Pennsylvania Department of Health
ACADIA NURSING AND REHAB CENTER
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

ACADIA NURSING AND REHAB CENTER
Inspection Results For:

There are 150 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.


ACADIA NURSING AND 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, and an Abbreviated survey in response to one complaint completed on June 9, 2026, it was determined that Beaver Healthcare and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Plan of Correction - To be completed: 07/28/2026

Moving forward the facility will store will prepare, and will distribute food in accordance with professional standards for food service safety.
When noted, all areas of concern were addressed by the dietary manager and staff. Any opened and undated items were disposed of.
The facility will label and date food, maintain dish washing temperature logs, keep kitchen clean and sanitized, store chemicals appropriately, properly restrain hair, and store food in accordance with professional standards for food safety.
The NHA or designee will educate the dietary manager along with the dietary staff on kitchen sanitation, food safety, storing, preparing, distributing and serving food in accordance with professional standards for food service safety.
The NHA or designee will monitor kitchen sanitation, food safety, storing, preparing, distributing and serving food in accordance with professional standards including labeling and dating food, maintaining dish washing temperature logs, keeping kitchen clean and sanitized, storing chemicals appropriately, properly restraining hair, and storing food in accordance with professional standards for safety. This monitoring will be completed three times per week for four weeks, and then twice weekly for two weeks, but the NHA or designee.
The findings of this monitoring will be reported to the QAPI committee monthly for one quarter.

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

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

Observations:

Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (R5, R17, and R45).

Findings include:

Review of the facility policy "Departmental (Respiratory Therapy) Prevention of Infection" dated 4/30/26, indicated that the oxygen cannula (thin flexible tubing used to deliver oxygen) and tubing are changed every seven days.

Review of the admission record indicated Resident R5 admitted to the facility on 3/15/26.

Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/20/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident R5's physician order dated 3/26/26, indicated Albuterol Sulfate Inhalation Nebulization Solution (delivers medicine directly into the lungs to treat respiratory diseases) three milliliters inhale orally every four hours as needed for shortness of breath and wheezing.

Observation on 6/7/26, at 8:48 a.m. Resident R5 was observed out of bed in a wheelchair with a nebulizer machine on the bedside stand. The nebulizer was not labeled with a date and time last changed.

Review of the admission record indicated Resident R17 admitted to the facility on 6/17/25.

Review of Resident R17's MDS dated 5/21/26, indicated the diagnoses of heart failure, high blood pressure, and anxiety.

Review of Resident R17's current physician orders indicated change oxygen tubing and bottle weekly and as needed. Initial tubing and bottle at time of change. Place tubing in dated plastic bag when not in use.

Observation on 6/7/26, at 9:00 a.m. Resident R17 was observed lying in bed with a nasal cannula in the nose connected to an oxygen concentrator. The cannula was not labeled with a date and time last changed.

Observation and interview on 6/7/26, at 9:05 a.m. with Licensed Practical Nurse (LPN) Employee E2 confirmed Resident R17's cannula was not labeled with a date and time last changed as required.

Review of the admission record indicated Resident R45 admitted to the facility on 11/11/25.

Review of Resident R45's MDS dated 2/24/26, indicated the diagnoses of high blood pressure, depression, and anxiety.

Review of Resident R45's current physician orders indicated change oxygen tubing and bottle weekly and as needed. Initial tubing and bottle at time of change. Place tubing in dated plastic bag when not in use.

Observation on 6/7/26, at 9:07 a.m. Resident R45 was observed in bed, a portable oxygen tank was on the back of the wheelchair with an oxygen cannula, not dated and not bagged, dangling on the seat of the wheelchair.

Observation and interview on 6/7/26, at 9:09 a.m. with Registered Nurse (RN) Employee E1 confirmed Resident R5's nebulizer and Resident R45's oxygen cannula were not labeled with a date and time last changed as required.

28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing Services.

Plan of Correction - To be completed: 07/28/2026

Residents 5, 17, and 45 had their respiratory equipment assessed and replaced as needed by a licensed nurse.

An in-house audit of other residents was conducted, and respiratory equipment was changed per policy.

Licensed Nursing staff will be re- educated by the DON/designee on facility policy for Respiratory Therapy Prevention of Infection.

DON /designee will audit respiratory care equipment provided to 10 random residents weekly for 6 weeks to ensure infection control practices are followed.

Results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meeting

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 review of clinical records and staff interview, it was determined that the facility provider failed to notify a resident of planned changes to resident's medications and failed to allow the resident to be able to participate in the decision-making process regarding resident's care for one of three residents (Resident R68).

Findings include:

Review of the facility policy "Resident Rights" dated 4/30/26, indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include resident's right to: be notified of his or her medical condition and of any changes in his or her condition. Be informed of, and participate in his or her care planning and treatment. Choose an attending physician and participate in decision-making regarding his or her care.

Review of the clinical record revealed Resident R68 was admitted to the facility on 5/25/26, with diagnoses of urinary tract infection, seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness), anxiety (intense, excessive, and persistent worry and fear about everyday situations), bulimia nervosa (a type of eating disorder), borderline personality disorder (a mental health condition characterized by profound emotional instability).

Review of resident R68's care plan dated 5/28/26, indicated:

-Episodes of anxiety related to disease process anxiety/depression/schizophrenia.

-Potential to exhibit behaviors that are a result of past trauma(s), which may impact

my moods or behaviors as evidence by a negative mood, avoidance symptoms and/or intrusion symptoms. Past and/or current drug abuse/sexual assault.

- Offer choices to enhance sense of control.

-Resistive/noncompliant with treatment and care related to Bulimia, PTSD, and borderline personality disorder. Ask physician to explain/reinforce need for treatment.

Review of Resident R68's hospital records dated 5/25/26, indicated resident was to continue clonazepam (medication to treat seizures and treat panic disorders) 0.5 mg (milligram) tablet two tablets at bedtime as needed for anxiety.

Review of Resident R68's physician orders dated 5/27/26, indicated Clonazepam Tablet 0.5 MG Give two tablets by mouth as needed for anxiety related to anxiety disorder for 14 days at bedtime.

Review of Resident R68's physician orders dated 5/27/26, indicated Ativan (antianxiety medication)Injection Solution 2 MG/ML inject 0.5 milliliter intramuscularly (in the muscle layer) as needed for Anxiety 1mg up to three times per day as needed for anxiety.

Review of physician visit progress note dated 6/2/26, at 11:19 p.m. Indicated Resident was seen today as a new patient. Assessment and plan: Resident will be admitted. We will continue resident's medications for resident's chronic medical issues and follow up with resident's specialists as scheduled. We will see resident on a routine basis or sooner if needed.

Review of Nurse Practitioner (NP) Employee E20's late entry dated 6/1/26, at 12:36 p.m. indicated resident is seen today for a routine visit. Assessment and plan: we will continue her medications for resident's chronic medical issues and follow up with the resident's specialists as scheduled. Will discontinue evening clonazepam and intramuscular (IM) Ativan. Increase oral as needed Ativan to 1mg. The note of the visit did not include documentation that Resident R68 was informed of the medication changes planned and able to participate in the decision-making process regarding resident's care.

Review of progress note dated 6/3/26, at 7:11 a.m. indicated at approximately 5:00 a.m. resident indicated they had a bad dream and were starting to feel anxious. Resident asked for something for anxiety. Upon review this nurse noted that resident was given bedtime Clonazepam as well as trazadone by this nurse. Although resident had order for intramuscular Ativan the medication was not available at that time due to previous order having expired and a new order required a new script.

Review of progress note dated 6/3/26, at 1:42 p.m. indicated notified physician of need for script renewal for Ativan injection. Physician reviewed resident's medications. Per physician, resident on too many benzodiazepines and medications need adjusted. Orders received to discontinue Clonazepam 0.5 mg tablet as needed and Ativan IM injection as needed. New order for Ativan 1 mg tablet every eight hours as needed for anxiety and seizures. Orders discontinued and placed. Notified resident of medication change, and resident began crying loudly stating, "I hate it here! Nobody listens to me! Why would the doctor take my medication away without talking to me first! How am I supposed to sleep?" RN supervisor informed the resident that they will still receive Ativan every eight hours as needed for anxiety or seizure activity. Resident was unable to be consoled. Resident's family notified of medication changes and resident's reaction to medication changes.

Review of progress note dated 6/3/26, at 5:38 a.m. indicated resident discharged Against Medical Advice and left the facility in the family vehicle with resident's family.

Interview on 6/9/26, at 2:00 p.m. the Director of Nursing confirmed that the facility provider failed to notify a resident of planned changes to resident's medications and failed to allow the resident to be able to participate in the decision-making process regarding resident's care for one of three residents (Resident R68).

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

Plan of Correction - To be completed: 07/28/2026

Resident R68 was discharged from the facility.

A review of the last seven days of medication changes were completed to determine resident and resident representative notification.

DON/designee re-educated licensed nursing staff and CRNP on Resident Rights, including residents right to be notified of planned changes to medications and residents right to be able to participate in the decision-making process regarding their care.

DON/designee will review a random 5 residents weekly for 6 weeks for medication changes to ensure resident/resident's representative notification is completed.

Results of audits will be reported to Quality Assurance Performance and Improvement (QAPI) committee for review.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(h)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain a confidential personal medical record for one of two residents (Resident R20).

Findings include:

A review of the facility policy titled, "Resident Rights" last reviewed 4/30/26, indicated that federal and state law guarantee certain basic rights to all residents in the facility these include but not inclusive to:
A dignified experienceBe treated with respect, kindness, and dignityBe supported by the facility in exercising his/her rights
Review of the clinical record revealed that Resident R20 was admitted to the facility on 4/20/26.

Review of Resident R20's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/9/26, indicated diagnoses of high blood pressure, hyperlipidemia (high fat in the blood), and anxiety.

During an observation on 6/7/26, at 10:58 a.m. two signs were observed above Resident R20's bed that read: Please see nurse prior to giving water cup and needs hearing aids put on charger every night, use dry erase board.

Review of Resident R20's clinical record failed to include any documentation that the above residents or their representatives approved the posting of private health information.

During an interview completed on 6/8/26, at 10:42 a.m. Licensed Practical Nurse (LPN) Employee E7 confirmed the two signs were posted above Residet R20's bed and that the facility failed to maintain residents' confidential personal medical record for one of two residents (Resident R20).

28 Pa. Code: 201.18(e)(1) Management

Plan of Correction - To be completed: 07/28/2026

Resident 20's private information was immediately protected by being covered and taken out of view.

A facility-wide audit of resident records and privacy practices was conducted to ensure no other residents were affected.

Facility staff will receive education on HIPAA regulations, CMS F-tag requirements, and facility privacy protocols by the NHA or designee.

The Director of Nursing (DON) or designee will conduct five random privacy compliance audits 2 x's weekly for 6 weeks.

Results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meeting.

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg:

§483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)

Observations:

Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to conduct a Significant Change Minimum Data Set assessment for one of four sampled residents (Resident R1).

Findings include:

Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (reference used to complete an MDS) dated 10/1/25, indicated the significant change status assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The assessment reference date must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than).

The facility "Certifying accuracy of the resident assessment" policy last reviewed on 4/30/26, indicated that the information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.

Review of Resident R1's admission record indicated he was originally admitted on 12/19/25.

Review of Resident R1's MDS assessment dated 4/18/26, indicated he had the following diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), acute kidney failure, hypertension (a condition impacting blood circulation through the heart related to poor pressure), anxiety disorder (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination).

Review of Resident R1's care plans dated 4/29/26, indicated that he was admitted to hospice. Comfort measures only "CMO" with the potential for weight loss.

Review of Resident R1's social services note dated 4/28/26, indicated that the social worker spoke to Resident R1 about the topic of Hospice. He stated that he is Alert and Oriented and that he knows his rights and that he wants to drink thin liquids and eat what he wants. He stated he wanted to begin Hospice care. Social services provided Resident R1 with a list of Hospice Agencies, and he chose a provider.

Review of Resident R1's physician orders dated 5/13/26, indicated that he was ordered hospice care services.

Review of Resident R1's MDS assessments did not include a significant change MDS assessment that included hospice services for Resident R1.

During an interview on 6/8/26, at 10:27 a.m. the Regional clinical director Employee E15 and the Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E16 confirmed that the facility failed to conduct a Significant Change Minimum Data Set assessment for Resident R1 as required.

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

Plan of Correction - To be completed: 07/28/2026

Resident R1 was unable to have the Significant change implemented secondary to not being within the 14 days of hospice election.

R1's June 3, 2026, quarterly MDS reflects the resident being on hospice at this time.

A review of other residents receiving hospice care was completed to ensure MDS reflects current status.

NHA/designee provided education to the Interdisciplinary team related to any resident electing hospice services must have a Significant change MDS completed within the 14 days of hospice election.

NHA/designee will audit new residents electing hospice services weekly for 6 weeks to ensure Significant Change MDS has been completed.

Results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) 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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Resident R8, and R58).

Findings include:

Review of the facility policy "Cleaning and Disinfection of Resident Care Items and Equipment" last reviewed 4/30/26, indicated resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC recommendations for disinfection and the OSHA Bloodborne Pathogen Standard.

Review of the facility policy "Infection Control" last reviewed 4/30/26, indicated the facility adopted infection prevention and control policies to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

Review of the clinical record indicated Resident R8 was admitted to the facility on 4/28/23.

Review of Resident R8's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/8/26, indicated diagnoses of Parkinsons disease (progressive brain disease that affects movement and causes tremors, stiffness and slowness), dementia (decline of brain function) and insomnia (sleep disorder that makes it hard to fall asleep and stay asleep).

Review of Resident R8's physician order dated 4/21/26, indicated Enteral Feed (delivers liquid nutrition directly into digestive system using a flexible tube that bypasses normal swallowing) every shift Osmolite 1.5 (formula type) to run 24 hours continuous at 60 milliliter (ml) per hour. Free water flushes with 50 ml every hour.

During an observation completed on 6/7/26, at 10:40 a.m. the enteral feeding pole was found soiled with what appeared to be spilled or leaked enteral formula which was dried covering the bottom surface of the pole.

During an interview completed on 6/7/26, at 11:22 a.m. Registered Nurse (RN) Employee E1 confirmed dried enteral formula was covering the bottom surface of the pole and that the facility failed to ensure a resident receiving enteral feeding received appropriate care and services for one of three residents (Resident R8).

Review of facility policy "Enteral Tube Feeding via Syringe (Bolus)" dated 4/30/26, indicated to check the order to verify the type, amount, method and rate of administration. Verify placement of tube. Attach a 60-milliliter syringe to the tube and elevate syringe approximately eighteen inches above the resident's head. Fill the syringe with the prescribed amount of enteral feeding to be given. Unclamp the tube and allow feeding to flow by gravity.

Review of the admission record indicated Resident R58 was admitted to the facility on 5/22/26.

Review of Resident R58's MDS dated 5/28/26, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and heart failure (heart doesn't pump blood as well as it should).

Review of Resident R58's physician order dated 5/23/26, indicated enteral feed order three times a day for nutrition - Osmolite 1.5 bolus one can (eight fluid ounces).

Observation on 6/7/26, at 12:05 p.m. of Licensed Practical Nurse (LPN) Employee E4 administering Resident R58's bolus feeding, the following was observed:

-LPN drew the feeding solution into the syringe and connected the syringe to the feeding tube.

-Opened the clamp and pushed plunger of syringe to administer the feeding.

Interview on 6/7/26, at 12:06 p.m. LPN Employee E4 indicated the feeding tube flows without problems when asked if the feeding tube clogged easily.

During an interview on 6/7/26, at 2:00 p.m. the Director of Nursing confirmed that the bolus feeding procedure should be done by gravity and not forced by a syringe plunger.

28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 07/28/2026

Resident R8 had his enteral feeding pole cleaned.

Resident R58's enteral feeding orders were reviewed and clarified.

Other residents receiving enteral nutrition were reviewed.

Licensed Nursing staff will be re-educated by the DON/designee on enteral feeding procedures and cleaning resident care items/equipment policies.

DON/designee will audit all enteral feeding equipment and enteral feeding administration weekly for 6 weeks for cleanliness and proper administration.

Results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meeting.

483.25(m) REQUIREMENT Trauma Informed Care:

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

Observations:

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R11).

Findings include:

Review of facility policy " Trauma Informed Care" last reviewed 4/30/26, indicated to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Triggers are highly individualized. Develop individualized care plans that address past trauma in collaboration with the resident and family.

Review of the clinical record indicated Resident R11 was admitted to the facility on 8/25/25.

Review of Resident R11's MDS (minimum data set - a periodic assessment of care needs), dated 3/18/26, indicated diagnosis of anxiety, depression, and bi-polar disorder (mental health condition that causes extreme mood swings).

Review of Resident R11's current care plan revealed survivor of trauma related to experiencing abuse either physical, sexual, verbal or mental abuse but failed to identify triggers to prevent re-traumatization.

During an interview on 6/9/26, at 11:50 a.m. Social Worker Employee E17 confirmed that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two (Resident R11).

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

Plan of Correction - To be completed: 07/28/2026

Resident 11 does have a trauma history assessment, and care plan has been updated.

Resident records have been reviewed for completion of appropriate trauma history assessments, and care plans are updated when appropriate.

DON/designee will reeducate licensed nursing staff and social services on trauma informed care, triggers and risk for re-traumatization.

DON/designee will audit 5 random resident care plans weekly for 6 weeks to ensure trauma-informed care elements are present and followed.

Results of audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meeting.

§483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:

§483.35(g) Nurse Staffing Information.

§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:

(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).

(C) Certified nurse aides.

(iv) Resident census.

§483.35(g)(2) Posting requirements.

(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.

(ii) Data must be posted as follows:
(A) Clear and readable format.

(B) In a prominent place readily accessible to residents, staff, and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Observations:

Based on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift for one of three observed days (6/7/26).

Findings include:

Observation conducted on 6/7/26, at 9:00 a.m., indicated that nurse staffing information was posted on the wall of the nurses' station nearest to the dining room. At that time, the nurse staffing information had the date of (6/4/26), resident census, and the staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for the current date.

Interview with Registered Nurse (RN) Employee E1 5/26/26, at 9:00 a.m., confirmed the facility failed to post the required current facility information for staffing hours and the facility census.

201.18(b)(3) Management.

Plan of Correction - To be completed: 07/28/2026

The facility will post nursing staff information daily for the current day. This includes weekends.
The DON /designee will educate the facility scheduler and facility licensed nursing supervisors on the policy of posting requirements of the current daily staff information.
The Director of Nursing (DON) / Designee will conduct 2 x's weekly audits of daily posted nursing staffing requirements for 6 weeks.
Audit results will be reviewed in the Quality Assurance and Performance Improvement (QAPI) meeting.

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 store medications in one of two medication storage rooms (Front Hall Medication Room) and two of three medication carts (Zone 2 Medication Cart and Zone 3 Medication Cart).

Findings include:

Review of the facility policy "Medication Labeling and Storage" last reviewed 4/30/26, indicated medications are stored in an orderly manner in cabinets, rooms, refrigerators and carts. Medications requiring refrigeration are stored in a refrigerator located in the medication room. Medications are stored separately from food and are labeled accordingly. Medications for external use are stored separately from other medications. Medications and biologicals are stored in the packaging in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

During an observation completed on 6/7/26, at 11:23 a.m. the Front Hall Med Room Contained the following:
A pair of black athletic shoes stored under the sink.A box of medication cart dividers stored under the sink.A black travel coffee cup on the counter near the sink.A Reacher for picking up items on the counter near the sink.The medication room refrigerator contained the following:
2 bottles of Lansoprazole oral liquid open and not labeled with a date as required.4 Tylenol Suppositories lying on the bottom shelf not stored in packaging as required.The medication room refrigerator freezer section contained:
2 ice packs
During an interview completed on 6/7/26, at 11:31 a.m. Registered Nurse (RN) Employee E1 confirmed the above observations and that the facility failed to properly store medications in the Front Hall Medication Room.

During a Medication Cart observation completed on 6/7/26, at 11:39 a.m. the Zone 3 Medication Cart contained the following:
A Sodium Chloride inhaler opened and not labeled with a date as required.2 boxes of Albuterol nebulizer solution opened and not labeled with a date as required.A Fluticasone Propionate nasal spray opened and not labeled with a date as required.A box of Bisacodyl Suppositories stored with oral medications.
During an interview completed on 6/7/26, at 11:46 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the above observations and confirmed that the facility failed to properly store medications in the Zone 3 Medication Cart.

During an observation completed on 6/8/26, at 9:05 a.m. The Zone 2 Medication Cart contained the following:
6 boxes of Ipratropium Bromide opened and not labeled with a date as required1 package of Budesonide opened and not labeled with a date as required.
During an interview completed on 6/8/26, at 9:05 a.m. LPN Employee E2 confirmed the above observations and that the facility failed to properly store medications in the Zone 2 Medication Cart.

28 Pa. Code: 201(a) Responsibility of licensee.
28 Pa. Code: 211.9(a)(1) Pharmacy services.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 07/28/2026

All mislabeled or expired medications identified during the survey were immediately removed and disposed of according to facility policy and state regulations.
A full audit of all medication storage areas (med carts, medication rooms, refrigerators) was completed, and all noncompliant items were corrected immediately.
The DON /designee will re-educate licensed nursing staff on medication labeling, storage, and disposal policies.
DON/designee will conduct weekly audits of medication storage areas for labeling and dating for 4 weeks, then randomly for 2 weeks.
Audit results will be reviewed in Quality Assurance and Performance Improvement (QAPI) meeting.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations:

Based on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of three observed meals (lunch meal 6/7/26) and failed to have the registered dietitian review and approve the menu and nutritional substitutes prior to implementation for one out three meals served (lunch meal 6/7/26).

Findings include:

Review of the facility policy "Dietician" last reviewed 4/30/26, a qualified, competent, and skilled dietician will help oversee the food and nutrition services in the facility. The dietician is responsible for, but not limited to:
. Assessing the nutritional needs of residents.
. Developing and evaluating regular and therapeutic diets.

Review of the facility policy "Menus" last reviewed 4/30/26, indicated menus are developed and prepared to meet resident choices while following established national guidelines for nutritional adequacy. The dietician reviews and approves all menus.

The posted 4-week menu cycle for 6/7/26, was observed and indicated the following: fried chicken, gravy, mashed potatoes, Brussel sprouts, chocolate chip cookie, coffee or tea, milk. Lunch observations indicated that the lunch meal served on 6/7/26, did not match the resident posted menu.

During observations on 6/7/26, at 12:09 p.m. main dining room was observed with lunch service being provided for 22 residents.

During observations on 6/7/26, at 12:23 p.m. Resident R6 meal was observed and his lunch tray included turkey, mixed vegetables (corn, green beans, carrots), cheese potatoes, and a juice in cup.

During an observation completed on 6/7/26, at 12:38 p.m. Resident R33's lunch tray included turkey, mixed vegetables (corn, green beans, carrots), cheese potatoes, chocolate chip cookie and beverage in cup.

During an observation completed on 6/7/26, at 12:40 p.m. Resident R13's lunch tray consisted of turkey, mixed vegetables (corn, green beans, carrots), cheese potatoes, and beverage in cup.

During an interview completed on 6/7/26, at 12:30 p.m. upon asking Dietary Manager Employee E12 concerning the lunch meal changes stated, "it was changed due to an issue with the cooler". Upon asking Dietary Manager Employee E12 if the dietician had approved the menu changes replied, "I think I e-mailed it to her". Upon looking for the e-mail Dietary Employee E12 could not find any correspondence to the dietician and confirmed that the dietician did not sign off on the menu changes as required and confirmed facility failed to follow the displayed menu for one of three observed meals (lunch meal 6/7/26) and failed to have the registered dietitian review and approve the menu and nutritional substitutes prior to implementation for one out three meals served (lunch meal 6/7/26).

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

Plan of Correction - To be completed: 07/28/2026

Moving forward, the facility will serve the displayed menu and has the registered dietitian review and approve menu and nutritional substitutes prior to implementation.
The Dietary Manager employee 12 will be educated by the NHA or designee on the policy for Dietitian to review and approve the menu and nutritional substitutes prior to any implementation of the menu.
The NHA, Dietitian, or designee will monitor the menus for the dietitian review and nutritional substitutes approval prior to any implementation of the menu. This monitoring will be completed three times per week for four weeks, and then twice weekly for two weeks by the NHA, Dietitian, or designee.
The findings of these audits will be reported to the QAPI committee at the monthly meeting for one quarter.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations:

Based on observation and staff interview, it was determined that the facility failed to dispose of garbage into the dumpster properly for one dumpster observed outside of the building.

Findings include:

Review of the facility policy "Food-Related Garbage and Refuse Disposal" last reviewed 4/30/26, indicated garbage and refuse containing food waste will be stored in a manner that is inaccessible to pest. Outside dumpsters will be kept closed and free of surrounding litter.

During an observation completed on 6/7/26, at 9:22 a.m. the outside dumpster lid was open with debris scattered on the ground.

During an interview completed on 6/7/26, at 9:22 a.m. Dietary Cook Employee E13 confirmed the dumpster lid was open and there was debris scattered on the ground and stated, " I haven't gotten to it yet, we usually clean it up in the morning" and confirmed that the facility failed to dispose of garbage into the dumpster properly for one dumpster observed outside of the building.

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

Plan of Correction - To be completed: 07/28/2026

Food -related garbage and refuse disposal will be placed in outside dumpsters. These dumpsters are kept closed and free of surrounding litter.
On 6/7/2026, the area around the dumpster was cleaned up and the lids were closed.
Dietary department employees are responsible for maintaining the outside dumpsters by keeping them closed and free of any surrounding litter. Facility employees are responsible to place any garbage and refuse disposal from the facility into the dumpster and close the dumpster lids when task completed.
Facility staff will be educated by the NHA or designee on appropriate food-related garbage and refuse disposal into the dumpsters. The Dietary staff will be educated by the NHA or designee on the policy of maintaining the outside dumpsters by keeping them closed and free of any surrounding litter.
The NHA, Dietary Manager, or designee will monitor the outside dumpsters for cleanliness and closure at random times three times per week for four weeks, and then at random times twice weekly for two weeks.
The findings of this monitoring will be reviewed at the monthly QAPI meetings for one quarter.

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 facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions (EBP) for one of three residents (Resident R58) with enteral feeding tubes (G- Tube, a tube inserted in the stomach through the abdomen), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for two of 12 months (July 2025, and April 2026).

Findings include:

Review of the facility policy "Enhanced Barrier Precautions" dated 4/30/26, indicated enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBP employ targeted gown and glove us in addition to standard precautions during high-contact resident care activity. An example of high-contact resident care activity includes device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator etc.).

Review of facility policy "Infection Prevention and Control Plan" dated 4/30/26, indicated an infection prevention and control program is established to maintain and provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveillance tools are used for identifying the occurrence of infections, recording their numbers and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications.

Review of the admission record indicated Resident R58 was admitted to the facility on 5/22/26.

Review of Resident R58's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/28/26, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and heart failure (heart doesn't pump blood as well as it should).

Review of Resident R58's physician order dated 5/23/26, indicated enteral feed order three times a day for nutrition - Osmolite 1.5 bolus one can (eight fluid ounces).

Review of Resident R58's physician order dated 5/25/26, indicated EBP: G-tube/surgical incision right groin. Requires utilization of gowns and gloves during high contact resident care activities.

Observation on 6/7/26, at 12:05 p.m. of Licensed Practical Nurse (LPN) Employee E4 administered Resident R58's bolus feeding through the G tube. LPN Employee E4 did not put on a gown as required with EBP.

Review of the facility's monthly tracking of surveillance on 6/9/26, for the period of June 2025, through May 2026, failed to include surveillance tracking to identify possible communicable diseases or infections for two of 12 months (July 2025, and April 2026).

Interview on 6/9/26, at 12:15 p.m. Infection Preventionist Employee E18 confirmed that a gown is to be worn during administration of a tube feeding and that the facility failed to include surveillance tracking to identify possible communicable diseases or infections for two of 12 months (July 2025, and April 2026).

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)(5) Nursing services.

Plan of Correction - To be completed: 07/28/2026

Nursing staff were immediately re-educated on proper infection control protocols, including hand hygiene and PPE use for Enhanced Barrier Precautions (EBP) by the DON or designee. Monthly tracking of surveillance for July of 2025 and April of 2026 will be reviewed and updated.

The Infection Preventionist Nurse or designee will conduct refresher training for facility staff on the facility's Infection Prevention and Control Program, including CDC guidelines for hand hygiene, PPE donning/doffing, and transmission-based precautions, inclusive of EBP. DON or designee will re-educate Infection Preventionist as it relates to monthly surveillance tracking.

The Infection Preventionist/designee will conduct random infection control observations on multiple shifts 2 x's weekly for 4 weeks and weekly for 2 weeks to ensure Enhanced Barrier Precautions are being followed. The DON or designee will conduct weekly audits of monthly infection control surveillance tracking.

The Infection preventionist nurse will document all observation results, DON or designee will report monthly surveillance tracking audits, and report findings to the Quality Assurance and Performance Improvement (QAPI) Committee.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:

§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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Observations:

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for two of twelve months (July 2025, and April 2026) and failed to provide a complete antibiotic order for one of four residents (Resident R33).

Findings include:

Review of facility policy "Antibiotic Stewardship" dated 4/30/26, indicated as part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist or designee.

If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following: drug name, dose, frequency of administration, duration of treatment, route of administration, and indications for use.

Review of the facility's Infection Control surveillance for June 2025, through May 2026, failed to include documentation to indicate that antibiotic monitoring was completed for July 2025, and April 2026.

Interview on 6/9/26, at 12:15 p.m. Infection Preventionist Employee E18 confirmed the facility could not produce documentation to indicate that antibiotic monitoring was completed for July 2025, and April 2026.

Review of the clinical record indicated Resident R33 was admitted to the facility on 12/30/25.

Review of Resident R33's MDS (minimum data set - a periodic assessment of care needs), dated 3/18/26, indicated diagnoses of hypertension (high blood pressure), hyperlipidemia (high fat in the blood) and anxiety.

Review of Resident R33's physician orders dated 6/3/26, indicated Cephalexin Capsule 500 milligram give one capsule by mouth every eight hours for infection. The order failed to include the type or site of infection.

During an interview completed on 6/8/26, at 2:09 p.m. Infection Preventionist Employee E18 confirmed Resident R33's physician order for antibiotic treatment did not contain the type of infection or the site of the infection and that the facility failed to provide a complete antibiotic order for one of four residents (Resident R33).

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

Plan of Correction - To be completed: 07/28/2026

An antibiotic stewardship program will be implemented and will be monitored in accordance with regulatory requirements.

R33 completed antibiotics as ordered with no adverse outcome.

DON/designee will re-educate the current Infection Preventionist and the back-up IP on the Antibiotic Stewardship policy.

The Infection Preventionist nurse will conduct audits of newly prescribed antibiotics with complete documentation 2 x's weekly for 4 weeks, then weekly for 2 weeks to ensure stewardship is maintained.

Audit results will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee.

483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role:

§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.

Observations:

Based on review of facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for two periods during the time frame from June 2025, through May 2026 (11/12/25 - 11/24/25, and 4/26/26 - 5/20/26).

Findings include:

Review of the facility policy "Infection Preventionist" dated 4/30/26, indicated the infection preventionist (IP) coordinates the development and monitoring of the infection prevention and control program. The IP is employed on site and at least part time.

Review of the facility provided document IP Timeline on 6/8/26, indicated the following IPs were responsible during the following time frames for the period of June 2025 - May 2026:

-RN Employee E5 was responsible 5/1/24 - 11/12/25.

-IP Employee E19 was responsible 11/13/25 - 3/5/26.

-IP Employee E18 was responsible 3/5/26 - present.

Review of IP Employee E19's certificate for qualifying education required was dated 11/24/25; therefore, there was not a qualified IP designated from 11/12/25, through 11/24/25.

Review of facility provided documentation indicated IP Employee E19 became the Director of Nursing on 4/26/26.

Review of IP Employee E18's certificate for qualifying education required was dated 5/20/26; therefore, there was not a qualified IP designated from 4/26/26, through 5/20/26.

Interview on 6/8/26, at 2:00 p.m. the Director of Nursing confirmed there were two periods of IP designation gaps between 11/12/25 - 11/24/25, and 4/26/26 - 5/20/26.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 201.19(3) Personnel records.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 07/28/2026

The facility currently has two active Infection Preventionist nurses in the facility. One is primary and the other is a backup.

NHA/designee will educate nursing leadership of requirement to maintain a qualified Infection Preventionist at all times for the facility.

NHA/designee will monitor any time the primary is unable to fulfill the requirements and place the backup IP in the role as needed.

Infection Preventionist position openings will be monitored by the QAPI committee.

§ 201.14(a) LICENSURE Responsibility of licensee.:

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

Observations:

Based on staff interview and review of the facility's Infection Control Committee attendance records, the facility failed to ensure that the nine required multidisciplinary members were present at the Infection Control meetings for three of four quarters during the period of June 2025 - May 2026 (Quarter one January - March, Quarter two April - May, and Quarter four October - December).

Findings include:

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

Review of the facility's infection control attendance records for Quarter one January - March, indicated all nine of the required multidisciplinary members were not present as required. Laboratory representative nor pharmacy representative were present.

Review of the facility's infection control attendance records for Quarter two April - May, indicated all nine of the required multidisciplinary members were not present as required. Physical Plant nor Community member were present.

Review of the facility's infection control attendance records for Quarter four October - December, indicated all nine of the required multidisciplinary members were not present as required. The Medical Director, laboratory representative, pharmacy representative, or Physical Plant were present.

Interview with Infection Preventionist Employee E18 on 6/9/26, at 1:00 p.m. confirmed the facility failed to ensure that the nine required multidisciplinary members were present at the Infection Control meetings for three of four quarters during the period of June 2025 - May 2026 (Quarter one January - March, Quarter two April - May, and Quarter four October - December).

Plan of Correction - To be completed: 07/28/2026

The Infection Preventionist nurse will oversee the Infection Control committee meetings.

NHA or designee will re-educate Infection Control committee members on necessary attendance and signing off on the attendance record for the Infection control committee meetings.

The NHA/designee will audit the Infection Control meeting attendance and signature page of the meetings prior to closing out the meeting for the next quarter.

Audit results will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee.

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