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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GREENE HEALTH & REHAB CENTER
Inspection Results For:

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

Initial comments:Based on an abbreviated complaint survey completed on April 22, 2026, it was determined that Greene Health and Rehab Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(b)(3)-(7)(i)-(iii) REQUIREMENT Rights Exercised by Representative:

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.

§483.10(b)(3) In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated.
(i) The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the representative.
(ii) The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law.

§483.10(b)(4) The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law.

§483.10(b)(5) The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law.

§483.10(b)(6) If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns when and in the manner required under State law.

§483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident's behalf. The court-appointed resident representative exercises the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law.
(i) In the case of a resident representative whose decision-making authority is limited by State law or court appointment, the resident retains the right to make those decisions outside the representative's authority.
(ii) The resident's wishes and preferences must be considered in the exercise of rights by the representative.
(iii) To the extent practicable, the resident must be provided with opportunities to participate in the care planning process.

Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's legal representative (power of attorney) was given the opportunity to make decisions regarding physical/sexual contact between residents for one of 14 residents reviewed (Resident 12).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2026, indicated that the resident was severely confused, was independent with ambulation, and had diagnoses that included Korsakoff's dementia (a type of brain disorder that causes memory loss, impaired thinking and behaviors).

Resident 12's clinical record revealed that his daughter, Family Member 1 was his power of attorney and decision maker.

Observations of Resident 12 on April 21, 2026 at 10:22 a.m. revealed that he was walking with Resident 11 with her holding his arm as they walked. Staff redirected them from the exit door and had them sit together at the dining table.

Nursing note for Resident 12, dated December 14, 2025 at 5:29 a.m. revealed that Resident 12 was observed talking with Resident 11, holding her hand and kissing her.

Nursing note for Resident 12, dated December 14, 2025 at 1:24 p.m. indicated that Resident 12 was wandering the unit with Resident 11 and they were trying to leave the unit.

Nurse's note for Resident 12, dated December 29, 2025 indicated that Resident 12 was walking with and holding hands with Resident 11.

Nurse's note for Resident 12, dated March 12, 2026 at 7:10 p.m. revealed that he was found in Resident 11's bed next to her with his pants unbuttoned and he was exposed to her. When the facility notified his daughter/POA she was angry because she was previously told that they would be separated.

Interview with Family Member 1 on April 22, 2026 at 9:26 a.m. revealed that she was told in early December, shortly after Resident 12's admission, that Resident 11 had "attached herself to him like he was her boyfriend." She stated that because her father is only 54 years old and is still married to her mother, she did not want him around Resident 11. She said that she had visited several times and each time Resident 11 would follow them around and tell Resident 12 that they needed to leave together. She said on March 12, 2026 the nurse phoned her and told her that her father was found in bed with Resident 11 and that he was exposed. She said she was angry and came to the facility within an hour or so and when she arrived he was sitting with Resident 11 on the bench in front of the nurse's station. She said he was holding Resident 11's hand and she had her head resting on his shoulder. She said she was angry because she asked that they be separated and that any contact between them not be permitted or encouraged. She said that she has made it very clear that she does not want her father to be around Resident 11.

Interview with Assistant Director of Nursing on April 22, 2026 at 2:30 p.m. revealed that Resident 11 believes Resident 12 to be her boyfriend and that they are always together. She further stated that Resident 12's daughter has said she does not want her father with Resident 11, but that Resident 11 is too difficult to redirect.

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

Plan of Correction - To be completed: 05/08/2026

Residents R11 and R12 now reside on separate hallways. Staff on each shift will monitor and oversee that there is no physical contact between Residents R11 and R12.

No other residents identified as at risk.

Psyche evals were completed on both residents with no additional recommendations noted

Staff were educated by Staff Development on separating residents when they are seen together and give them activities to do.

The Director of Nursing or designee will audit to ensure that staff are separating residents. This audit will be completed daily x 2 weeks. Then weekly x 8 weeks.

The results of the audit will be taken to Quality Assurance Performance Improvement meeting for further recommendations as needed.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Plan of Correction - To be completed: 05/08/2026

The activities department has hired another FTE effective 5/5/26. The schedule in the activities department has been revised to include the memory care neighborhood to facilitate meaningful activities.

The activities staff was educated by Staff Development/Designee on the need for meaningful activities in the Memory Care Neighborhood.

The Activities Director/Designee will audit for meaningful activities being completed in the Memory Care Neighborhood. This audit will occur daily times 2 weeks then weekly x 8 weeks.

The results of this audit will be reviewed at the Quality Assurance Performance Improvement meeting for further recommendations as necessary.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

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

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that intravenous catheters were flushed according to the facility's policy for one of 14 residents reviewed (Resident 4).

Findings include:

The facility's policy regarding flushing intravenous (IV) catheters (a thin tube placed in a vein that can be used for an extended period of time to deliver fluids and/or medications), dated April 20, 2026, revealed that flushing is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. All peripheral IV catheters are flushed between incompatible medications with normal saline or other flush solution as recommended by the manufacturer.

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated March 13, 2026, revealed that the resident was cognitively impaired and was dependent on staff for daily care needs.

Physician's orders for Resident 4, dated April 13, 2026, included orders to insert a peripheral IV catheter to administer 1 gram (gm) of Rocephin (an antibiotic) once a day during the evening from April 14 thru April 18, 2026.

Review of Resident 4's Medication Administration Records (MAR's) for April 2026 revealed that the resident received 1 gm Rocephin in the evening from April 14 thru April 18, 2026; however, there was no documented evidence that staff flushed the peripheral IV catheter before and after the administration.

Interview with the Director of Nursing on April 22, 2026, at 8:49 a.m. confirmed that there was no documented evidence that Resident 4's IV catheter was flushed before and after the medication administration.

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

Plan of Correction - To be completed: 05/08/2026

Resident R 4 had IVs discontinued.

All other residents receiving IVs were reviewed to ensure pre- and post-flush orders were present.

Licensed staff were educated by Staff Development on the need for pre and post flushes with intermittent IVs

The Director of Nursing or designee will audit for pre- and post-flush orders with every IV order for 30 days.

These audits will be reviewed at the Quality Assurance Performance Improvement meeting for further recommendations as necessary.

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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for four of 14 residents reviewed (Residents 4, 10, 11, 12).

Findings include:

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated March 13, 2026, revealed that the resident was cognitively impaired and was dependent on staff for daily care needs.

Physician's orders for Resident 4 dated November 7 and December 26, 2025, March 14 and April 15, 2026, included orders for the resident to receive 0.2 milligrams (mg) of Clonidine HCl (used to treat high blood pressure) every day in the morning, 20 mg of Lasix (used to treat fluid retention) every day in the morning, 10 mg of Memantine (used to treat memory) two times a day in the morning and evening, 50 mg Metoprolol tartrate (used to treat high blood pressure) two times a day in the morning and evening and 50 mg of Sertraline (used to treat depression) every day in the morning.

Interview with Licensed Practical Nurse 1 on April 21, 2026, at 12:44 p.m. revealed that the morning medication administration times were between 6:15 and 10:00 a.m. and as of April 21, 2026, at 12:44 p.m. Resident 4 had not received her morning medications as ordered by the physician.

Interview with the Nursing Home Administrator on April 21, 2026, at 12:54 p.m. confirmed that Resident 4 did not receive her morning medication as ordered by her physician and she should have.

A quarterly MDS assessment for Resident 10, dated January 29, 2026, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, and had diagnoses that included dementia.

Nurse Practioner's note for Resident 10, dated April 6, 2026 revealed that the resident had fallen and that staff were to obtain orthostatic blood pressures (blood pressure taken while sitting, then standing, then lying) for three days.

There was no documented evidence that staff obtained orthostatic blood pressures for Resident 10 as ordered.

A quarterly MDS for Resident 11, dated March 29, 2026, revealed that the resident was cognitively impaired, ambulated independently, had verbal behaviors, and had diagnoses that included dementia.

A quarterly MDS assessment for Resident 12, dated March 18, 2026, revealed that the resident was cognitively impaired, ambulated independently, and had diagnoses that included dementia.

Nurse's note for Resident 12, dated March 12, 2026 at 7:10 p.m. revealed that he was found in Resident 11's bed next to her with his pants unbuttoned and he was exposed to her. When the facility notified his daughter/POA she was angry because she was previously told that they would be separated and she was told that Resident 12 would be seen by psychiatric services in the morning.

Nursing note for Resident 11, dated March 16, 2026 revealed that the resident's legal guardian and daughter were notified of the incident with Resident 12 and that Resident 11 would be seen by psychiatric services in the morning.

There was no documented evidence that Resident 11 or Resident 12 were seen by psychiatric services after the incident on March 12, 2026 as their families were told would happen.

An interview with the Nursing Home Administrator and Clinical Consultant on April 22, 2026 at 4:24 p.m. revealed that the orthostatic blood pressures were not obtained for Resident 10, and Residents 11 and 12 were not seen by psychiatric services and they should have been.

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

Plan of Correction - To be completed: 05/08/2026

Education was given to Licensed Practical Nurse 1 on acceptable times of med pass

Resident R4 received medications late and the physician was notified.

Psyche Evals were completed on Resident R11 and R12.

Orthostatic B/Ps completed on Resident R10

A look-back of 14 days was completed to ensure physician orders were followed

Licensed staff were educated by Staff Development on the process to follow MD orders.

The Director of Nursing or designee will audit physician orders for follow up. These audits will be completed 2 times per week times 30 days.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident:

§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Observations:

Based on a review of facility policy, the facility assessment and clinical records, as well as observations and family and staff interviews, it was determined that the facility failed to provide adequate ongoing activities designed to meet the needs of six of six residents reviewed (Residents 7, 8, 9, 10, 11, 12) who resided in the Memory Impaired Unit (MIU) and had behaviors and/or dementia.

Findings include:

The facility's policy regarding Dementia Care, dated April 20, 2026 revealed that staff will be trained to provide necessary care and services that are person-centered and reflect the resident's goals, while maximizing the dignity, autonomy, privacy, socialization, independence, choice, and safety of the resident. Staff would be familiar with dementia care approaches and each resident's person-centered care plan. Individualized, non-pharmacological approaches to care will be utilized, including the provision of meaningful life enrichment activities.

The facility's assessment, dated April 6, 2026 revealed that the MIU offers specialized cognitive activities provided by staff trained in dementia care and that the Life Enrichment staffing requirements were one full time director and three full time aides.

An quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated March 18, 2026, revealed that the resident was cognitively impaired, was dependent on staff for care needs, and had diagnoses that included dementia (a brain disorder that causes memory loss). The resident's care plan failed to identify the resident's activity preferences.

A quarterly MDS assessment for Resident 8, dated March 11, 2026, revealed that the resident was cognitively impaired, required staff assistance for daily care needs, was independently ambulatory, and had diagnoses that included dementia. The resident's care plan failed to identify the resident's activity preferences.

A quarterly MDS assessment for Resident 9, dated March 30, 2026, revealed that the resident was cognitively impaired, required staff assistance for daily care needs, and had diagnoses that included dementia. The resident's care plan failed to identify the resident's activity preferences.

A quarterly MDS assessment for Resident 10, dated January 29, 2026, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, and had diagnoses that included dementia. The resident's care plan, dated March 5, 2026, was not individualized to identify the resident's activity preferences.

A quarterly MDS for Resident 11, dated March 29, 2026, revealed that the resident was cognitively impaired, ambulated independently, had verbal behaviors, and had diagnoses that included dementia. The resident's care plan, dated November 11, 2025, indicated that the resident had behaviors and that staff were to provide activities that resembled her prior lifestyle, however, the resident's care plan was not individualized to reflect the resident's prior lifestyle or what she enjoyed to do.

A quarterly MDS assessment for Resident 12, dated March 18, 2026, revealed that the resident was cognitively impaired, ambulated independently, and had diagnoses that included dementia. The resident's care plan failed to identify the resident's activity preferences.

Observations in the MIU on April 21, 2026 at 11:20 a.m. revealed that there were 14 residents sitting around the tables in the common room. The activity aide was playing music, but was not engaging the residents in any activity. One resident pulled her shirt over her head exposing her breasts multiple times and staff was not always present in the common room to pull the resident's shirt down or cover her up. There were no further activities observed in the MIU on April 21, 2026.

Observations in the MIU on April 22, 2026 at 10:00 a.m. revealed that the activity aide brought a coffee cart with donuts into the unit. At 10:20 a.m. the first resident was served a half a donut and a cup of iced tea. At 10:31 a.m. she finished passing donuts and drinks to the residents. There were two residents in the common room that were not offered donuts or drinks. She did not engage any residents in a group activity. Residents were observed wandering aimlessly, getting into the cupboards and drawers around the room, and yelling out. There were no other activities observed in the MIU on April 22, 2026.

Observations in the MIU on April 22, 2026 at 10:46 a.m. revealed that there were two residents wandering the unit aimlessly, 11 residents sitting in the common area with no stimulation, and six residents sleeping in the common area.

Interview with Family Member 2 on April 21, 2026 at 12:14 p.m. revealed that she visits her mother daily and she has not seen any activities in the MIU for several months. She stated that she has asked that her mother be able to participate in some activities, especially bingo, but that none have been provided. She said she tries to interact with as many residents as she can so that they get some kind of stimulation because she felt bad that they just "sit around and do nothing but sleep." She further stated that the activity aide was putting on a show today because she has not done anything in the MIU for months.

Interview with Registered Nurse 1 on April 21, 2026 at 12:53 p.m. revealed that there have not been any activities in the MIU for some time. She stated that activities would help some of the residents who have behaviors and keep them from acting out, but she does not have time to do activities with them, nor do the nurse aides. She stated that the MIU might have three nurse aides scheduled, but one is usually pulled to go on appointments and that leaves two nurse aides for 30 residents and they do not have time to do activities.

Interview with the Activities Director on April 21, 2026 at 1:36 p.m. revealed that she does not have enough staff to do activities in the MIU currently. She stated that she hopes to hire more staff, but in the mean time there is no one available to provide activities in the MIU and there has not been anyone for at least two months.

Interview with the Nursing Home Administrator on April 22, 2026 at 3:24 p.m. revealed that the activity department is currently understaffed and that she is in the process of hiring new staff. She acknowledged that there is a need for activities in the MIU.

28 Pa. Code 211.11(d) Resident care plan.

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

Plan of Correction - To be completed: 05/08/2026

The activities department has hired another FTE. The schedule in the activities department has been revised to include the memory care neighborhood to facilitate meaningful activities.

The activities staff was educated by Staff Development/Designee on the need for meaningful activities in the Memory Care Neighborhood.

The Activities Director/Designee will audit for meaningful activities being completed in the Memory Care Neighborhood. This audit will occur daily times 2 weeks then weekly times 8 weeks.

The results of this audit will be reviewed at the Quality Assurance Performance Improvement meeting for further recommendations as necessary.

483.10(j)(1)-(4) REQUIREMENT Grievances:

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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations:

Based on review of policies, clinical records, and facility grievance forms, as well as staff interviews, it was determined that the facility failed to include the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the family's concerns, or any corrective action taken or to be taken by the facility as a result of the grievance for one of 14 residents reviewed (Resident 6).

Findings include:

The facility's grievance policy, dated April 20, 2026, indicated that the resident had a right to voice grievances to the facility, or other agencies or entities that hear grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment that has been furnished, the behavior of staff, and other residents and any other concern regarding the resident's stay. Upon receipt of an oral, written, or anonymous grievance submitted by a resident, the Grievance Official would take immediate action to prevent further potential violations of any resident right while the alleged violation was being investigated, if indicated. The Grievance Committee/Grievance Official would complete an investigation of the residents' grievance. This may include a review of the facility processes, programs and policies, as well as interviews with staff, residents and visitors, as indicated, and any other review deemed necessary by the Grievance Committee. The grievance review would be completed in a reasonable time frame consistent with the type of grievance, but in no event would the review exceed thirty days. Upon completion of the review, the Grievance Official would complete a written grievance decision the included the date the grievance was received, a summary of the statement of the resident's grievance, steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the resident's grievance was confirmed or not confirmed, whether any corrective action was taken or would be taken, and the date the written decision was issued.

An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 30, 2026, revealed that the resident was moderately cognitively impaired, able to make her needs known, and had a urinary tract infection.

A nursing note written by the Case Manager, dated April 15, 2026, at 8:03 a.m. revealed that a voicemail was received from Resident 6's family member to return her call regarding Resident 6. Resident Family Member 6 was upset about the move from a private room and multiple other things on the 400 wing. It was explained that she would speak with management on this in the morning meeting, and she would return her call.

However, there was no documented evidence that Resident Family Member 6's concerns were followed up with, as indicated in the nurse's notes. There was no documented evidence that Resident Family Member 6's complaint/grievance was thoroughly investigated.

A review of the Grievance log for April 2026 revealed that there was no grievance investigation regarding Resident Family Member 6's concerns.

Interview with the Case Manager on April 22, 2026, at 11:47 a.m. confirmed that she did not make a follow up call to Resident Family Member 6 regarding her concerns.

Interview with Social Service on April 22, 2026, at 12:21 p.m. revealed that Resident Family Member 6 had concerns regarding the move out of a private room and that staff weren't being nice to her. She confirmed that there had been no call to the family and they were very angry.

28 Pa. Code 201.29(i) Resident rights.

Plan of Correction - To be completed: 05/08/2026

The facility cannot retroactively correct the grievance as Resident 6 was discharged.

A lookback of 90 days of grievances was completed to ensure follow through was done.

All grievances will be brought to morning meeting for review and completion.

Staff have been educated by Staff Development on the grievance process and completing a grievance.

The Administrator or designee will audit all new grievances 2 times per week x 30 days for completeness and follow-through. The results of this audit will be taken to the Quality Assurance Performance Improvement meeting for further recommendations as necessary.

483.25(f) REQUIREMENT Colostomy, Urostomy, or Ileostomy Care:

§483.25(f) Colostomy, urostomy,, or ileostomy care.
The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for two of 14 residents reviewed (Residents 3, 10).

Findings include:

The facility's policy regarding colostomy care (care for an artificial opening in the bowel), dated April 20, 2026, indicated that when colostomy care was provided and the drainage bag was replaced, staff were to measure the stoma (surgically created opening that connects the intestines to the outside) size using the measuring guide and trace the pattern of the size of the opening on the wafer (adhesive component that attaches to the skin around the stoma) backing and cut the opening to size.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 24, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had an ostomy (a surgically created opening in the abdomen- part of the body between the chest and the hips). A physician's order, dated September 19, 2025, included an order for the colostomy bag and set up to be changed every three days, and the bag to be dated when changed, per the family request.

Observations of Resident 3 on April 21, 2026, at 1:15 p.m. with Licensed Practical Nurse 3, revealed that there was no date marked anywhere on her colostomy bag.

Interview with Licensed Practical Nurse 3on April 21, 2026, at 1:15 p.m. confirmed that the colostomy bag was not dated and should have been.

A quarterly MDS assessment for Resident 10, dated January 29, 2026, revealed that the resident was cognitively impaired, required assistance from staff for all her daily care needs, and had a colostomy (an opening in the abdomen that allows waste to exit the body).

Observations of Resident 10 on April 21, 2026, at 12:35 p.m. revealed that the resident's colostomy bag/site was being changed by Registered Nurse 1. The registered nurse was standing at her medication cart in the common room where she was observed to cut a hole in the ostomy wafer and gathered other materials. Once in the resident's room Registered Nurse 1cleaned the skin around the stoma, applied skin prep (a barrier applied on skin to be a barrier between the skin and adhesive), and then applied the wafer and attached bag. The wafer was visibly large compared to the stoma. Registered Nurse 1 did not measure the stoma site or apply the wafer close to the stoma.

Interview with Registered Nurse 1 on April 21, 2026, at 12:35 p.m. revealed that she did not measure the stoma to cut the wafer and stated she just "eyeballs it."

Interview with the Director of Nursing on April 21, 2026, at 2:48 p.m. confirmed that staff should measure the stoma to cut the wafer to size.

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

Plan of Correction - To be completed: 05/08/2026

Residents R3 and R10 were evaluated for orders, care plans and correct placement of ostomy.

All other residents with ostomies were evaluated for orders, care plans and correct placement.

Licensed staff were educated by Staff Development on proper ostomy care.

The Director of Nursing or Designee will audit for proper ostomy care 2x per week for 30 days.

These audits will be reviewed by the Quality Assurance Performance Improvement committee for further recommendations as needed.

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

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

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

Observations:

Based on a review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a device for fall prevention was in place as care planned for one of 14 residents reviewed (Resident 10).

Findings include:

The facility's policy regarding fall prevention and management, dated April 20, 2026, indicated if risks are identified, preventive measures will be put in place as care planned.

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated January 29, 2026, revealed that the resident had severe cognitive impairment, was sometimes understood, rarely/never understand, and had diagnoses that included dementia. Resident 10's care plan, dated March 5, 2026, indicated that the resident utilized a chair alarm while she is in her chair, and for staff to ensure the alarm is always working.

Observations of Resident 10 on April 21, 2026, at 11:56 a.m. revealed that she was sitting in her Broda chair (specialized wheel chair) and that there was chair alarm visible.

Observations of Resident 10 on April 21, 2026 at 12:27 p.m. revealed that she stood up out of her chair, no alarm sounded, and staff was not aware of her standing.

Interview with Registered Nurse 2on April 21, 2026, at 12:34 p.m. confirmed that Resident 10's chair alarm was not in place, and that it should have been.

Interview with the Nursing Home Administrator on April 21, 2026, at 3:50 p.m. confirmed that Resident 10's chair alarm should have been in place.

28 Pa. Code 211.10(a) Resident care policies.

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

Plan of Correction - To be completed: 05/08/2026

Resident R 10 had alarm discontinued

All other residents with alarms were reviewed for placement, orders and care plans.

Education was completed to nursing staff by Staff Development on following fall prevention care plans.

The Director Of Nursing or Designee will audit fall prevention care plans 2x per week for 30 days.

The results of these audits will be reviewed in the Quality Assurance Performance Improvement meeting for further recommendations as needed.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision:

§483.25(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

§483.25(a)(1) In making appointments, and

§483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from the optometrist for a follow-up appointment for one of 14 residents reviewed (Resident 5).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated December 31, 2025, revealed that the resident was cognitively intact and required maximum assistance for daily care needs.

An optometry (a profession that specializes in caring for your eyes) consult for Resident 5, dated March 21, 2025, revealed that the resident presented for a diabetic eye exam and an evaluation of bilateral cataracts (a progressive eye condition that causes blurred vision) and recommended that the resident returned in six months for a follow up examination.

There was no documented evidence that the optometrist recommendation for Resident 5 to return in six months was completed or that the resident's physician disagreed with the optometrist's plan of care.

Interview with the Nursing Home Administrator on April 22, 2026, at 3:10 p.m. confirmed that there was no documented evidence that Resident 5 had a follow up appointment completed as recommended by the optometrist.

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

Plan of Correction - To be completed: 05/08/2026

Resident R5 was seen by the eye doctor in March and received new glasses. Resident does not want to be seen every 6 months.

A look back of 30 days was completed to ensure consults were completed as recommended.

Licensed staff have been educated to review consult sheets for follow up and recommendations.

The Director of Nursing or Designee will audit consults for follow-up and recommendations 2x per week x 30 days.

These audits will be reviewed at the Quality Assurance Performance Improvement meeting for further recommendations as needed.

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 the Pennsylvania Nursing Practice Act, residents' clinical records, and staff interviews, it was determined that the facility failed to ensure that a registered nurse completed a timely assessment when changes in condition occurred for one of 14 residents reviewed (Resident 8).

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 resident's abilities and care needs) for Resident 8, dated March 11, 2026, revealed that the resident was cognitively impaired and required assistance from staff for daily care.

A nursing note for Resident 8, dated March 29, 2026, at 6:00 p.m. revealed that the resident reported pain in peri area (area of skin and muscle between the genitals and anus) when sitting in chair in dining area. Resident reports she has no pain with laying in bed or walking. During a shower the Licensed Practical Nurse was called in to observe resident's peri area, where resident had previously had a prolapse observed, now the area is very enlarged more than three times any size previously observed. Licensed Practical Nurse reported to supervisor the prolapse and complaints of pain when sitting in a chair. Will monitor and await supervisor's assessment and any changes made by physician.

There was no documented evidence that a registered nurse assessed Resident 8's change in condition when she complained of pain.

Interview with the Clinical Consultant on April 22, 2026, at 1:21 p.m. confirmed that Resident 8 should have been assessed by a registered nurse and the assessment should have been documented in the resident's medical record.

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

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

Plan of Correction - To be completed: 05/08/2026

The Registered Nurse and Certified Registered Nurse Practitioner assessed Resident R8 for a reported prolapse.

A look-back of 14 days was completed to identify any areas needing an RN assessment. Assessments completed as identified.

RNs were educated by Staff Development on completing an RN assessment and notification to the physician.

The Director of Nursing or designee will audit for changes in condition requiring an RN assessment and MD notification.

The Director of Nursing or designee will audit for changes in condition daily x 14 days for the need for an RN assessment and MD notification. Progress notes will be reviewed in morning meeting for any changes in condition requiring an RN assessment.

These audits will be reviewed at the Quality Assurance Performance Improvement meeting for further recommendations as needed.

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 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 with dementia for two of 14 residents reviewed (Residents 8, 12) and failed to develop a comprehensive care plan that included specific and individualized interventions to address the activity preferences of residents residing within the Memory Impaired Unit for 1 of 14 residents reviewed (Resident 9).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 11, 2026, indicated that the resident was cognitively impaired, required moderate assistance with daily care needs, and had diagnoses that included Dementia (a type of brain disorder that causes memory loss, impaired thinking and behaviors).

There was no documented evidence that a care plan was developed to address Resident 8's individual care and treatment needs related to her dementia.

A quarterly MDS assessment for Resident 12, dated March 18, 2026, indicated that the resident was severely confused, was independent with ambulation, and had diagnoses that included Korsakoff's dementia (a type of brain disorder that causes memory loss, impaired thinking and behaviors).

Observations of Resident 12 on April 21, 2026 at 10:22 a.m. revealed that he was walking with Resident 11 with her holding his arm as they walked. Staff redirected them from the exit door and had them sit together at the dining table.

Nursing note for Resident 12, dated December 14, 2025 at 5:29 a.m. revealed that Resident 12 was observed talking with Resident 11, holding her hand and kissing her.

Nursing note for Resident 12, dated December 14, 2025 at 1:24 p.m. indicated that Resident 12 was wandering the unit with Resident 11 and they were trying to leave the unit.

Nurse's note for Resident 12, dated December 29, 2025 indicated that Resident 12 was walking with and holding hands with Resident 11.

Nurse's note for Resident 12, dated March 12, 2026 at 7:10 p.m. revealed that he was found in Resident 11's bed next to her with his pants unbuttoned and he was exposed to her. When the facility notified his daughter/POA she was angry because she was previously told that they would be separated.

There was no documented evidence that a care plan was developed to address Resident 12's individual care and treatment needs related to his dementia or behaviors.

A quarterly MDS assessment for Resident 9, dated March 30, 2026, revealed that the resident was cognitively impaired, required staff assistance for daily care needs, and had diagnoses that included dementia.

There was no documented evidence that a care plan was developed to address Resident 9's individual activity preferences, likes, or dislikes.

An interview with the Activity Director and Social Services Director on April 22, 2026 at 4:33 p.m. revealed that they were not educated regarding care planning for resident's dementia needs and that is why Resident's 8 and 12 did not have dementia specific care plans or activity care plans.

28 Pa. Code 211.11(d) Resident care plans.

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

Plan of Correction - To be completed: 05/08/2026

Comprehensive care plans were developed to include individual interventions for residents with dementia for Resident R8 and R12. A comprehensive care plan was developed to include activity preferences for Resident R9.
Education was given to the Social Services Director by Staff Development for development of individual interventions for residents with dementia.
An audit will be completed on comprehensive care plans for residents with dementia weekly x 8 weeks.
These audits will be reviewed at the Quality Assurance Performance Improvement meeting for further recommendations as needed.

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

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

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

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

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

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

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

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

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

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

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

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

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the resident/resident's responsible party with complete information regarding medications upon discharge for one of 14 residents reviewed (Resident 6) who were discharged to home.

Findings include:

An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 6, dated November 21, 2025, revealed that the resident was cognitively intact, was incontinent of bowel and bladder, was at risk for developing pressure ulcers, and had no current pressure ulcers.

An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 30, 2026, revealed that the resident was moderately cognitively impaired, able to make her needs known, and had a urinary tract infection.

Physician's orders, dated March 12 and 24, and April 6, 2026, included orders for the resident to receive 650 milligrams (mg) of acetaminophen every six hours as needed, 100 mg of allopurinol (used to treat gout) twice a day, 5 mg of Eliquis (blood thinner) twice day, 10 mg of famotidine (used to treat acid reflux and heartburn) daily, 800 micrograms (mcg) of folic acid (supplement) daily, 24 units of Lantus(insulin glargine) daily, 500 mg of levetiracetam (anti-convulsant medication) twice a day, 25 mcg of levothyroxine (used to treat thyroid disease) daily, a multivitamin daily, 20 mg of nadolol (used to treat heart disease) daily, a sliding scale (amount of insulin based on blood sugar results) of Novolog (insulin) before meals and at bedtime, 50 mg of pregabalin (anti-convulsant medication) daily, 17 grams of polyethylene glycol as needed for constipation, 100 mg of thiamine (vitamin B supplement) daily, 50 mg of tramadol (pain medication) every six as needed, and 550 mg of Xifaxan (antibiotic) twice a day.

A nursing note dated April 15, 2026, at 11:12 a.m. revealed the resident's family member was in to take Resident 6 home. The resident was educated on all discharge orders and medications and all belongings and medications including narcotics were sent home with the resident.

The discharge instructions for Resident 6, dated April 15, 2026, revealed that the resident was being discharged home and the current list of medications and instructions provided to the resident at the time of discharge only included Novolog, Lantus, acetaminophen, and polyethylene glycol. There was no documented evidence that the resident or her family was provided a complete list of current medications and instructions.

Interview with the Director of Nursing on April 22, 2026, at 6:07 p.m. confirmed that there was no documented evidence that Resident 6 or her family was provided a complete list of her current medications and instructions.

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

Plan of Correction - To be completed: 05/08/2026

The facility cannot retroactively correct for Resident R 6 as she was discharged.

Licensed staff were educated by Staff Development on the proper discharge process.

Moving forward, the assigned nurse will complete a medication reconciliation before discharge to ensure all medications are present.

The Director of Nursing or designee will audit discharges 2x per week times 30 days to ensure all medications are present upon discharge.

These audits will be reviewed at the Quality Assurance Performance Improvement meeting for further recommendations as needed.

51.3 (g)(1-14) LICENSURE NOTIFICATION:

51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on review of clinical records and information provided by the facility, as well as staff interviews, it was determined that the facility failed to report to the Department of Health incidents that had the potential to compromise resident safety for three of 14 residents reviewed (Residents 11, 12, 14 ).

Findings include:

Nurse's note for Resident 12, dated March 12, 2026 at 7:10 p.m. revealed that he was found in Resident 11's bed next to her with his pants unbuttoned and he was exposed to her. When the facility notified his daughter/POA she was angry because she was previously told that they would be separated.

Review of information submitted by the facility revealed that the incident between Resident 11 and 12 was not reported to the Department of Health.

An interview with the Nursing Home Administrator on April 22, 2026 at 4:24 p.m. confirmed that the incident between Residents 11 and 12 was not reported to the Department of Health, nor was the incident with Resident 14.

A nursing note for Resident R14, dated April 14, 2026, at 2: 00 p.m. revealed that the resident was on the floor and still attached to the mechanical lift. She was being transferred from the shower bed to her bed and the lift tipped and the resident was lowered to the floor with the nurse aide under her. The mechanical lift was laying on the floor on its side. The resident's right foot was under her roommate's bed and was bleeding.

Review of information submitted by the facility following the lift tipping on its side revealed that the incident was never reported to the Department of Health.

Interview with the Nurse Consultant on April 22, 2026 at 5:41 p.m. revealed that the incident with the lift tipping over was something that they usually wouldn't report.

28 Pa. Code 201.14(c)(e) Responsibility of the licensee.

Plan of Correction - To be completed: 05/08/2026

The incident between Resident R11 and R12 was reported to the Department of Health.

The event involving Resident R14 was reported to the Department of Health.

The Regional Nurse will educate the Administrator and Director of Nursing on Chapter 51 requirements.

The Regional Nurse will audit for events meeting the Chapter 51 requirements for reporting weekly times 4 weeks.

The results of these audits will be taken to the Quality Assurance Performance meeting for further recommendations as needed.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:

(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on a review of closed records and staff interviews, it was determined that the facility failed to document the disposition of medications and/or the quantity of drugs disposed for one of one closed clinical records reviewed (Resident 6).

Findings include:

Physician's orders for Resident 6, dated March 12 and 24, and April 6, 2026, included orders for the resident to receive 650 milligrams (mg) of acetaminophen every six hours as needed, 100 mg of allopurinol (used to treat gout) twice a day, 5 mg of Eliquis (blood thinner) twice day, 10 mg of famotidine (used to treat acid reflux and heartburn) daily, 800 micrograms (mcg) of folic acid (supplement) daily, 24 units of Lantus(insulin glargine) daily, 500 mg of levetiracetam (anti-convulsant medication) twice a day, 25 mcg of levothyroxine (used to treat thyroid disease) daily, a multivitamin daily, 20 mg of nadolol (used to treat heart disease) daily, a sliding scale (amount of insulin based on blood sugar results) of Novolog (insulin) before meals and at bedtime, 50 mg of pregabalin (anti-convulsant medication) daily, 17 grams of polyethylene glycol as needed for constipation, 100 mg of thiamine (vitamin B supplement) daily, 50 mg of tramadol (pain medication) every six as needed, and 550 mg of Xifaxan (antibiotic) twice a day.

A nursing note dated April 15, 2026, at 11:12 a.m. revealed the resident's family member was in to take Resident 6 home. The resident was educated on all discharge orders and medications and all belongings and medications including narcotics were sent home with the resident.

There was no documented evidence in Resident 6's clinical record to indicate the disposition of the resident's medications and/or the quantity that was provided upon discharge from the facility.

Interview with the Director of Nursing on April 22, 2026, at 6:07 p.m. confirmed that there was no documented evidence to indicate the disposition of Resident 6's medications and/or the quantity that was provided upon discharge from the facility.

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