Pennsylvania Department of Health
REDSTONE HIGHLANDS HEALTH CARE CTR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

REDSTONE HIGHLANDS HEALTH CARE CTR
Inspection Results For:

There are 108 surveys for this facility. Please select a date to view the survey results.

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REDSTONE HIGHLANDS HEALTH CARE CTR - 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 completed on April 16, 2026, it was determined that Redstone Highlands Health Care 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:

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

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.

§483.45 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 30 residents reviewed (Residents 4, 5, 11).

Findings include:

The facility's policy for medication administration, dated July 11, 2025, indicated that staff are to sign the Medication Administration Record (MAR) after a medication is administered, and if the medication is a controlled substance, staff are to sign the narcotic book.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 17, 2026, revealed that the resident had moderated cognitive impairment, requires assistance from staff and had diagnoses that included arthritis (inflammation, pain, and stiffness in one or more joints), and Parkinson's Disease (progressive neurodegenerative disorder that causes tremors and rigid limbs).

Physician's orders for Resident 4, dated February 10, 2026, included an order for the resident to receive 5 mg of oxycodone, two tablets, every six hours as needed for severe pain.

Review of the controlled drug records for Resident 4 dated February, March, and April 2026, revealed that two five mg oxycodone tablets were signed out on February 21, 2026, at 7:21 p.m., March 2, 2026 at 5:20 a.m., and on April 9, 2026, at 9:00 p.m.; However, there was no documented evidence in Resident 4's clinical record that the signed-out doses of controlled medication were administered to the resident on the above-mentioned dates and times.

An admission MDS assessment for Resident 5, dated March 9, 2026, indicated that the resident was cognitively

Plan of Correction - To be completed: 05/19/2026

Residents 4, 5 and 11 were noted not to have any adverse effects from not having documented narcotic medication administration in the electronic Medication Administration Record (MAR). Resident 5 is no longer in the facility. A facility-wide sweep of all residents in-house with physician orders for Oxycodone and Alprazolam was completed. Any issues identified were corrected at the time of discovery. All licensed nursing staff were re-educated regarding F755 and medication administration documentation policy. The Director of Nursing or designee will conduct audits 3 times per week for 2 weeks and then weekly x 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property:

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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Observations:

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of one of 30 residents reviewed (Resident 100) who had an indwelling urinary catheter.

Findings include:

Review of admission records for Resident 100 revealed she was admitted to the facility on April 11, 2026, with a diagnosis of aftercare following joint replacement surgery and had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine).

Observations of Resident 100 on April 15, 2026, at 12:08 p.m. revealed that the Resident was sitting in her wheelchair on the left side of her bed eating her lunch. Her urinary catheter drainage bag was attached to the bed frame on the left side of her bed, visible form the Resident's doorway, with no privacy bag on the urinary drainage bag and yellow urine visible in the bag.

Interview with Registered Nurse 1 on April 15, 2026, at 12:11 p.m. confirmed that there was no dignity or privacy bag on the Resident 100's urine drainage bag.

Interview with the Nursing Home Administrator on April 15, 2026, at 12:24 p.m. confirmed that urinary catheter drainage bags should be kept in dignity/privacy bags.

Interview with the Director of Nursing on April 15, 2026, at 1:08 p.m. confirmed that Resident 100's urinary catheter bag was not in a dignity/privacy bag, and it should have been.

28 Pa. Code 201.29(a) Resident Rights.

Plan of Correction - To be completed: 05/19/2026

Privacy cover was immediately placed on foley bag for Resident 100. Resident 100 had no adverse effects from the lack of privacy cover on the foley bag. A facility-wide sweep for all foley bags was conducted to ensure that all privacy covers were in place. Any issues identified were corrected at the time of discovery. All nursing staff and therapy staff were re-educated on resident privacy and dignity. Director of Nursing or designee will conduct audits to ensure that privacy covers are in place 3x/week x 4 weeks then weekly x 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

483.10(e)(1),483.12(a)(2),483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

§483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations: Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications and that non-pharmacological interventions and informed consent were implemented prior to initiation of an antipsychotic medication for one of 30 residents reviewed for unnecessary medications (Resident 2). Findings included: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated July 11, 2025, indicated that psychotropic medications are not used unless clinically indicated, are prescribed at the lowest effective dos, and are subject to gradual dose reduction and behavioral interventions in accordance with federal regulations and informed consent will be obtained per state law. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 6, 2026, revealed that the resident is cognitively impaired, requires assistance with daily care needs and has medical diagnosis that includes anxiety and depression. Physician orders for Resident 2 dated July 4, 2025, included orders for the resident to receive 2 milligrams of Aripiprazole (an antipsychotic) one time a day for confusion. The facility was unable to provide evidence of informed consent for the psychotropic medication aripiprazole, and it was not available in the clinical record for review. During an interview with the Director of Nursing on April16, 2026, at 9:30 AM, it was confirmed the facility failed to ensure that Resident 2 had an informed consent prior to administering an antipsychotic medication. 28 Pa. Code 211.12(d)(5) Nursing Services. \li0

Plan of Correction - To be completed: 05/19/2026

The psychotropic consent for Resident 2 for Aripiprazole was immediately obtained. Resident 2 had no adverse effects from receiving the medication as ordered without having a psychotropic consent on file. A facility-wide sweep for all psychotropic consents was completed. Any issues identified were corrected at the time of discovery. All nursing staff were re-educated on F605 and the psychotropic medication policy. Director of Nursing or designee will conduct audits to ensure that psychotropic medication consents are documented 3x per week x 4 weeks then weekly x 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for two of 30 residents reviewed (Residents 100 and 105).

Findings include:

A facility policy for Care Planning dated July 11, 2025, indicated that the licensed nurse will initiate a baseline care plan upon admission to facility and complete within 48 hours. On the first business day following admission the licensed nurse will review and update the care plan and complete a comprehensive care plan.

Review of admission records for Resident 32 dated April 11, 2026, revealed that the resident was admitted to the facility for aftercare following a joint replacement and she had a foley catheter (a flexible tube inserted into the bladder to drain urine) in place.

Observations of Resident 100 on April 13, 2026, at 10:58 a.m. revealed the resident lying in bed with a urinary drainage bag visible, hanging on the right side of the Resident's bed frame.

Observations of Resident 100 on April 15, 2026, at 12:08 p.m. revealed that the resident was sitting in her wheelchair on the left side of her bed eating her lunch. Her urinary catheter drainage bag was attached to the bed frame on the left side of her bed.

Interview with the Director of Nursing on April 16, 2026, at 10:54 a.m. confirmed the Resident 100's baseline care plan did not include care and treatment needs required for the resident's foley catheter use and should have.

Review of admission records for Resident 105 dated April 4, 2026, revealed that the resident was admitted to the facility for aftercare following urinary tract infection (UTI) and he had a

Plan of Correction - To be completed: 05/19/2026

Resident 32 is not identified in the Resident Sample listing as two of the 30 residents reviewed at the time of survey. Resident 100 had no adverse reactions to not having the foley identified on the baseline care plan. Resident 105 had no adverse reactions to not having the midline catheter identified on the baseline care plan. Resident 100's care plan was updated to include the foley catheter. Resident 100 is no longer in the facility. Resident 105's care plan was updated to include the midline catheter. Resident 105 is no longer in the facility. A facility-wide sweep of all catheters was completed to ensure that the baseline care plan includes information regarding the resident's individualized care needs. The registered nurse assessment coordinator (RNAC) and all licensed nursing staff were re-educated regarding updating of the baseline care plan to include resident individualized care needs. The Director of Nursing or designee will conduct audits 3 times per week for 2 weeks and then weekly x 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

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

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

Observations:

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 30 residents reviewed (Residents 5 and 42).

Findings include:

A facility policy for Comprehensive Care Planning, dated July 11, 2025, included that all residents will have a comprehensive care plan that provides guidance to the interdisciplinary team related to care needs, and when appropriate, discharge plans and goals. Care plans will be updated by the licensed nurse and interdisciplinary team as needed with changes. The licensed nurse will make every effort to update the care plan within 24 hours of changes.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 5 dated March 9, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included fusion of the spine and had surgical wounds.

Physician's orders for Resident 5 dated March 17, 2026, included for staff to cleanse her mid back wound with normal sterile saline (NSS- sterile salt water), dry, pack the open wounds on the mid back with black foam, (bridge away from bony prominences if necessary) and apply wound VAC (vacuum-assisted closure-a therapeutic technique using a suction pump, tubing, and a foam dressing to remove excess fluid, bacteria, and debris from complex or chronic wounds) at -125mmhg (millimeters of mercury) continuously. Change three times a week on Monday, Wednesday and Friday and as needed for dislodgement. Wound VAC must be removed if the resident must go out of the facility for

Plan of Correction - To be completed: 05/19/2026

Resident 5 had no adverse reactions to not having specific and individualized interventions for care of the wound vac identified on the comprehensive care plan. Resident 42 had no adverse reactions to not having specific and individualized interventions for care of the midline catheter identified on the comprehensive care plan. Resident 5's care plan was updated to include the specific individualized interventions to address care needs for the wound vac. Resident 5 is no longer in the facility. Resident 42's care plan was updated to include the specific individualized interventions to address care needs for the midline catheter. A facility-wide sweep of all wound vacs and catheters was completed to ensure that the comprehensive care plan includes information regarding the specific and individualized interventions to address care for the resident. The registered nurse assessment coordinator (RNAC) and all licensed nursing staff were re-educated regarding updating the comprehensive care plan to include resident individualized interventions to address care needs of the resident. The Director of Nursing or designee will conduct audits 3 times per week for 2 weeks and then weekly x 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

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 and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician of a change in condition and obtain physicians orders for one of 30 residents reviewed (Resident 2).

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.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 2 dated February 6, 2026, revealed that the resident is cognitively impaired, requires assistance with daily care needs and has medical diagnoses that include anxiety, depression, gastrostomy status (a tube inserted into the stomach to provide nourishment).

A nurse's note for Resident 2, dated April 13, 2026, at 1:17 p.m. revealed that the resident went to therapy where they stood her several times. Upon returning from therapy staff stated the resident was very tired all of the sudden. Resident 2 went to lunch and did not eat. At 12:20 p.m. she was brought out to the nurse's station where eyes were closed, very diaphoretic, blood sugar was 164 mg/dl, temperature 98.0 Fahrenheit, pulse 72 bpm, respirations 18, and blood pressure of 61/43 mmHg. She opened her eyes to name but spoke very little. She was placed back to bed, legs elevated, given 500 cc water via Gastrostomy tube. Her Blood pressure at 12:50 p.m. w

Plan of Correction - To be completed: 05/19/2026

Resident 2 had no adverse reactions noted from the 2x 500cc water bolus being administered prior to obtaining physician order or physician notification. The facility is unable to retroactively correct this issue. The nurse who completed the administration prior to obtaining physician order or notifying physician of resident's change in condition was re-educated on F658. A facility-wide sweep of physician notification regarding resident change in condition was completed. Any issues identified were corrected at the time of discovery. All other licensed nursing staff were re-educated regarding physician notification with resident change in condition. The Director of Nursing or designee will conduct audits 3 times per week for 2 weeks and then weekly x 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education

483.25 REQUIREMENT Quality of Care:

§ 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 clinical record reviews and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders after a change in condition for one of 30 residents reviewed (Resident 54).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated February 20, 2026, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of heart failure.

A nursing note dated March 10, 2026, at 3:00 a.m. indicated that the resident felt as though she is falling out of bed and "everything is just wrong." An on call practitioner was contacted and orders of orthostatic vitals in the morning.

An advanced practice nursing note for resident 54 dated March 10, 2026, at 1:49 a.m. central time, indicated the resident was complaining of the room spinning while lying in bed. The staff were to perform orthostatic vital signs (measurements of blood pressure and heart rate taken while lying, sitting, and standing) in the morning.

There was no documented evidence in Resident 54's clinical record to indicate that orthostatic blood pressures were obtained by facility staff as ordered.

Interview with the Director of Nursing on April 15, 2022, at 12:44 a.m. confirmed that there was no documented evidence that orthostatic vital signs were obtained as ordered for Resident 54 after her change in condition

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

Plan of Correction - To be completed: 05/19/2026

Resident 54 had no adverse reactions to not having orthostatic blood pressures completed and documented as per physician orders. The facility is unable to retroactively correct this issue. A facility-wide sweep of physician orders for orthostatic blood pressures was completed. Any issues identified were corrected at the time of discovery. All licensed nursing staff were re-educated regarding F684. The Director of Nursing or designee will conduct audits 3 times per week for 2 weeks and then weekly x 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

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 facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to ensure that an anticoagulant medication was held per physician's orders for one of 30 residents reviewed (Resident 3).

Findings include:

Facility policy for medication errors, dated July 11, 2025, indicated that the interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. A "medication error" is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 15, 2026, indicated that the resident was cognitively impaired and was receiving an anticoagulant (blood thinner). A care plan, dated February 24, 2026, indicated that the resident had a diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm), and warfarin to be administered as ordered, laboratory tests as ordered, and abnormal results to be reported to physician.

Physician's orders for Resident 3, dated April 6, 2026, included an order for four milligrams (mg) of warfarin (a blood thinner) to be administered daily at bedtime and to check the PT/INR (a test that indicates how much time it takes for the blood to clot) on April 13, 2026.

Laboratory facsimile report sent to facility with results of Resident 3's PT/INR on April 13, 2026 indicated a critical INR of 5.7 with results also called to the facility. A

Plan of Correction - To be completed: 05/19/2026

Resident 3 had no adverse effects from not having the Coumadin order held per physician orders. The facility is unable to retroactively correct this issue. A facility-wide sweep of all physician orders for Coumadin was completed. Any issues identified were corrected at the time of discovery. All licensed nursing staff were re-educated regarding F760 and medication error policy. The Director of Nursing or designee will conduct audits 3 times per week for 2 weeks and then weekly x 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

483.50(a)(1)(i) REQUIREMENT Laboratory Services:

§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one of 30 residents reviewed (Resident 3).

Findings include:

Facility policy for laboratory tests, dated July 11, 2025, indicated that when a physician has ordered laboratory test for a resident, there will be a systemic way in which that order is processed to ensure accuracy in completion of the order and promote that the physician receives timely results.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 15, 2026, indicated that the resident was cognitively impaired and was receiving an anticoagulant (blood thinner). A care plan, dated February 24, 2026, indicated that the resident had a diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm), and warfarin to be administered as ordered, laboratory tests as ordered, and abnormal results to be reported to physician.

Physician's orders for Resident 3, dated April 6, 2026, included an order for four milligrams (mg) of warfarin (a blood thinner) to be administered daily at bedtime and to check the PT/INR (a test that indicates how much time it takes for the blood to clot) on April 13, 2026.

Facsimile report from laboratory sent to facility with critical INR of 5.7 with results called to facility with read back from nursing staff. Written order on facsimile from physician to hold coumadin for three days and check INR daily for five days.

A review of Resident 3's clinical record revealed that staff failed to obtain the INR on April 14, 2026, as ordered.

Interview with the Director of Nur

Plan of Correction - To be completed: 05/19/2026

Resident 3 had no adverse effects from failing to check and report INR as per physician orders. The facility is unable to retroactively correct this issue. A facility-wide sweep of all physician orders for PT/INR was completed. Any issues identified were corrected at the time of discovery. All licensed nursing staff were re-educated regarding F770 and laboratory testing policy. The Director of Nursing or designee will conduct audits 3 times per week for 2 weeks and then weekly x 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

483.75(c)(1)-(4)d)(1)(2)(e)(1)-(3)(g)(2)(ii)(iii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations: Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey's ending March 20, 2025, April 8, 2025, August 5, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending April 16, 2026, identified repeated deficiencies related to baseline care plans, develop/implement comprehensive care plan, services provided meet professional standards, quality of care, residents are free of significant med error, pharmacy records, and infection prevention and control. The facility's plan of correction for a deficiency regarding baseline care plans, cited during the survey ending March 20, 2025, revealed that baseline care plans would be monitored by QAPI. The results of the current survey, cited under F655, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding baseline care plans. The facility's plan of correction for a deficiency regarding develop/implement comprehensive care plan, cited during the survey ending March 20, 2025, and April 8, 2025, revealed that the develop/implement comprehensive care plan would be monitored by QAPI. The results of the current survey, cited under F656, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding develop/

Plan of Correction - To be completed: 05/19/2026

Residents identified as potentially affected by the deficient practice were immediately reviewed. Focused audits were conducted and any identified issues were immediately addressed and corrected, including physician notification, care plan updates, Narcotic to Medication Administration Record discrepancies, and Infection Prevention and Control. The Quality Assurance Performance Improvement plan was reviewed and the Quality Performance Improvement Plan committee will meet monthly to review data, trends and initiate Performance Improvement Projects (PIPs). A tracking tool was implemented, and staff education was completed. Ongoing audits will be conducted weekly for 2 weeks and monthly for 2 months. Results will be reviewed by the QAPI committee and Governing Body.

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 established infection control guidelines, facility policy, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 30 residents reviewed (Resident 5).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated July 11, 2025, indicated that EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs

Plan of Correction - To be completed: 05/19/2026

Resident 5 had no adverse effects from wound care being provided without enhanced barrier precautions (EBP) protocol being identified. EBP was immediately placed on resident door. Resident 5 has since been discharged from the facility. A facility-wide sweep was completed for all residents requiring EBP protocol. Any issues identified were corrected at the time of discovery. All nursing staff and licensed therapy staff were re-educated on EBP protocol. The Infection Preventionist or designee will conduct audits 2x/week for 4 weeks then weekly for 2 months. Issues identified during audits will be corrected at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

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 residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received pneumococcal immunizations for one of 30 residents reviewed (Residents 16).

Findings include:

The facility's pneumococcal vaccine policy, dated July 11, 2025, indicated that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. The resident/representative have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the refusal of pneumococcal vaccination.

An annual Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated March 13, 2026, revealed that the resident was admitted to the facility on April 9, 2024. The sections of the MDS assessment related to the resident's pneumococcal vaccination revealed that the resident's pneumococcal vaccination was not up to date due to being offered but declining the vaccine. There was no documented evidence that the facility offered, or the resident declined the pneumococcal vaccine.

Interview with the Infection Control Nurse on April 16, 2026, at 11:17 a.m. confirmed that there was no documented evidence that Resident 16 was offered the pneumococcal vaccine at the time of their admissions or at any time afterward.

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

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

Plan of Correction - To be completed: 05/19/2026

Resident 16 had no adverse effects from not having evidence of pneumonia vaccine offered. Pneumonia vaccine was immediately offered to Resident 16 and pneumonia vaccination administered on 4/16/26. A facility-wide sweep of pneumonia vaccines offered to all in-house residents was completed. Any issues identified were corrected at the time of discovery. All nursing staff were re-educated on F883 and Vaccination policies. Infection Preventionist or designee will conduct audits 3x/week for 2 weeks and then weekly x 2 months. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for improvement and needs for additional staff training and education.

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