Pennsylvania Department of Health
SUSQUEHANNA HEALTH AND WELLNESS CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SUSQUEHANNA HEALTH AND WELLNESS CENTER
Inspection Results For:

There are 264 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


SUSQUEHANNA HEALTH AND WELLNESS CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to a complaint, completed June 17, 2026, it was determined that Susquehanna Health and Wellness Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.\~

Plan of Correction:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

�483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

�483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

�483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

�483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

�483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based upon clinical record review, staff interviews, and observations, it was determined that the facility failed to ensure residents are provided with dignity while receiving care for one of 33 residents reviewed (Resident 156).

Findings include:

Review of Resident 156's diagnosis list revealed diagnoses including Parkinson's Disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), seizures and anxiety disorder).

Review of Resident 156's clinical record revealed Resident 156 is receiving hospice services.
Observation on June 15, 2026, at 9:52 a.m. revealed Resident 156 sitting in a Broda chair in the hallway near the "B" Wing nurses' station.

Further observation on June 15, 2026, in the hallway near the nurses' station revealed that a hospice nurse was standing near Resident 156 and conducting a comprehensive physical examination of Resident 156 including taking blood pressure readings, pulse oximeter readings and questioning Resident 156 regarding resident's overall health and pain levels.

Observation on June 15, 2026, at 10:00 a.m. revealed Resident 156's hospice nurse received a face-time phone call from the hospice agency nurse practitioner at the "B" Wing nurses' station. This call was also placed on speaker phone.

Further observation of the phone call revealed the hospice nurse and the hospice nurse practitioner speaking via facetime and speaker phone about Resident 156's overall health and his continuing need for hospice services. This face-time phone conversation consisted of discussions including continence, pain, seizures, medication doses, diet and fluid intake.
Further observation of the phone call also revealed the hospice nurse practitioner requesting an "arm circumference measurement" which the hospice nurse obtained while in the hallway at the nurses' station.

Further observation of this phone call revealed the hospice nurse practitioner asking the hospice nurse questions regarding Resident 156's diet and nutrition intake. The hospice nurse then called out to a nurse aid who was walking by and asked about the quantity of food consumed by Resident 156 daily.

The face-time phone call ended at approximately 10:19 a.m.

Interview with the Nursing Home Administrator on June 15, 2026, at 10:30 a.m. revealed that the above conversations and subsequent phone call should not have occurred in the hallway at the nurses' station as it does not provide dignity in the care setting for Resident 156.

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

Plan of Correction - To be completed: 08/11/2026

1. Hospice RN was educated immediately by administrator. Hospice agency held a QAPI to discuss the findings and process of tele health visits/assessments. Resident 156 interviewed and showed no signs of distress as did not recall event.

2. Any resident receiving tele health visits by hospice will be reviewed to ensure the visits are not being held in a public area.

3. Education will be completed by the DON/designee with hospice agencies to ensure tele health visits are completed in a nonpublic area.

4. The DON/designee will audit 5 hospice residents with tele health visits to verify these visits are not taking place in a public area for 4 weeks than monthly times 2. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.

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 upon clinical record review and facility documentation, it was determined that the facility failed to ensure notification to the State ombudsman's office occurred for hospital transfers for two of thirty-three residents reviewed. (Resident 18 and Resident 25).
Findings include:

Findings Include:

Review of Resident 18's clinical record revealed Resident 18 was transferred to an acute care facility on February 7, 2026, and readmitted to the nursing facility on February 18, 2026.
Further review of Resident 18's clinical record revealed Resident 18 was also transferred to an acute care facility on March 23, 2026, and returned to the nursing facility on March 31, 2026.
Review of facility documentation failed to reveal evidence that the facility notified the State Ombudsman's office of Resident 18's two transfers and admissions to an acute care facility.

Interview with the Nursing Home Administrator on June 17, 2026, at approximately 10:00 a.m. confirmed that the State Ombudsman's office was not properly notified of the transfers.

Review of Resident 25's clinical record revealed Resident 25 was transferred to an acute care facility on April 26, 2026, and subsequently admitted with a diagnosis of pneumonia.

Further review of Resident 25's clinical record reveals that Resident 25 returned to the facility on April 28, 2026.

Review of facility documentation failed to reveal evidence that the facility notified the State Ombudsman's office of Resident 25's admission to an acute care facility.

Interview with the Nursing Home Administrator on June 17, 2026, at approximately 10:00 a.m. confirmed that the State Ombudsman's office was not properly notified of the transfers.

28 Pa. Code 211.5(b) Medical Records

Plan of Correction - To be completed: 08/11/2026

1. The ombudsman's office was notified of R 18 and R 25.

2. Any resident that was transferred in the last 30 days to the acute care setting will be reviewed to ensure appropriate notification to the State Ombudsman's office.

3. Education will be completed by the DON/designee with social services related to notification to the State Ombudsman's office.

4. The DON/designee will audit 5 transfers to the acute care hospital for 4 weeks than monthly times 2 to verify the State Ombudsman's office was notified. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:

�483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

�483.20(b) Comprehensive Assessments
�483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

�483.20(b)(2) When required. Subject to the timeframes prescribed in �413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in �413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.

Observations:

Based on clinical record review and staff interview it was determined the facility failed to accurately assess residents for two of two residents reviewed. (Residents 24 and 149)

Findings Include:

Review of Resident 24's clinical record reviewed Resident 24 was admitted to the facility on January 23, 2026 with diagnosis of chronic respiratory failure.

Further review of Resident 24's clinical record revealed resident was discharged to an acute care facility on January 28, 2026.

Further review of Resident 24's clinical record failed to reveal evidence that a discharge MDS (periodic assessment of resident needs) was completed upon discharged.

Review of Resident 149's clinical record revealed resident was admitted January 9, 2026, and discharged January 30, 2026.

Further review of Resident 149's clinical revealed that a Discharge MDS (Minimum Data Set - periodic assessment of resident needs) was not completed.

Interview with Licensed Employee E5 on June 17, 2026 at 2:15 p.m. confirmed that no discharge MDS was completed for Resident 24 and Resident149 after discharge from the facility.

The above information was conveyed to the Nursing Home Administrator on June 17, 2026 at 12:00 p.m.

28 Pa Code 211.5(f) Clinical Records

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

Plan of Correction - To be completed: 08/11/2026

1. R 24 and R 149's assessments are completed.

2. Any resident that was discharged from the facility in the last 30 days will be reviewed to ensure the discharge MDS assessments were completed upon discharge.

3. Education will be completed by the DON/designee with the MDS coordinator on discharge assessment completion.

4. The DON/designee will audit 5 discharged residents for 4 weeks then monthly times 2 to verify discharge MDS assessments were completed. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.

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 resident interview, review of clinical records, and interviews with staff, it was determined that the facility failed to provide timely care and services for two of 33 residents reviewed (Residents 2 and 11).

Findings include:

Review of Resident 2's clinical record finds an SBAR (Situation, Background, Assessment, Recommendation) Summary on June 12, 2026, at 11:24 p.m. that states, "2246 Notified by staff that resident was having a seizure, resident had tonic-clonic movements, with muscle spasms, lasting 20 minutes in bed... PRN (as needed) seizure med was not available from pharmacy... Notified on call provider, ordered for resident to be sent to ER, 911 was called."

Further review of Resident 2's electronic medication administration on June 12, 2026, record reveals that there was not an administration of Nayzilam Nasal Solution (Anticonvulsant) which was ordered as needed for breakthrough seizures.

Further review of Resident 2's progress notes on June 12, 2026, at 11:24 p.m. finds that, "EMT came at 2315 gave resident 2 rounds of IV versed resident was still seizing."

Interview with the Director of Nursing (DON) on June 17, 2026, at approximately 9:50 a.m. reveals that the nurse assigned to Resident 2 on June 12, 2026, was on break at the time Resident 2 began seizing. The nurse covering during the break did not have the keys to access the medication cart that contained Resident 2's PRN seizure medication and was unable to locate the original nurse to obtain them. The covering nurse then contacted the DON via phone for instructions on how to access additional cart keys from the DON's office. While the DON was on the phone, EMS arrived and began treating Resident 2.

Further interview with the DON on June 17, 2026, at approximately 10:30 a.m., finds that no investigation was completed nor statements from staff obtained.

Interview with Resident 11 on June 15, 2026, at 1:13 p.m. revealed that resident was having pain in both knees.

Review of Resident 11's physician's assistant note of May 19, 2026, revealed that given the resident's "persistent pain recommending still to get CT [computed tomography also called a CAT scan, is a medical imaging technique that combines multiple X-ray images taken from different angles to produce detailed 3D images of bones, organs, blood vessels, and soft tissues] scans however referring to orthopedics".

Review of progress note of May 26, 2026, revealed resident was seen by the physician's assistant on May 19, 2026, with new recommendations approved by the CRNP (certified registered nurse practitioner). New order for CT scan bilateral knees and ortho (orthopedics) referral. Review of physician's order dated May 26, 2026, indicated refer to orthopedics related to bilateral knee pain and CT scan for left and right knee without contrast. Order was faxed to CT facility.

Review of progress note of May 29, 2026, revealed resident went to appointment for CT scan of bilateral knees, but facility received a call that a written order was needed.

Review of physician's assistant note of June 2, 2026, revealed that resident was seen for bilateral knee pain and resident indicated the pain was still present. Resident stated he/she went to get the CT scans on his/her knees, however, did not have scans. Note indicated that "CT scan appointment was made for 5/27 however he/she did not get it done because there was no order. Will await CT scan to be completed. There is also an order to have her/him follow up with orthopedics and will see patient after that". Recommendations indicated to reschedule/reorder CT scan of bilateral knees, refer to orthopedic appointment. Review of order dated June 1, 2026, indicated CT without contrast to bilateral knees.

Interview with the Director of Nursing (DON) on June 17, 2026, at 11:44 a.m. confirmed that the resident went for the CT scan on May 26, 2026, but it was not completed due to the order not having a diagnosis code, so the CT scan was reordered. The DON confirmed that the the appointment for orthopedics was scheduled today (22 days after the initial order) and that the CT scan was rescheduled today (15 days after the reorder).

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 08/11/2026

1. R 2 was sent out to the hospital and returned. The medication cart keys are kept in a lock box in the medication room with access only by the supervisors. R 11 CT scan is scheduled for July 10, 2026. R 11 orthopedic appointment is scheduled07/01/2026.

2. Residents with appointments in the last 30 days will be reviewed to verify timely scheduling of the appointments. Any event related to medication cart keys not being available will be investigated with statements.

3. Education will be completed by the DON/designee with the scheduler/supervisors on timely scheduling of appointments. Education will be completed with the supervisors on how to access the spare medication cart keys.

4. The DON/designee will audit 5 appointments for 4 weeks then monthly times 2 to verify appointments are scheduled timely. The DON/designee will audit any event related to medication carts keys not being available to ensure investigation occurred for 4 weeks and then monthly times 2. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.

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 staff interviews, clinical record review, and facility documentation review it was determined the facility failed to ensure that one of five residents reviewed was free from accidents and provided adequate supervision for Resident 12.

Findings Include:

Review of Resident 12's diagnosis sheet revealed diagnoses type 2 diabetes (insufficient production of insulin, causing high blood sugar), and Alzheimer's Dementia (a progressive disease that destroys memory and other important mental functions).

Review of Resident 12's June 2026 Medication Administration Record revealed an order for Metformin HCl Tablet 500 MG Give 1 tablet by mouth two times a day.

Review of facility documentation revealed that on June 12, 2026, Resident 12 was administered crushed Metformin HCL tablet 500mg in coffee by Licensed Nursing Employee E6. Licensed Nursing Employee E6 then failed to observe Resident 12 until they had finished the coffee with the medications crushed inside.Resident 12 drank some of the coffee with the medication and set the coffee cup on the table. Nursing Employee E6 then failed to observe Resident 12 until they had finished the coffee with the medications crushed inside.Resident 170 went over to the table, took the cup and drank Resident 12 ' s coffee.of Resident 170 progress notes revealed a nursing entry dated June 12, 2026, at 7:18 p.m. stating Resident 170 "got up and went to this resident's table and took the coffee and when staff attempted to intervene and retrieve the cup from her, she gulped down the entire contents. Writer observed pill fragments in the bottom of the cup after she sat it down. MD (medical doctor) notified, new orders for obtain vitals for alert charting q (every) shift x3days, obtain blood sugar q shift x3 days. RP (responsible party) updated, DON (Director of Nursing) notified.review of Resident 12 ' s facility documentation revealed that there was no supervision for Resident 12 while taking medication to ensure all medication had been administered.

Review of Resident 12 ' s active care plan failed to reveal a care plan or interventions for putting crush medication in coffee.

Interview with the Director of Nursing on June 17, 2026, at 1:20 p.m. confirmed the above findings.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management\~

Plan of Correction - To be completed: 08/11/2026

1. E 6 was reeducated on medication passes specifically pertaining to follow care plans and observation of taking medications. R12's care plan was reviewed. R12's care plan was not updated as unit manager was unable to determine if continuation of placing medications in coffee was the residents' preference.

2. No other residents receive their medications in their coffee.

3. Education will be completed by the DON/designee for RN/LPNs on care planning of alternative preferences when administering medications and staying with a resident until they have finished taking their medications.

4. The DON/designee will. Observe 5 nurses weekly for medication administration weekly for 4 weeks and monthly for 2 months.

5. The DON/designee will audit 10 medication passes for 4 weeks then monthly times 2. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.

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

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

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

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

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

Observations:

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for one of eight residents reviewed for nutrition (Resident 45).

Findings Include:

Review of facility policy "Weight Assessment and intervention" revised September 2008 revealed that " ...Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met ... Interventions for undesirable weight loss shall be based on careful consideration."

Review of Resident 45's clinical record revealed recorded weights of 151.4 pounds January 7, 2026; 140.2 pounds February 2, 2026, with a reweight on February 18, 2026, of 162 pounds; 140.4 pounds March 4, 2026.

Further review of Resident 45's clinical record revealed a dietary note dated March 4, 2026, indicating the resident's weight. Further review of the same dietary note failed to reveal recommendations to address the weight loss from January 7, 2026, to February 2, 2026 (loss of 11.2pounds or 7.40% in one month).

Interview with Employee E4 on June 17, 2026, at 11:39 a.m. confirmed that further dietary interventions should have been implemented to address Resident 45's weight loss.

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.10(c) Resident Care Policies

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

Plan of Correction - To be completed: 08/11/2026

1. R 45's weight is stable no new interventions at this time.

2. Any resident with a weight loss greater than 5% in the last 30 days will be reviewed to ensure interventions are in place as appropriate.

3. Education will be completed by the DON/designee for the dietician related to appropriate weight loss interventions.

4. The DON/designee will audit any resident with weight losses equal to or greater than 5% to ensure appropriate interventions are in place as appropriate for 4 weeks then monthly times 2. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

�483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

�483.45(h) Storage of Drugs and Biologicals

�483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

�483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based upon medication insert review, observation, and staff interview it was determined that the facility failed to ensure medications were labeled with open and expiration dates for three of six medication carts observed (A South Medication Cart, A South Back Medication Cart and B South Back Medication Cart).

Findings include:

Review of medication packaging inserts for Novolog (short acting) Insulin and Lantus (long acting) Insulin revealed that Novolog Insulin Pens and Lantus Insulin Pens are to be refrigerated until opened. If unrefrigerated, the pens must be marked with the date of removal from the refrigerator and used within 28 days.

Observation of the A South Medication Cart on June 17, 2026, at 11:00 a.m. revealed three unopened and undated Novolog Insulin Pens and two unopened and undated Lantus Insulin Pens.

Observation of the A South Back Medication Cart on June 17, 2026, at 11:08 a.m. revealed one opened and undated Novolog Insulin Pen.

Observation of the B South Back Medication Cart on June 17, 2026, at 11:14 a.m. revealed one unopened and undated Novolog Insulin Pen; one opened and undated Novolog Insulin Pen and one opened and undated Lantus Insulin Pen.

Interview with the Nursing Home Administrator and Director of Nursing on June 17, 2026, at 12:00 p.m. confirmed that the above insulin pens should have been marked with open or unrefrigerated dates.

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

Plan of Correction - To be completed: 08/11/2026

1. The 4 undated/unopened insulin pens were discarded. The 5 undated/opened insulin pens were discarded.

2. Facility medication carts were audited to ensure that insulin pens are dated when removed from the refrigerator and/or opened.

3. Education will be completed by the DON/designee for licensed nurses on the policy for dating medications with shortened expiration dates when open and when removing from the refrigerator.

4. The DON/designee will audit 6 medication carts to ensure insulin pens are dated and stored correctly if unopened. weekly for 4 weeks then monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:

�483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

�483.55(b) Nursing Facilities.
The facility-

�483.55(b)(1) Must provide or obtain from an outside resource, in accordance with �483.70(f) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

�483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

�483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

�483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

�483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Observations:

Based on review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was assessed by a dentist for one of one resident. (Resident 164)

Findings include:

Review of Resident R164's clinical record revealed the resident was admitted to the facility on March 29, 2025, with a diagnosis of type 2 diabetes (insufficient production of insulin, causing high blood sugar), and congestive heart failure (excessive body/lung fluid caused by a weakened heart muscle).

Interview on June 16, 2026, at 9:33 a.m. with Resident R164 revealed the resident does not have dentures and had requested dentures several times.

Review of Resident R164's clinical record revealed no evidence that the facility arranged for or followed up on dental services to obtain dentures following the request.

Interview on June 17, 2026, at 10:22 a.m. with Director of Social Services confirmed there was no documentation about further dental consults for Resident R164.

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

Plan of Correction - To be completed: 08/11/2026

1. R 164 was added to be seen by dental services.

2. Current residents were reviewed to verify dental services were provided.

3. Education will be completed by the DON/designee for social services on verifying the residents within the facility are scheduled for dental services.

4. The DON/designee will audit 5 long term care residents to ensure dental services were referred weekly for 4 weeks then monthly times 2. The results of the audits will be reviewed by the Quality Assessment and Assurance Committees for the need to complete further audits.

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

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

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

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

Observations:

Based on interviews with residents, review of facility policy, observations, and interviews with staff, it was determined that the facility failed to serve food that was at an appetizing temperature on one of four units (B wing - Countryside).

Findings include:

An interview held with alert and oriented residents on June 15, 2026, at 10:00 a.m. revealed that food is cold for all meals.

Review of facility policy, "Food Presentation", undated, indicated foods will be served at proper temperatures. "Hot foods hot and cold foods cold".

A test tray conducted on June 16, 2026, on B-wing Countryside, in the presence of Employee E3, revealed that the meal cart left the kitchen at 12:03 p.m. Food temperatures taken at 12:37 p.m. after all residents had been served revealed the following:

Rice Pilaf - 119.8 degrees Fahrenheit
Crab Cake - 123.7 degrees Fahrenheit
Mixed Vegetables 109.0 degrees Fahrenheit

Interview at that time with Employee E3 indicated that food "could be a little hotter".

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 08/11/2026

1. On June 16, 2026, upon discovery that food temperatures on B-wing (Countryside) fell below palatable and regulatory standards, Employee E3 immediately halted meal services of substandard temperatures provided alternate hot food options to the affected residents on B-wing to ensure an appetizing meal was received.

2. Random food temperatures were taken from the serving carts to verify residents are receiving appropriate temperature meals.

3. The Dietary Manager/designee will conduct mandatory re-educations for dietary staff for strict adherence to the food presentation policy, emphasizing food serving temperature.

4. The Food Service Director or designee will conduct random meal service audits and test trays to ensure hot food items remain above appropriate food temperatures as indicated by facility policy. Auditing will occur 5 times per week across variable meals (breakfast, lunch, and dinner) then weekly for 3 consecutive months. The results of these food temperature audits will be compiled by the Food Service Director and reported directly to the Quality Assurance Performance Improvement (QAPI) Committee monthly. The QAPI committee will review the data to determine if further systemic action or a reduction in auditing frequency is warranted based on sustained compliance.

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