before/upon next scheduled shift to any staff member who is unable to attend the in-person training session.
The facility completed daily audits for 2 weeks of residents with sexual behaviors to validate appropriate interventions are in place to prevent sexual abuse. The facility will now complete these audits weekly for 2 weeks, then monthly for 3 months to ensure residents are protected from sexual abuse.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

483.70 REQUIREMENT Administration:

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.

§483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Observations:

Based on review of job descriptions, facility documents, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to protect residents from resident to resident initiated sexual abuse. This failure resulted in a resident (Resident R2), who had demonstrated inappropriate sexual behaviors, touching a cognitively impaired resident in an inappropriate manner (Resident R1) and making unwanted sexual comments to a resident (Resident R3). This failure created an Immediate Jeopardy situation.

Findings include:

Review of the facility-provided Nursing Home Administrator (NHA) job description signed by the current NHA on 1/14/26, indicated, " To manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. " Included in the list of responsibilities were:

Ensures that all incidents or suspected incidents of resident abuse are investigated immediately and appropriate action is taken.

Understands and follows the Abuse Prohibition policy and procedure.

Ensures a safe environment.

Review of the facility-provided Director of Nursing (DON) job description, signed by the current DON on 2/26/25, indicated, " The Director of Nursing will plan, organize, develop, and direct the overall operation of the Nursing Services department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality of care is maintained at all times. " Included in the list of responsibilities were:

Complete incident reports and follow up on reports.

Knowledge of complaint goals, objectives, policies, procedures, and federal, state, and local regulations.

Review nurses ' notes to ensure proper documentation is maintained relating to residents' treatment, medications, and conditions.

Knowledgeable of all residents ' rights according to facility policy and regulations.

Understands and follows the Abuse Prohibition policy and procedure.

Based on findings identified in this report, the facility failed to prevent and protect residents from unwanted sexual statements and actions. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed.

During an interview on 9/4/26, at approximately 12:30 p.m. the NHA and DON confirmed that facility administration failed to effectively manage the facility to protect residents from resident to resident initiated sexual abuse. This failure resulted in a resident, who had demonstrated inappropriate sexual behaviors, touching a cognitively impaired resident in an inappropriate manner and making unwanted sexual comments to a resident. This failure created an Immediate Jeopardy situation.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.

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

Plan of Correction - To be completed: 10/13/2026

The facility will ensure the highest degree of quality care is always provided to all residents. The facility will ensure that all residents are protected from sexual abuse and inappropriate sexual interactions through effective processes for prevention, identification, reporting, investigation, and response.
The facility implemented a process to assess residents for vulnerability to abuse and neglect and will initiate individualized care plans and interventions to address identified risks and promote resident safety.
The facility completed a 30-day review of resident progress notes, incident and accident reports, and resident interviews. No additional allegations of sexual abuse or inappropriate sexual interactions were identified during the review.
Staff were educated on abuse prevention, recognition, reporting, and care plan updates, with additional training scheduled for September 29, 2026.
The Regional Clinical Consultant and Regional Director of Operations will educate the Nursing Home Administrator and Director of Nursing on Federal Regulation 0835 and discuss and review Job Descriptions.
The Nursing Home Administrator and Director of Nursing will review facility policies and procedures to ensure adherence to current standards and regulations.
The Nursing Home Administrator and Director of Nursing will audit the plan of corrections weekly for 4 weeks and then monthly for 3 months to ensure all corrective actions are being completed. The Regional Clinical Consultant will oversee and review the facilities audits to ensure compliance and effectiveness of audits.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

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

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(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 a review of clinical records and staff interview, it was determined that the facility failed to notify the resident representative / responsible party of an incident where the resident may have been the victim of inappropriate sexual behavior for one of three residents (Resident R1) and that the facility failed to notify the physician of a change in condition for one of three residents (Discharged Resident R3).

Findings include:

Review of Resident R1's clinical record indicated admission to the facility on 5/22/24, and documented a family member as the responsible party and a family member as an emergency contact.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/18/26, indicated diagnoses of dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) diabetes (high sugar in the blood) and depression. Further review of MDS Section C- Cognitive Patterns, C0500 BIMS Summary Score indicated Resident R1 scored a "7", severe impairment.

Review of Resident R1's care plan dated 6/16/25, indicated chronic/progressive decline in intellectual functioning characterized by; deficit in memory, judgment, decision making and thought process.

Review of facility-submitted documentation on 8/21/26, indicated that on 8/21/26, "[Resident R2] was observed by facility staff in the common area of the facility with his hands inside his pants and touching his genital area. [Resident R1] was seated/near Resident R2 at the time of observation. As staff approached the residents to intervene, [Resident R2] was observed placing his hand on [Resident R1's] lap in a patting motion." The report continued on to state, "The families/responsible parties of both residents were contacted and notified of the incident."

Review of Resident R2's clinical record failed to reveal documentation included in the medical record to indicate that Resident R2's responsible party was notified of the incident of possible in appropriate sexual behavior.

During an interview on 9/4/26, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify the resident representative / responsible party of an incident where the resident may have been the victim of inappropriate sexual behavior for one of three residents.

Review of Discharged Resident R3's clinical record indicated admission to the facility on 2/28/25.

Review of Discharged Resident R3's MDS dated 5/15/26, indicated diagnosis of anxiety, schizophrenia (affects how people think, feel and behave) and post-traumatic stress disorder (PTSD-severe and potentially debilitating mental health disorder that affects people who have experienced or witnessed a traumatic event).

Review of Discharged Resident R3's nursing progress note date 8/13/26, at 10:10 p.m. indicated Resident complaining of chest pain with a feeling of a lump in her throat. She states that she is having a bad day and has gotten into arguments with multiple residents today. Vital signs assessed and within normal limits. Resident demanded that the on-call physician be called now, I told resident that it was not emergent and can wait until provider comes in tomorrow, however she was not happy with that plan so I told her that we will not be sending her to the emergency room due to stable vital signs. Resident went to the front desk and called 911. RN supervisor notified, and resident was sent to local emergency room.

During an interview completed on 9/3/26 at 12:20 p.m. the Director of Nursing confirmed that Discharged Resident R3's physician was not notified of complaints of chest pain with a feeling of a lump in residents throat and that the facility failed to notify the physician of a change in condition for one of three residents (Discharged Resident R3).

28 Pa. Code 201.18 (b)(1) Management.
28 Pa. Code 211.12 (d)(1)(2)(3) Nursing services.

Plan of Correction - To be completed: 10/13/2026

The facility cannot retroactively correct that the notification of R1's representative/responsible party was not documented appropriately.
The facility cannot retroactively correct that the facility failed to notify the physician of a change in condition for R3.
The Director of Nursing or designee will educate all licensed clinical staff on the notification of representative/responsible party per facility Abuse Reporting and Investigation Policy and Procedures.
The Director of Nursing or designee will educate all licensed clinical staff on physician notification for resident changes in condition.
The Director of Nursing or designee will review Incidents/Accidents and Progress Notes 5x week for 4 weeks then monthly for 3 months to ensure representatives/responsible party have been notified appropriately of inappropriate sexual behavior.
The Director of Nursing or designee will review Incidents/Accidents and Progress Notes 5x week for 4 weeks then monthly for 3 months to ensure physician notification is completed for resident change in condition.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Plan of Correction - To be completed: 10/13/2026

The facility will ensure that a complete, thorough and timely investigation is completed for all allegations of sexual abuse.
The facility completed a thorough investigation for R1 and R3.
The Administrator or designee will educate all staff on facilities Abuse Reporting and Investigation Policy detailing a complete, thorough and timely investigation must be completed on all allegations of sexual abuse.
The facility completed a 30-day look back to ensure all allegations of sexual abuse were identified and that a complete, thorough and timely investigation was completed. No additional sexual abuse allegations were identified in this look-back.
The Administrator or designee will review Incidents/Accidents and Progress Notes 5x week for 4 weeks then monthly for 3 months to ensure all allegations of sexual abuse have a complete, thorough and timely investigation completed.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Plan of Correction - To be completed: 10/13/2026

The facility will ensure that all allegations of sexual abuse are reported timely.
The facility completed a thorough investigation for R1 and R3 and reported as required.
The Regional Clinical Consultant or designee will educate the Nursing Home Administrator and Director of Nursing on federal regulation 0609. Detailing thoroughly investigating suspected or alleged sexual abuse and timely reporting to the local state field office.
The facility completed a 30-day look back to ensure all allegations of sexual abuse were identified and reported timely to the local state field office. No additional sexual abuse allegations were identified in this look-back.
The Director of Nursing or designee will audit Incidents/Accidents and Progress Notes 5x week for 4 weeks then monthly for 3 months to ensure all allegations of sexual abuse are reported timely to the local state field office.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Plan of Correction - To be completed: 10/13/2026

The facility cannot retroactively correct that the facility failed to identify and/or investigate potential sexual abuse.
The facility has completed a thorough investigation of all related incidents of R2 with residents R1 and R3. R3 has been discharged from the facility.
The Care Plans for R1 and R2 were reviewed and revised to reflect the identified risks, interventions, monitoring needs and individualized approaches to promote ongoing safety. R3 has been discharged from the facility.
The Regional Clinical Consultant will educate the Nursing Home Administrator and Director of Nursing on federal regulation 0610. Detailing the identification of sexual abuse and thoroughly investigating suspected or alleged sexual abuse.
The Director of Nursing or designee will audit Incidents/Accidents and Progress Notes 5x week for 4 weeks then monthly for 3 months to ensure all potential allegations of sexual abuse are appropriately identified and investigated to ensure resident safety.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) REQUIREMENT Discharge Process:

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents with facility-initiated transfers (Discharged Residents R3) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of two resident hospital transfers (Discharged Residents R3).

Findings include:

Review of the facility policy "Transfer and Discharge " policy last reviewed 4/4/26, indicated the facility must notify the resident and if know the resident ' s representative of the transfer, and the reason for the transfer. Upon transfer the facility will provide a written notice to the residents or representatives of the facility bed hold policy. When a resident is discharged a description of the significant findings and events of the residents ' stay the condition on discharge shall be provided.

Review of Discharged Resident R3's clinical record indicated admission to the facility on 2/28/25.

Review of Discharged Resident R3's MDS dated 5/15/26, indicated diagnosis of anxiety, schizophrenia (affects how people think, feel and behave) and post-traumatic stress disorder (PTSD-severe and potentially debilitating mental health disorder that affects people who have experienced or witnessed a traumatic event).

Review of the clinical record indicated Discharged Resident R3 was transferred to the hospital on 8/14/26, at 5:17 p.m.

Review of Discharged Resident R3's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility and failed to have documentation of a bed hold policy given to the resident or representative.

During an interview on 9/3/26, at 12:30 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents with facility-initiated transfers (Discharged Residents R3) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of two resident hospital transfers (Discharged Residents R3).

28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Plan of Correction - To be completed: 10/13/2026

The Facility cannot retroactively correct that for R3 the facility failed to ensure and document all necessary information was communicated to the receiving health care provider and that the resident was notified of the facility bed hold policy.
The facility will ensure with resident transfers that necessary information is communicated to the receiving health care provider and that the resident and/or representative is notified of the facility Bed Hold Policy.
The Director of Nursing or designee will educate all Licensed Clinical Staff on facility Transfer and Discharge Policy to ensure that all necessary information is communicated with the receiving health care provider and that the resident and/or representative are notified of the facility Bed Hold Policy.
The Director of Nursing or designee will audit resident transfers weekly for 4 weeks then monthly for 3 months to ensure all necessary information was communicated to the receiving health care provider and that the resident and/or representative was notified of the facility Bed Hold Policy.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Plan of Correction - To be completed: 10/13/2026

The facility cannot retroactively correct the issues identified with R1 and R2 Comprehensive Care Plan. The facility will ensure that all residents will have a Comprehensive Care Plan with individualized interventions to address the care needs of the resident.
The Comprehensive Care Plans for R1 and R2 were reviewed and revised to reflect the identified risks, interventions, monitoring needs and individualized approaches to promote resident safety.
The Director of Nursing or designee will educate the RNAC's on facility MDS/RAI/Care Planning Policy to ensure that all residents have a Comprehensive Care Plan that includes specific individualized interventions to address the care needs of each resident.
The Director of Nursing or designee will audit residents with sexual behaviors weekly for 4 weeks then monthly for 3 months to ensure appropriate individualized interventions are in place to prevent sexual abuse.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

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 properly secure a treatment cart for one of two carts observed (Northwest Hallway).

Findings include:

During an observation completed on 9/1/26, at 12:34 p.m. the treatment cart was left unattended and unlocked outside of room 409. A pair of scissors was sitting on the top, available to anyone passing by.

During an interview completed on 9/1/26, at 12:38 p.m. Licensed Practical Nurse Employee E13 confirmed that the treatment cart was left unattended and unlocked outside of room 409. A pair of scissors was sitting on the top, available to anyone passing by and the facility failed to properly secure a treatment cart for one of two carts observed (Northwest Hallway).

28 Pa. Code: 201(a) Responsibility of licensee.

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

Plan of Correction - To be completed: 10/13/2026

The facility cannot retroactively correct the treatment cart left unattended and unlocked.
As soon as the facility was made aware of the deficient practice the Director of Nursing ensured that the scissors were accounted for and removed from the top of the treatment cart and the LPN utilizing the cart at that time was immediately educated.
The Director of Nursing or designee will educate all Licensed Clinical Staff on Medication Storage Policy detailing properly securing treatment carts.
The facility completed a house audit of all treatment carts to verify proper function and to ensure treatment carts can be fully closed and locked when not in immediate use.
The Director of Nursing or designee will conduct audits of treatment storage and treatment cart security weekly for 4 weeks and then monthly for 3 months.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

§ 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.

Plan of Correction - To be completed: 10/13/2026

The facility cannot correct that nurse aide staffing ratios were not met on 8/13/26, 8/14/26, 8/20/26 through 8/25/26, 8/27/26, 8/30/26, 8/31/26, and 9/2/26.
The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift.
Daily staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler or designee will be responsible to call off duty personnel and/or call extra support staff to assist.
The Nursing Home Administrator or designee will audit staffing daily for 4 weeks then monthly for 3 months to ensure nurse aide staffing ratios are being met.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

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

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

Plan of Correction - To be completed: 10/13/2026

The facility cannot correct that LPN staffing ratios were not met on 8/13/26, 8/20/26 through 8/22/26, 8/25/26, 8/27/26, 8/31/26, and 9/2/26.
The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift.
Daily staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet LPN staffing ratios on a given shift, the scheduler or designee will be responsible to call off duty personnel and/or call extra support staff to assist.
The Nursing Home Administrator or designee will audit staffing daily for 4 weeks then monthly for 3 months to ensure LPN staffing ratios are being met.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

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

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

Observations:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 11 of 23 days (8/14/26, 8/21/26, 8/22/26, 8/23/26, 8/24/26, 8/25/26, 8/26/26, 8/27/26, 8/30/26, 9/1/26, and 9/2/26).

Findings include:

Review of the nursing schedules and census information for 8/11/26, through 9/2/26, revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates:
-8/14/26, Census 110. PPD 3.12.
-8/21/26, Census 110. PPD 2.88.
-8/22/26, Census 110. PPD 3.02.
-8/23/26, Census 109. PPD 2.96.
-8/24/26, Census 109. PPD 2.96.
-8/25/26, Census 112. PPD 3.13.
-8/26/26, Census 113. PPD 3.18.
-8/27/26, Census 114. PPD 3.14.
-8/30/26, Census 113. PPD 3.12.
-9/01/26, Census 114. PPD 3.18.
-9/02/26, Census 110. PPD 3.16.

During an interview on 9/4/26, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 11 of 23 days.

Plan of Correction - To be completed: 10/13/2026

The facility cannot correct that the PPD was below a 3.20 staffing level on 8/14/26, 8/21/26 through 8/27/26, 8/30/26, 9/1/26, and 9/2/26.
The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5640 and make sure that PPDs are met. Daily schedules will be reviewed to monitor the projected PPD and the IDT will adjust if needed to ensure PPDs are met. The Nursing Supervisors will review staffing sheets on the weekends. If the facility projects to not meet PPD on any given day, the scheduler/designee will be responsible for calling off duty personnel and/or call extra support staff to assist.
The Nursing Home Administrator or designee will audit staffing daily for 4 weeks then monthly for 3 months to ensure PPDs are being met.
The results of these audits will be forwarded monthly to Quality Assurance and Performance Improvement Committee for review, recommendations and frequency of audits.

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