Pennsylvania Department of Health
FOREST PARK NURSING AND REHABILITATION
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

FOREST PARK NURSING AND REHABILITATION
Inspection Results For:

There are 240 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.


FOREST PARK NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, Complaint, State Licensure, and Civil Rights Compliance survey, which ended on August 6, 2026, it was determined that Forest Park Nursing and Rehabilitation 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, and Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

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.

�483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

�483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

�483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

�483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Plan of Correction - To be completed: 09/09/2026

1.Weight will be obtained; MD and Dietician will be notified for resident #4. Weight will be obtained; MD and Dietician will be notified for resident #10. MD to be notified of Dietician recommendation for supplement to be TID for resident #10, order will be updated as directed by MD. Weight will be obtained, MD and Dietician will be notified or resident #103. Care plan for resident #103 will be updated to address significant weight loss and reduced PO intake related to tooth abscess. MDS will be changed to address significant weight loss for resident #103. Weight will be obtained; MD and dietician will be notified for resident #110.

2.DON/Designee will conduct audit of current residents to ensure weights have been obtained per MD order.

3.NHA/Designee will educate licensed nursing to ensure that resident weights are obtained per MD orders. Education will include if weights are not obtained, there must be documentation as to why they were not obtained promptly. MD and Dietician must be notified. It is important to reattempt to obtain weight if a resident refuses, Physicians must be notified of weight changes, care plans must be updated to address significant weight changes, and implementation of supplement recommendations/orders, there must be timely nutritional assessments following significant weight changes. Dietician will be educated on notifying the practitioner of significant weight changes and timely completion of nutrition assessment following significant weight changes.

4.DON/Designee will audit 10 residents weekly for 1 month, then monthly for 2 months to ensure weights are obtained per MD order, physician notification of weight changes, care plan updates for significant weight changes, implementation of supplement recommendations, and timely nutritional assessment for significant weight changes. Results of audits will be reviewed during monthly Quality Assurance Performance Improvement meetings.

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 facility policy review, facility document review, observations, and staff interview, it was determined that the facility failed to properly label medications in two of two medications carts reviewed (Laurel Lane and Evergreen) and in one of two medication rooms reviewed (Evergreen/Stepping Stones).

Findings include:

Review of facility policy, titled "Administering Medications," dated April 2019, with a last review date of February 9, 2026, revealed, in part, "17. Insulin pens are clearly labeled with the resident's name or other identifying information. 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container."

Review of facility policy, titled "Storage of Medications," dated November 2020, with a last review date of February 9, 2026, revealed, in part, "7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly."

Review of facility policy, titled "Labeling of Medication Containers," dated April 2019, with a last review date of February 9, 2026, revealed, in part, "All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations."

Review of facility document, titled "Medications with Shortened Expiration Dates," dated August 2022, revealed that Lantus insulin expires 28 days after opening and that tuberculin skin testing solution should be discarded 30 days after opening.

Observation of the Laurel Lane medication cart with Employee 6 (Licensed Practical Nurse) on August 4, 2026, at 9:24 AM, revealed an opened, half-full bottle of liquid protein supplement with no open date noted on the bottle. The bottle indicated that it was to be discarded 60 days after opening. In addition, there was an albuterol inhaler stored in the cart without a manufacturer package noted and no label containing a resident's name.

Observation of the Evergreen medication cart with Employee 7 (Licensed Practical Nurse) on August 4, 2026, at 9:30 AM, revealed three Lantus insulin pens were not dated with an open date (Residents 14, 85, and 87).

Observation of the Evergreen/Stepping Stones medication room with Employee 8 (Licensed Practical Nurse) on August 4, 2026, at 9:39 AM, revealed an opened multi-dose vial of tuberculin testing solution with no opened date indicated on vial or box.

During a staff interview with the Nursing Home Administrator on August 4, 2026, at 11:16 AM, she confirmed that she would expect medications to be labeled and stored properly.

28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.9(a)(1)(j)(1) Pharmacy services.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 09/09/2026

1.Unlabeled medications found in Laurel Lane and Evergreen medication carts and medication rooms in Evergreen/Steppingstone were disposed of immediately.

2.ADON conducted audit of facility medication carts and rooms for any unlabeled medications.

3.NHA/Designee will educate licensed nursing on labelling and storage of medications to ensure there are no unlabeled medications.

4.DON/Designee will audit medication carts and medication rooms weekly for 3 months to ensure there are no unlabeled medications. Results of audits will be reviewed during monthly Quality Assurance Performance Improvement meetings.

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

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.

�483.21(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.

Plan of Correction - To be completed: 09/09/2026

1.Facility unable to retroactively correct care plan for resident #56 as condition has been resolved. Facility unable to retroactively correct care plan for residents 84 prior to 7/28/26. Care plan for resident #97 was corrected on 8/5/26

2.DON/Designee will complete audit of current resident's care plans to ensure they appropriately reflect residents' current status.

3.DON/Designee will provide education to licensed nursing staff on Ftag 657 Care plan timing and Revision.

4.DON/Designee will audit 5 resident care plans weekly for 1 month and then monthly for 2 months to ensure care plans are appropriate for resident's status including resolution of care plans that are no longer applicable. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.

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

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

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

Observations:

Based on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and failed to provide adequate supervision and assistance devices to prevent accidents for one of four residents reviewed for falls (Resident 3).

Findings include:

Review of facility policy, titled "Falls Clinical Protocol" last reviewed February 9, 2026, read, in part, "While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling."

Review of Resident 3's clinical record revealed diagnoses that included need for assistance with personal care, muscle weakness, and difficulty in walking.

Review of Resident 3's clinical record revealed that he sustained a fall on July 28, 2026, and that he has had a history of falls due to impaired mobility and non-compliance with transfers.

Review of Resident 3's comprehensive care plan revealed he had active fall interventions including "bilateral fall mats" with a start date of August 14, 2025, and "signage to remind resident to ring the call bell for assistance," with a start date of October 27, 2025.

Observations in Resident 3's room on August 3, 2026, 11:37 AM; August 4, 2026, 12:58 PM; and August 5, 2026, 9:37 AM, failed to reveal a sign to remind the Resident to ring the call bell for assistance.

Observation in Resident 3's room on August 4, 2026, 12:58 PM, revealed he was lying in bed, and he only had one fall mat on the right side of his bed. There was no fall mat on the left side of his bed, which was the side he transfers in and out of bed. Multiple staff were observed to be passing by the room at that time and looking into the room.

Observation in Resident 3's room on August 5, 2026, 1:49 PM, revealed he was lying in bed, and he only had one fall mat on the right side of his bed. There was no fall mat on the left side of his bed.

Interview with Resident 3 on August 5, 2026, 1:49 PM, revealed staff had helped him into bed that afternoon.

Review of Resident 3's nurse aide task for turning and repositioning revealed staff had recently turned and repositioned him in bed on August 5, 2026, at 1:21 PM.

During an interview with the Director of Nursing on August 6, 2026, at 11:39 AM, she revealed she spoke with staff who stated the sign used to be on his closet door, but months ago his closet door was removed and converted to a curtain, and that must have been when the sign got removed from his room. She further revealed would expect fall interventions to be in place as applicable, and she would expect that the resident environment remains as free of accident hazards as is possible to prevent accidents.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 09/09/2026

1.Facility is unable to retroactively correct fall interventions not being in place for resident #3.

2.DON/Designee will audit current resident fall interventions are in place per resident care plan.

3.NHA/Designee will educate nursing staff that resident fall interventions must be in place per resident care plan to ensure resident safety.

4.DON/Designee will audit 10 residents weekly for 1 months, then monthly for 2 months to ensure fall interventions are in place per resident care plan. Results of audits will be reviewed during monthly Quality Assurance Performance Improvement meetings.

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 facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed for respiratory care (Resident 13).

Findings include:

Review of facility policy, titled "Oxygen Administration," dated October 2010, with a last review date of February 9, 2026, revealed, in part, "Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.; and Reporting: 1. Notify the supervisor if the resident refuses the procedure."

Review of Resident 13's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and chronic respiratory failure with hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood).

Review of Resident 13's physician orders revealed an order for oxygen at 2 liters/minute via nasal cannula every shift, dated June 7, 2026.

During a resident interview with Resident 13 on August 3, 2026, at 10:00 AM, Resident 13 was observed to have her oxygen concentrator running but she was not wearing her oxygen. During an immediate interview with Resident 13, she indicated that she took it off because she only wears her oxygen at night.

Observation of Resident 13 on August 4, 2026, at 11:04 AM, revealed her oxygen concentrator was running and her nasal cannula was lying on her bed. Resident 13 indicated that she only wears it when she wants to, and that is usually at night.

Observation of Resident 13's room on August 5, 2026, at 9:25 AM, revealed that she was not present in her room. Her oxygen concentrator was running, and her nasal cannula was lying on her bed.

During a staff interview with Employee 6 (Licensed Practical Nurse) on August 5, 2026, at 9:29 AM, Employee 6 indicated that Resident 13 was out of the facility on a leave of absence. When asked if Resident 13 had taken oxygen with her on her leave of absence, Employee 6 said that Resident 13 did not take any portable oxygen with her because her oxygen was only ordered for nighttime.

Review of Resident 13's August Medication Administration Record revealed that she had been documented as receiving her oxygen on every shift for August 1, 2, 3, 4, and 5, 2026.

During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on August 5, 2026, at 1:05 PM, the DON indicated that Resident 13 had been hospitalized recently and, prior to her hospitalization, her oxygen was ordered at night and as needed for an oxygen saturation level below 90%, but when she returned from the hospital the oxygen order was entered for continuous use. She said that she was clarifying the order.

28 Pa. Code 211.10(c) Resident care policies.
28 Pa code 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 09/09/2026

1.Oxygen orders were changed for resident #13 to address her current need for oxygen use.

2.DON/Designee will conduct audit of current residents to ensure that oxygen use is being followed per MD orders.

3.NHA/Designee will educate licensed nurses to ensure residents are receiving oxygen per MD orders.

4.DON/Designee will audit 10 residents weekly for 1 month, then monthly for 2 months to ensure oxygen is being provided per MD order. Results of audits will be reviewed during monthly Quality Assurance Performance Improvement meetings.

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

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

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

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

Observations:

Based on review of facility meal tray test form, review of resident council meeting minutes, a resident group interview, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages at appetizing temperatures.

Findings include:

Review of form titled "Culinary and Nutrition Test Tray" not dated, revealed standard temperatures for hot foods and beverages at point of service are greater than 135 degrees Fahrenheit (F- unit of measure); and the standard temperature for cold beverages at point of service is below 41 degrees F.

Interview with Resident 47 on August 3, 2026, at 11:25 AM, revealed the food is often served cold and the trays sit in the meal carts on the units for extended periods of time before they are passed to the residents. He stated the cold items just sit on the trays for extended periods, and the coffee is usually not hot.

During a group interview with residents on August 4, 2026, at 10:30 AM, they revealed the food tastes poor and the temperatures are not appetizing.

Review of Resident Council Minutes from February 27, 2026, under dietary concerns it was revealed that residents complained of food served cold.

Review of Resident Council Minutes from July 31, 2026, under dietary concerns it was revealed that residents complained of food served cold.

Review of facility menu on August 5, 2026, revealed the main lunch meal consisted of Ham,Green beans &; Potatoes (EntrDinner Roll, and a Brownie.

A test tray was completed on August 5, 2026, at 12:06 PM, with Employee 4 (Cook) that included the Ham, Green beans &; Potatoes, Dinner Roll, Brownie, Milk, and Coffee. The test tray was placed on a meal cart and delivered to the Chapel Wood unit with other trays being delivered at that time; approximately 35 minutes had elapsed between leaving the kitchen and when the test tray was served for evaluation, as it was the last tray served on that unit after all others had been passed.

Employee 4 took temperatures of the food items at the time the test tray was served for evaluation. At that time, the entrhad a highest recorded temperature of 120.4 degrees F; the coffee had a highest recorded temperature of 125 degrees F; and the milk had a lowest recorded temperature of 59 degrees F. The aforementioned entree, coffee, and milk were not served at appetizing temperatures.

During an interview with Employee 2 (Certified Dietary Manager) on August 5, 2025, at 12:12 PM, she confirmed that the aforementioned food and beverage temperatures were not within acceptable ranges.

During an interview with the Nursing Home Administrator (NHA) on August 5, 2026, at 1:24 PM, the surveyor revealed the concern with food palatability and the test tray results. The NHA revealed her expectation that food and beverages would be served at appetizing temperatures.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 09/09/2026

1.Facility unable to retroactively correct concerns of food and beverages being served at unappetizing temperatures and taste. Dietary does meet with residents during monthly resident council meetings and as needed to address individual food grievances or concerns.

2.Dietary Manager conducted initial audits for each unit during a breakfast, lunch, and dinner meal.

3.NHA/Designee will educate nursing staff of importance of delivering meal trays in a timely manner to ensure proper temperatures.

4.Dietary Manager/Designee will audit 3 test trays weekly for 3 months to ensure food is being served at proper temperatures. Dietary Manager will continue to address individual food grievance/concern as needed. Results of audits will be reviewed during monthly Quality Assurance Performance Improvement meetings.

483.60(e)(1)(2) REQUIREMENT Therapeutic Diet Prescribed by Physician:

�483.60(e) Therapeutic Diets
�483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.

�483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.

Observations:

Based on facility policy review, review of facility diet extension sheets, review of select facility recipes, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive and consume foods in the appropriate nutritive content as prescribed by a physician for 6 of 34 resident's reviewed on a consistent carbohydrate diet (Resident's 1, 14, 40, 56, 77, and 92).

Findings include:

Review of facility policy, titled "Therapeutic Diets" last reviewed February 9, 2026, read, in part, "A 'therapeutic diet' is considered a diet ordered by a physician, practitioner, or dietitian as part of a treatment for a disease or clinical condition, to modify specific nutrients in a diet, or to alter the texture of a diet, for example: diabetic/calorie controlled diet."

Review of facility menu extension sheets for day 25 of the spring and summer menu, revealed residents on a carbohydrate controlled (diabetic) restriction should be served 4 ounces (unit of measure) of diet pudding with topping in place of the brownie for dessert.

Review of select facility menus for brownies and diet pudding revealed the brownie contains 31.27 grams of carbohydrate (sugar, starch and dietary fiber occurring in foods) per serving, and the diet pudding contains 9.54 grams of carbohydrate per serving.

Review of physician orders for Residents 1, 14, 40, 56, 77, and 92, revealed they were ordered a consistent carbohydrate diet for diabetes.

Observations during tray line meal service on August 5, 2026, revealed residents were being served brownies as dessert.

During an interview with Employee 4 (Cook) at the completion of tray line meal service on August 5, 2026, at 11:17 AM, she revealed everyone was served a brownie for dessert at lunch that day, and there was not an alternate dessert served.

Observation of Residents 1, 14, 40, 56, 77, and 92 in their rooms on August 5, 2026, between 11:19 AM and 11:36 AM, revealed they had been served lunch, and a brownie was on their tray.

Interview with the Nursing Home Administrator on August 5, 2026, at 1:23 PM, revealed she would expect therapeutic diets to be provided as ordered and extension sheets followed for therapeutic diet alterations.

28 Pa Code 201.18(b)(1)Management

Plan of Correction - To be completed: 09/09/2026

1.Facility unable to retroactively correct meals provided to residents #1, 14, 40, 56, 77, and 92 on 8/5/26.

2.Dietary Manager conducted audit of current residents to ensure meals were provided per diet as ordered by MD.

3.NHA/Designee will educate dietary staff on ensuring meals are provided to residents per their diet as ordered by MD.

4.Dietary Manager/Designee will audit 3 tray lines weekly for 3 months to ensure residents are being provided with a meal according to their diet as ordered by MD. Dietary Manager will continue to address individual food grievance/concern as needed. Results of audits will be reviewed during monthly Quality Assurance Performance Improvement meetings.

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

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

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

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

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

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

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

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

Observations:

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to ensure staff implemented appropriate infection control guidelines during medication preparation and administration for one of three residents observed (Resident 3).

Findings include:

Review of facility policy, titled "Storage of Medications," dated November 2020, with a last review date of February 9, 2026, revealed, in part, "2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received."

Review of facility policy, titled "Administering Medications," dated April 2019, with a last review date of February 9, 2026, revealed, in part, "25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable."

During a medication administration observation of Employee 6 (Licensed Practical Nurse) on August 4, 2026, at 8:57, revealed that while preparing medications for Resident 3, Employee 6 dropped an albuterol inhaler onto the floor. Prior to Employee 6 dropping the inhaler, the inhaler was noted to be lying in the drawer of the medication cart with no box and no label containing a resident's name. Employee 6 picked the inhaler up off the floor and placed it back inside the medication cart. Employee 6 said that the inhaler was not for Resident 3 and confirmed that the inhaler had no resident name on it. He indicated that he would have to investigate it further when he was done with the medication pass. In addition, Employee 6 was observed to take a cup of oral medications, a nasal inhaler, and an oral inhaler into Resident 3's room to administer. After entering Resident 3's room, Employee 6 sat the nasal inhaler and oral inhaler onto Resident 3's overbed table. The overbed table was noted to be soiled with a clear sticky looking substance and a white colored powdery-like substance. After Employee 6 finished administering the medications, he took the nasal and oral inhaler and placed them back into their boxes inside the medication cart.

During an immediate interview with Employee 6, he confirmed that Resident 3's overbed table was soiled and that he should not have sat the inhalers on the dirty table or cleaned them before returning to the cart. Employee 6 also acknowledged that he should not have placed the inhaler that he dropped on the floor back into the cart without cleaning it first.

During a staff interview with the Nursing Home Administrator on August 4, 2026, at 11:20 AM, she confirmed that she would expect appropriate infection control measures to be followed by nurses during medication preparation and administration.

28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.9(a)(1) Pharmacy services.
28 Pa. Code 211.10(c) Resident care policies.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 09/09/2026

1.Facility is unable to retroactively correct the administration of medications for resident #3 regarding infection control procedures.

2.DON/Designee will conduct initial audit of medication passes with current licensed nurses to ensure they are using proper infection control procedures.

3.DON/Designee will conduct education with licensed nurses regarding mediation pass using proper infection control procedures.

4.DON/Designee will audit 5 medication passes weekly for 3 months to ensure licensed nurses are using proper infection control procedures during medication pass. Results of audits will be reviewed during monthly Quality Assurance Performance Improvement meetings.

� 201.22(b) LICENSURE Prevention, control and surveillance of tuber:

(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:

Based on facility policy review, personnel file review, and staff interviews, it was determined the facility failed to ensure recommendations of the Centers for Disease Control and Prevention (CDC) were followed in testing for Tuberculosis (TB) for two of five employees reviewed (Employees 9 and 10).

Findings include:

Review of facility policy, titled "Tuberculosis, Employee Screening For," with a last review date of February 9, 2026, revealed, in part, "Screening includes a baseline test for LTBI using either a TST or IGRA ... The employee health coordinator (or designee) will accept documented verification of TST or IGRA results within the preceding 12 months."

Review of Employee 9's personnel file revealed that her hire date was May 11, 2026. Her personnel file included results of a two-step TST prior to hire completed in February 2026 and March 2026 with negative results. Her personnel file failed to include a one-step TST at time of hire as per current CDC guidelines.

Review of Employee 10's personnel file revealed that her hire date was April 9, 2026. Her personnel file included results of a two-step TST prior to hire completed in November 2025 and December 2025 with negative results. Her personnel file failed to include a one-step TST at time of hire as per current CDC guidelines.

During a staff interview with Employee 11 (Human Resources Director) on August 4, 2026, at 1:47 PM, she revealed that their facility policy accepts two-step TST results that were completed within the last 12 months.

During a staff interview with Nursing Home Administrator (NHA) and Director of Nursing on August 6, 2026, at 11:28 AM, the NHA acknowledged that the facility should follow current CDC guidelines for tuberculosis testing regarding new hires.

Plan of Correction - To be completed: 09/09/2026

1.Employees #9 and 10 will have completed TB testing per CDC guidelines.

2.HR/Designee will conduct audit of current employees to ensure TB testing was completed per CDC guidelines.

3.NHA/Designee will educate HR Director on TB testing per CDC guidelines.

4.NHA/Designee will audit new hire charts to ensure TB testing is being conducted per CDC guideline for 3 months. Results of audits will be reviewed during monthly Quality Assurance Performance Improvement meetings.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement