Pennsylvania Department of Health
MIDTOWN OAKS HEALTH & REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MIDTOWN OAKS HEALTH & REHAB CENTER
Inspection Results For:

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MIDTOWN OAKS HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and complaint survey completed on February 26, 2026, it was determined that Midtown Oaks Health and Rehab Center 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:

483.25 REQUIREMENT Quality of Care:

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

Observations:

Based on review of polices and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 38 residents reviewed (Resident 42, 44 and 66).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 10, 2026, revealed that the resident was cognitively intact, was dependent on staff for daily care needs and had a diagnosis of disorder of the circulatory system (a condition affecting the heart resulting in impaired blood flow throughout the body).

Physician's orders for Resident 42 dated February 14, 2026, included an order for the resident to have surgical wounds of his left inner calf, left lateral calf, right lateral calf and right medial calf cleansed with normal saline, apply oil emulsion gauze over exposed area of the wound then sprinkle collagen particles throughout the wound bed over top of oil emulsion gauze to base of the wound, secure with ABD (abdominal pad) and rolled gauze, change daily.

Observations of Resident 42's wound care on February 26, 2026, at 1:12 p.m. revealed that Licensed Practical Nurse 3used hand sanitizer, put on gloves, sprayed wound cleanser on the old dressing, removed the old dressing, removed gloves, used hand sanitizer, put on gloves, applied oil emulsion gauze over exposed area of the wound then sprinkled collagen particles throughout the wound bed over top of oil emulsion gauze to base of the wound, secured with ABD and rolled gauze. Interview with Licensed Practical Nurse 3 on February 26, 2026, at 1:44 p.m. confirmed that she should have cleansed the wounds with normal saline and she did not.

Interview with the Director of Nursing on February 27, 2026, at 11:10 a.m. confirmed that Resident 42's wounds should have been cleansed with normal saline per physicians orders and they were not.

An annual (MDS) assessment for Resident 44, dated November 25, 2025, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care tasks, had a care plan that indicated the resident had altered skin integrity, and had diagnoses that included venous ulcers to the left lower leg.

Physician's orders for Resident 44, dated October 27, 2025, included orders for staff to apply ACE (an all cotton elastic breathable bandage which provides support, reduces swelling and aides in circulation) wraps to the resident's left lower leg; on in the morning and off in the evening.

Observations of Resident 44 on February 24, 2026, at 2:37 p.m., February 25, 2026 at 10:00 a.m. and 2:00 p.m., February 26, 2026, at 10:10 a.m. and 12:43 p.m. revealed that she was sitting in her wheel chair beside her bed, the ACE wraps were lying on the blankets at the bottom of the bed and not on her left lower leg as ordered.

Interview with Resident 44 on February 26, 2026, at 12:43 p.m. indicated that she is to wear her ACE wraps when she is out of bed, and that some staff put them on and some do not.

Interview with Nurse Aide 4 on February 26, 2026, at 12:54 p.m. confirmed that Resident 44's ACE wraps were not on her left lower leg. She further indicated that she did not realize the ACE wraps were to be on the resident and that if they were ordered then they should be in place.

Interview with the Director of Nursing on February 27, 2026, at 2:26 p.m. confirmed that Resident 44's ACE wraps were not placed on her left lower leg as per physician's orders, and they should have been.

The facility's medication administration policy, dated April 29, 2025, indicated that staff were to verify each time a medication was administered that it was the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, and for the correct resident.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 66, dated December 9, 2025, indicated that the resident was cognitively impaired, received insulin, and had diagnoses that included diabetes. A care plan, dated July 31, 2023, indicated that the resident had diabetes and her medications were to be administered as ordered by the physician.

Physician's orders for Resident 66, dated September 10, 2025, included an order for the resident to receive 26 units of Insulin Lispro subcutaneously once a day for diabetes. The insulin was to be held if the resident's blood sugar was less than 100 milligrams/deciliter (mg/dL).

The Medication Administration Record (MAR) for Resident 66 for October and November 2025, and January and February 2026, revealed that the resident received 26 units of Insulin Lispro during the 4:00 p.m. to 7:00 p.m. medication pass on October 14 for a blood sugar of 75 mg/dL; on November 14, 2025 for a blood sugar of 82 mg/dL; on January 5 for a blood sugar of 82 mg/dL; on January 11 for a blood sugar of 93 mg/dL; and on February 18, 20216 for a blood sugar of 76 mg/dL.

Interview with the Director of Nursing on February 25, 2026, at 11:47 a.m. confirmed that there was no documented evidence that Resident 66's Insulin Lispro was held when the resident's blood sugar was less than 100 mg/dL on the dates and times mentioned above.

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

Plan of Correction - To be completed: 03/31/2026

The Medical Director was notified that resident #66 received insulin outside of parameters, and no new orders were received. Resident #42 dressing change was completed per physician's order. Wounds were assessed by Certified Registered Nurse Practitioner with no adverse findings. The Medical Director was notified with no new orders received. Resident #44 ACE wrap was reapplied per physician order. The Medical Director was notified with no new orders received.

To identify other residents that have the potential to be affected, the Director of Nursing and/or designee completed an audit of current resident insulin orders with hold parameters to ensure insulin was held accordingly. Any issues identified during the audit process will be addressed. The Director of Nursing and/or designee completed an audit of current wound orders to ensure accuracy. The Director of Nursing and/or designee completed an observation of wound care by responsible nurse to ensure physician orders were followed. The Director of Nursing and/or designee completed an observation of ACE wrap placement to ensure physician order followed. Any issues identified during the audit process will be addressed.

To prevent recurrence, the Director of Nursing and/or designee re-educated licensed staff on physician order policy with emphasis on double checking the order before preforming a procedure or administering medication.

To monitor and maintain compliance, the Director of Nursing and/or designee will audit insulin administration documentation 1x weekly for 4 weeks and monthly for 2 months to ensure administered medication is followed as ordered parameters. The Director of Nursing and/or designee will observe wound treatment 1x weekly for 4 weeks and monthly for 2 months to ensure treatment matches the physician's order. The Director of Nursing and/or designee will observe placement of ACE wraps 1x weekly for 4 weeks and monthly for 2 months to ensure they are applied per physician orders. The results of these audits will be reviewed at the Quality Assurance and Performance Improvement meeting.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the pneumococcal immunization for four of 38 residents reviewed (Residents 2, 16, 36, 45).

Findings include:

The facility's policy regarding the pneumococcal vaccine, dated April 29, 2025, indicated that the resident would be offered the pneumococcal vaccination if they were eligible for it.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 26, 2026, revealed that the resident was cognitively impaired and did not have the pneumococcal vaccine offered.

Review of the immunization records for Resident 2 revealed no documented evidence that the resident was offered, received, or refused a pneumococcal vaccine since admission on January 20, 2026.

A quarterly MDS assessment for Resident 16, dated January 14, 2026, indicated that the resident was cognitively impaired and that the resident was not offered the pneumococcal vaccination.

Review of the immunization records for Resident 16 revealed no documented evidence that the resident was offered, received, or refused a pneumococcal vaccine.

A quarterly MDS assessment for Resident 36, dated January 19, 2026, indicated that the resident was cognitively impaired and that the resident was not offered the pneumococcal vaccination.

Review of the immunization records for Resident 36 revealed no documented evidence that the resident was offered, received, or refused a pneumococcal vaccine.

An admission MDS assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated February 12, 2026, revealed that the resident was cognitively impaired and did not have the pneumococcal vaccine offered.

Review of the immunization records for Resident 45 revealed no documented evidence that the resident was offered, received, or refused an influenza vaccine since admission on February 6, 2026.

Interview with the Infection Preventionist on February 27, 2026 at 10:56 a.m. confirmed that Residents 2, 13, 36, and 45 were not offered a pneumococcal vaccine and that they should have been.

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

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

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

Plan of Correction - To be completed: 03/31/2026

Resident numbers 2, 16, 36, and 45 were offered pneumococcal vaccinations.

To identify other residents that have the potential to be affected, the Director of Nursing and/or designee completed an audit of current resident pneumonia vaccine documentation. Any issues identified during the audit process will be addressed.

To prevent recurrences, the Director of Nursing and/or designee re-educated licensed staff on the requirement for offering pneumococcal vaccination to long term care residents.

To monitor and maintain compliance, the Director of Nursing and/or designee will audit new admission residents for pneumococcal vaccination 1x weekly for 4 weeks and monthly for 2 months. The results of these audits will be reviewed at the Quality Assurance and Performance Improvement meeting.

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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during medication administration for one of 38 residents reviewed (Resident 13), and during wound care for two of 38 residents reviewed (Residents 8, 69).

Findings include:

The facility's policy regarding medication administration, dated April 29, 2025, indicated that staff were not to touch the medications with their bare hands.

Physician's orders for Resident 13, dated January 16, 2026 included an order for the resident to receive 667 milligrams (mg) calcium acetate (vitamin) three times per day with meals.

Observations of Licensed Practical Nurse 1 on February 25, 2026 at 2:02 p.m. revealed that he poured the calcium acetate out of the bottle and into his bare hand. He then attempted to pour the pill into a medicine cup, however, it missed the cup and landed on the medication cart. He picked the pill up with is bare hand and then administered it to Resident 13.

Interview with Licensed Practical Nurse 1 on February 25, 2026 at 2:04 p.m. revealed that he should not have touched the pill with his bare hand.

Interview with the Director of Nursing on February 25, 2026 at 3:01 p.m. confirmed that staff were not to touch residents' medications with their bare hands.

The facility's dressing change policy, dated April 29, 2025, indicated that after gloves were removed, hands were to be sanitized to avoid transfer of microorganisms.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 8, dated January 1, 2026, revealed that the resident was cognitively intact, was understood, able to understand, required assistance with care needs, had multiple wounds that included the left ankle, right heel, right posterior thigh and calf and a pressure ulcer to the sacrum/coccyx area, and was seen weekly by a nurse practitioner from Wound Healing Partners.

Observations of Resident 8's wound care on the left toe and right calf area on February 26, 2026, at 12:56 p.m. was as follows; Licensed Practical Nurse 5 donned gloves, cleansed the left toe area with dermal cleanser, cut and placed a piece of petroleum based xeroform on the area and covered with a boarder gauze, doffed gloves and without hand sanitizing, donned new gloves. She then removed the dressing from the calf area, and without removing her gloves, she cleaned the area with derma cleanser, cut and placed xeroform, then covered with an adhesive foam dressing, removed gloves and without hand sanitizing, she dated the dressing, and donned gloves and cleaned two small wounds on the coccyx are with dermal cleanser and 2x2's, then with her gloved finger she mixed hydrogen gel and collagen and placed it inside the wounds, removed her gloves and without hand sanitizing she donned gloves and placed a petroleum gauze dressing on one of the coccyx wounds and then covered both sites with an abdominal pad, removed her gloves and hand sanitized.

Interview with Licensed Practical Nurse 5 on February 26, 2026, at 1:40 p.m. confirmed that during wound care, she did not change gloves when moving from a dirty to a clean area, and did not hand sanitize after doffing her gloves and donning new gloves.

A quarterly MDS assessment for Resident 69, dated December 3, 2025, revealed that the resident cognitively intact, was understood, able to understand, required assistance with care needs, had a history of multiple venous ulcers and had diagnoses that included venous insufficiency (decreased blood flow in the legs) and currently had a chronic non-pressure ulcers of the right lower leg.

Observations of Resident 69's wound care on the right calf on February 26, 2026, at 1:32 p.m. was as follows; Licensed Practical Nurse 5 donned gloves and removed the dirty dressing on her right calf, and without changing gloves, she cleaned the area with dermal cleaning spray, cut a piece of dressing that was impregnated with calcium alginate and Silvadene, and placed it on the wound bed, covered it with rolled gauze and an abdominal pad, taped and dated it. She then removed her gloves and hand sanitized.

Interview with Licensed Practical Nurse 5on February 26, 2026, at 1:40 p.m. confirmed that during wound care, she did not change gloves when moving from a dirty to a clean area.

Interview with the Director of Nursing on February 26, 2026, at 3:15 p.m. confirmed that when providing wound care on Resident 8 and 69, staff did not change their gloves when moving from a dirty to a clean area, and hand sanitize after doffing their gloves, and they should have.

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

Plan of Correction - To be completed: 03/31/2026

The Assistant Director of Nursing re-educated the responsible licensed nurse on infection control practices during medication administration. The Assistant Director of Nursing re-educated the responsible licensed nurse on clean dressing policy.

The Director of Nursing and/or designee completed an observation of licensed nurse staff member(s) medication administration and wound care to ensure infection control standards were maintained. No issues were identified.

To prevent recurrence, the Director of Nursing and/or designee re-educated licensed staff on the medication administration policy with emphasis on maintaining infection control standards.

To monitor and maintain compliance, the Director of Nursing and/or designee will complete medication administration observations for 2 nurses 1x weekly for 4 weeks and monthly for 2 months to ensure infection control standards are maintained. The Director of Nursing and/or designee will complete treatment observations for 2 nurses 1x weekly for 4 weeks. The results of these audits will be reviewed at the Quality Assurance and Performance Improvement meeting.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 38 residents reviewed (Resident 10, 113).

Findings include:

The facility's policy regarding medication administration, April 29, 2025, indicated that staff were to document the administration of controlled substances in accordance with applicable law and document the necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site) on appropriate forms.

The facility's policy regarding disposal of medications, April 29, 2025, indicated that facility staff would destroy and dispose of medications in accordance with facility policy and applicable state law, and applicable environmental regulations. Facility staff were to destroy controlled substances in the presence of a registered nurse and a licensed professional or in accordance with facility policy or applicable state law.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated November 16, 2025, revealed that the resident was cognitively intact, had pain frequently, received pain medication as needed, and received an opioid (a controlled pain medication). Physician's orders, dated April 19, 2025, included an order for the resident to receive five milligrams (mg) of Oxycodone every six hours as needed for severe pain.

A review of Resident 10's controlled drug record for January and February 2026 revealed that staff signed out 5 mg of Oxycodone on January 11, at 8:34 p.m., January 16, at 9:30 a.m., January 22, at 10:00 p.m., and February 16, 2026 at 9:15 a.m. However, review of the resident's Medication Administration Records (MAR's), dated January and February 2026, revealed no documented evidence that the 5 mg of Oxycodone was administered to the resident on those dates and times.

Interview with the Director of Nursing on February 27, 2026, at 1:03 p.m. confirmed that there was no evidence on the Medication Administration Records of the Oxycodone being administered to Resident 10.

An admission MDS assessment for Resident 113, dated February 17, 2026, revealed that the resident was cognitively intact, received pain medication routinely, and received an opioid. Physician's orders, dated February 15, 2026, included an order for the resident to have a 50 microgram per hour (mcg/hr) Fentanyl (controlled medication used to treat pain) patch applied every 72 hours.

A nursing note, dated February 11, 2026, at 6:30 p.m. revealed the resident was admitted to the facility and had a Fentanyl patch on his left upper arm.

Review of Resident 113's MAR for February 2026 revealed that a Fentanyl patch was applied to the resident on February 15, 18, 21, and 24, 2026.

A controlled drug count record for Resident 113's Fentanyl patches revealed that one patch was signed out on the controlled drug log on February 18, 21, and 24, 2026. There was no documented evidence that a registered nurse and another licensed professional signed that the old patch was destroyed after removal on February 11, 15, 18, and 21.

Interview with the Director of Nursing on February 27, 2026, at 1:05 p.m. confirmed that there were not two witness signatures, by a registered nurse and another licensed professional, for the destruction of Fentanyl patches on the dates listed above.

28 Pa. Code 211.9(a)(h) Pharmacy Services.

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

Plan of Correction - To be completed: 03/31/2026

Resident numbers 10 and 113 medication documentation cannot be corrected at this time.

To identify other residents that have the potential to be affected, the Director of Nursing and/or designee completed an audit of two weeks narcotic sign out sheets to electronic medication records to ensure documentation reflected administration. The Director of Nursing and/or designee completed an audit of two weeks narcotic sign out sheets to ensure two signatures are present for the destruction of patches containing a controlled substance. Any issues identified during the audit process will be addressed.

To prevent recurrence, the Director of Nursing and/or designee re-educated licensed nursing staff on medication administration and prescribing, administration and disposal of fentanyl transdermal systems policies.

To monitor and maintain compliance, the Director of Nursing and/or designee will conduct audits of narcotic inventory sheets to ensure sign outs match narcotic administration documentation on the electronic medical record 1x weekly for 4 weeks and monthly for 2 months. The Director of Nursing and/or designee will conduct audits of narcotic inventory sheets to ensure destroyed patches containing a controlled substance have 2 nurse signatures 1x weekly for 4 weeks and monthly for 2 months. The results of these audits will be reviewed at the Quality Assurance and Performance Improvement meeting.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

§483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Observations:

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 38 residents reviewed (Resident 2) who had a feeding tube.

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 26, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, and had a feeding tube. A care plan, dated January 21, 2026, revealed that staff were to administer the resident's tube feeding as ordered.

Physician's orders for Resident 2, dated January 21, 2026, included orders for the resident to receive Isosource (a tube feeding formula) continuously at 65 cubic centimeters (cc's) per hour for 20 hours per day via a feeding tube pump and staff were to record the amount of formula provided every shift.

The Medication Administration Records (MAR's) for Resident 2 for January and February 2026 revealed that staff administered the resident's tube feeding; however, there was no documentation of the amount of formula provided every shift as ordered.

Interview with the Director of Nursing on February 27, 2026, at 1:05 p.m. confirmed that staff were not documenting the amount of formula provided every shift as ordered and they should have been.

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

Plan of Correction - To be completed: 03/31/2026

Resident #2 was weighted on February 25, 2026 with no adverse effects noted. Registered Dietitian notified and Resident #2 enteral feeding order updated per facility policy.

To identify other residents that have the potential to be affected, the Director of Nursing and/or designee completed an audit of current residents with enteral feeding orders to ensure accurate documentation on volume consumed. Any issues identified during the audit process will be addressed.

To prevent recurrence, the Director of Nursing and/or designee re-educated licensed staff on the Enteral tube feeding policy with emphasis on how to document Total Volume Infused.

To monitor and maintain compliance, the Director of Nursing and/or designee will audit enteral feeding documentation 1x weekly for 4 weeks and monthly for 2 months to ensure the documented Total Volume Infused is accurately recorded. The results of these audits will be reviewed at the Quality Assurance and Performance Improvement meeting.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Observations:

Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to honor the resident's right to make informed choices and participate in his/her treatment for one of 38 residents reviewed (Resident 71).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 71, dated February 12, 2026, revealed that the resident was cognitively intact, required partial assistance from staff for daily care needs and had a diagnosis of diabetes.

Physician's orders for Resident 71, dated February 10, 2026, included an order for the resident to receive 2.5 milligrams (mg) Mounjaro (used to control blood sugar control) pen injector subcutaneous (under the skin in a fatty layer) once a day on Wednesday.

Interview with Resident 71 on February 26, 2026, at 12:45 p.m. revealed that during morning med pass she asked Licensed Practical Nurse 1when she would receive her next dose of Mounjaro. Licensed Practical Nurse 1informed Resident 71 that her dose of Mounjaro was on hold and he was not aware of the reason.

Interview with Licensed Practical Nurse 1on February 26, 2026, at 1:00 p.m. revealed that he was not aware why Resident 71's Mounjaro was on hold.

Interview with Registered Nurse 2on February 26, 2026, at 1:30 p.m. revealed that Resident 71 was scheduled for an angiogram (a diagnostic X-ray that uses contrast dye to visualize blood flow through arteries and veins) on March 2, 2026, and Mounjaro needed to be on hold for seven days prior.

Interview with Resident 71 on February 26, 2026, at 1:40 p.m. revealed that she was not made aware that Mounjaro was on hold or that an angiogram was scheduled. Resident 71 also stated that on February 24, 2026, bloodwork was drawn and she was not made aware of the results.

A nursing note for Resident 71, dated February 24, 2026, at 10:00 a.m. revealed that bloodwork was collected on the first attempt via straight stick with butterfly needle to the right hand. Resident tolerated the procedure well and without complications. Once completed area was covered with cotton and secured with band aid; pressure was held until bleeding was controlled. Labs labeled with three patient identifiers, time and date of collection, area blood was collected and the initials of the nurse who collected them.

Review of Resident 71's medical record revealed that there was no documented evidence that the resident was informed that Mounjaro was on hold, that an angiogram was scheduled or lab results were discussed with her.

Interview with the Director of Nursing on February 26, 2026, at 2:25 p.m. confirmed that there was no documented evidence that Resident 71 was informed that Mounjaro was on hold, that an angiogram was scheduled or that lab results were discussed with her and there should be.

28 Pa. Code 201.29(a)(j) Resident Rights.

Plan of Correction - To be completed: 03/31/2026

Resident #71 was discharged from facility on March 2, 2026.

To identify other residents that have the potential to be affected, the Director of Nursing and/or designee will complete a review of facility current orders on hold, weekly lab results, and scheduled procedures to ensure notifications were completed. Any issues identified during the audit process will be addressed.

To prevent recurrence, the Director of Nursing and/or designee will re-educate licensed nursing staff on change in condition policy with emphasis on resident/responsible party notification.

To maintain and monitor compliance, the Director of Nursing and/or designee will audit orders on hold, lab results, and scheduled procedures 1x weekly for 4 weeks and monthly for 2 months to ensure resident(s) or their responsible party are notified. The results of these audits will be reviewed at the Quality Assurance and Performance Improvement meeting.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on review of Pennsylvania's Nursing Practice Act, Lippincott Medication Administration rights, facility policies, and observations, as well as staff interviews, it was determined that the facility failed to document medication administration at the time of administration for one of 38 residents reviewed (Resident 13).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

Lippincott Medication Administration rights, dated May 19, 2022, indicated that documentation of medication administration should occur immediately after the medication is administered.

The facility's policy regarding medication administration, dated April 29, 2025, indicated that medications would be administered in accordance with physician's orders and staff would document at the time of administration.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated December 25, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, and was a diabetic.

Physician's orders for Resident 11, dated November 11, 2025, included an order for the resident to receive 5 milligrams (mg) Amlodipine (blood pressure mediation) every day; 12.5 mg Carvedilol (heart medications) twice a day; 24mg/26mg Entresto twice a day (blood pressure medication); 10 mg Ezetimibe (cholesterol medication) daily; 400 mg Gabapentin (neuropathy medication) daily; 75 mg Plavix (anti-platelet medication) daily; 0.3 mg Calcifediol (Vitamin D); 10 mg Rosuvastatin (cholesterol medication); 6 units Lispro (insulin) three times a day; 81 mg aspirin (anti-platelet medication) daily; 1 capsule Rena-Vite (multivitamin) daily; a physician's order, dated November 19, 2025 for 30 cubic centimeters (cc) pro-stat (supplement) every day, a physician's order dated December 18, 2025 for 100 mg sertraline (anti-depressant) daily, a physician's order dated January 5, 2026 for 1 tablet preservision (vitamin) daily.

Observations of medication administration on February 25, 2026 at 8:54 a.m. revealed that Licensed Practical Nurse 3 administered the above named medications to Resident 13 at that time.

Review of Resident 13's Medication Administration Record (MAR), dated February 2026, revealed that as of 12:02 p.m. Resident 13's medication administration had not been signed off as administered.

Interview with Licensed Practical Nurse 3on February 26, 2026 at 12:02 p.m. revealed that she does not document her medication administration at the time of administration and that she goes back after all her medications are passed and then documents them.

Interview with the Director of Nursing on February 26, 2026 at 2:12 p.m. revealed that the nurses are expected to document the medications as they are administered and not later in the day.

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

Plan of Correction - To be completed: 03/31/2026

The Assistant Director of Nursing re-educated the responsible licensed nurse on medication administration and documenting in a timely manner. Licensed nurse completed documentation for Resident #13.

To identify other residents that have the potential to be affected, the Director of Nursing and/or designee conducted a medication administration observation for the responsible nurse to ensure administration documentation was completed with delivery. No documentation issues were observed.

To prevent recurrence, the Director of Nursing and/or designee re-educated licensed nursing staff on the medication administration policy with emphasis on administration documentation requirements.

To monitor and maintain compliance, the Director of Nursing and/or designee will complete medication administration observations for 2 nurses 1x weekly for 4 weeks and monthly for 2 months to ensure documentation is conducted at time of delivery. The results of these audits will be reviewed at the Quality Assurance and Performance Improvement meeting.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to follow physician's orders related to midline catheters (a type of peripheral catheter inserted into a large vein in the upper arm used to deliver fluids and/or medications) for 2 of 38 residents reviewed (Resident 3 and Resident 71).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 28, 2026, revealed that the resident was cognitively intact, was dependent on staff for daily care needs and received intravenous medications (IV).

Physician's orders for Resident 3, dated January 24, 2026, included an order for the resident to have the midline dressing changed every week on Fridays, measure arm circumference and external catheter length.

Review of the Medication Administration Record (MAR) for Resident 3, dated February 2026, indicated that the resident had a midline dressing change on February 6, 13 and 20, There was no documented evidence that arm circumference and external catheter length was measured at the time of the dressing on February 13 and 20.

An admission MDS assessment for Resident 71, dated February 12, 2026, revealed that the resident was cognitively intact, required partial assistance from staff for daily care needs and received intravenous medications (IV).

Physician's orders for Resident 71, dated February 6, 2026, included orders for the resident to receive 2 grams (gm) of cefazolin (and antibiotic) intravenously (administered through a vein) three times a day for osteomyelitis (infection of the bone) and to flush the midline twice a day with normal saline 10 mL prior to and after medication administration.

Review of the MAR for Resident 71, dated February 2026, revealed that there was no documented evidence that Resident 71's physician was contacted for orders to flush the resident's midline three times a day with Normal Saline 10mL prior to and/or after medication administration.

Physician's orders for Resident 71, dated February 12, 2026, included an order for the resident to have the midline line dressing and securement device changed every seven days.

Review of the MAR for Resident 71, dated February 2026, indicated that there was no documented evidence that midline dressing and securement device were changed every seven days.

Interview with the Director of Nursing on February 26, 2026, at 10:14 a.m. confirmed that Resident 3's arm circumference and external catheter length should have been measured at the time the dressing was changed on February 13 and 20 per physician's orders and that Resident 71's physician should have been contacted for orders to flush her midline three times a day prior to and/or after antibiotic administration and her midline dressing and securement device should have been changed every seven days per physician's orders.

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

Plan of Correction - To be completed: 03/31/2026

Resident #3 midline catheter was discontinued. Resident #71 flush order was updated, and midline dressing was changed per physician order.

To identify other residents that have the potential to be affected, the Director of Nursing and/or designee completed an audit of current residents with intravenous orders to ensure accuracy of orders. Any issues identified during the audit process will be addressed.

To prevent recurrence, the Director of Nursing and/or designee re-educated licensed staff on midline catheter dressing change and midline catheter flushing and locking policy.

To monitor and maintain compliance, the Director of Nursing and/or designee will observe intravenous dressings 1x weekly for 4 weeks and monthly for 2 months to ensure they are changed per physician order. The Director of Nursing and/or designee will audit normal saline flush and midline dressing change orders 1x weekly for 4 weeks and monthly for 2 months to ensure accuracy. The results of these audits will be reviewed at the Quality Assurance and Performance Improvement meeting.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on review of policies and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 38 residents reviewed (Resident 13).

Findings include:

The facility's medication administration policy, dated January 15, 2024, revealed that medications were to be administered as prescribed.

Manufacturer's instructions for Lispro, revised July 2023, indicated that the medication should be administered within five or ten minutes of a meal.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated December 25, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, and was a diabetic.

Physician's orders for Resident 13, dated December 16, 2025, included orders for the resident to receive 6 units of insulin Lispro (fast-acting insulin) with breakfast.

Review of the facility's meal times revealed that Resident 13 received her breakfast at 7:15 a.m.

Observations of medication administration with Resident 13 on February 26, 2025 at 8:54 a.m. revealed that the resident received 6 units of Lispro. She did not have any food at that time and her breakfast had been served at 7:15 a.m. Resident 13's insulin administration was not within five to ten minutes of receiving her meal.

Interview with the Director of Nursing on February 26, 2026 at 2:18 p.m. confirmed that Resident 13 had not received her insulin per the manufacturer's instructions and that she should have.

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

Plan of Correction - To be completed: 03/31/2026

The Assistant Director of Nursing re-educated the licensed nurse on administration of insulin in regard to following physician orders. The Medical Director was notified with no new orders received.

To identify other residents that have the potential to be affected, the Director of Nursing and/or designee completed an audit of ordered insulin with meals and review with physician for appropriateness. Any issues identified during the audit process will be addressed.

To prevent recurrence, the Director of Nursing and/or designee re-educated licensed staff on the physician order policy with emphasis on timely administration.

To monitor and maintain compliance, the Director of Nursing and/or designee will observe insulin administration 1x weekly for 4 weeks and monthly for 2 months to ensure administered medication follows ordered times. The results of these audits will be reviewed at the Quality Assurance and Performance Improvement meeting.

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