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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EAST END HEALTH & REHAB CENTER
Inspection Results For:

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

Initial comments:

Based on an Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance survey completed on September 12, 2025, it was determined that East End Health &; 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:

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

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

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

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

Observations:

Based on observations and staff interview, it was determined that the facility failed to maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen.

Findings include:

During an observation of the main designated kitchen on 9/08/25, at 9:30 a.m. the following was observed:

-Dish room walls, brown debris, paint peeling
-Ice machine, brown debris

During an interview on at om 9/8/25 at 10:30 a.m. Dietary Manager Employee E7 couldn't provide proof of documentation when the ice machine was last serviced.

During an interview on 9/8/25 at 10:45 a.m., Dietary Manager Employee E7 confirmed that the facility failed to maintain sanitary conditions which created the potential for food borne illness.

28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.6(c) Dietary services.
28 Pa. Code: 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 10/14/2025

On 9/8/2025, ice machine in the kitchen and the wall near the dishwasher was cleaned.
Ice machines deep cleaned by AIS every 6 months. Ice machines cleaned monthly and as needed by Director of Maintenance/designee.
Wall near the dishwasher will be cleaned monthly and as needed by Director Maintenance/designee
Maintenance Director/Designee will audit ice machine in the kitchen and wall near the dishwasher weekly X 4 and monthly X 2 to ensure cleanliness.

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

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

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

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

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

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

Observations:

Based on a review of facility policy and staff interview, it was determined the facility failed to ensure that the Infection Prevention and Control Program (IPCP)was overseen by an individual who adequately assesses, develops, implements, monitors, manages and has appropriate knowledge, skills and time to perform the IPCPfor eleven of twelve months.

Findings included:

Review of the facility policy "Infection Prevention and Control Program" last reviewed 4/1/25, indicated to maintain an organized, effective facility-wide programdesigned to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, andcontracted healthcareworkers; to conduct surveillance of communicable disease and infectious outbreaks; and to monitor employee health.

The infection preventionist responsibilities for infection control include but not limited to: Conducts surveillance of staff and residents for the facility-associatedinfections and/or communicable disease. Provide education, based on surveillance findings, outbreak analyses or changes in scientific knowledge/guidelines in theareas of infection prevention and control to employees, residents and families.

Review of facility policy "Antibiotic Stewardship Program" last reviewed 4/1/25, indicated the Antibiotic Stewardship will focus on improving antibiotic/antimicrobialuse by avoiding unnecessary or inappropriate antibiotics. The antimicrobial stewardship process will be overseen and managed by the Infection Preventionist (IP) whoworkscollaboratively with the medical director, pharmacist, nursing and administrative leadership.

During an interview completed on 9/9/25, at 2:00 p.m. IP Licensed Practical Nurse (LPN) Employee E5 stated that "from September of 2024, thru March of 2025, I workedthe floor on a cart, I also do the restorative program, I got caught up in April for the months of September 2024, thru March 2025. We have no mapping of infections, we don't use the maps, can't see if anything is spreading through the building. Upon asking the Infection Preventionist Licensed Practical Nurse (LPN) Employee E5 concerning the antibiotic stewardship program stated, "I don't have an answer to that you would have to ask the Director of Nursing she would know the answers to that".

During an interview on 9/9/25, at 2:30 p.m. the Director of Nursing confirmed the facility failed to ensure that the Infection Prevention and Control Program (IPCP)was overseen by an individual who adequately assesses, develops, implements, monitors, manages and has appropriate knowledge, skills and time to perform the IPCPfor eleven of twelve months.

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

Plan of Correction - To be completed: 10/14/2025

Facility will add 1 additional nurse for the role of Infection Preventionist, CDC course will be completed by 10/14/2025 (in progress now) certificate will be obtained.
Facility Infection Preventionist will oversee Infection Control Program and an alternate Infection Preventionist (certified) will cover if needed.
Audits will be completed monthly X3 to ensure Infection Preventionist is overseeing Infection control program.

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

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

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

Observations:

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement anantibiotic stewardship program for elevenof eleven months (September 2024 thru August 2025).

Findings include:

Review of facility policy "Antibiotic Stewardship Program" last reviewed 4/1/25, indicated the Antibiotic Stewardship will focus on improving antibiotic/antimicrobialuse by avoiding unnecessary or inappropriate antibiotics. The antimicrobial stewardship process will be overseen and managed by the Infection Preventionist who workscollaboratively with the medical director, pharmacist, nursing and administrative leadership.

Review of the facility's Infection Control surveillance for September 2024, thru August 2025, failed to include documentation to indicate that antibiotic monitoring was completed.

During an interview completed on 9/9/25, at 2:00 p.m. Infection Preventionist Licensed Practical Nurse (LPN) Employee E5 confirmed that antibiotic monitoring of infections was not completed for eleven of twelve months (September of 2024, thru August of 2025). Further interview revealed that upon asking Infection Preventionist LPN E5 concerning the antibiotic stewardship program stated, "I don't have an answer to that you would have to ask the Director of Nursing she would know the answers to that".

During an interview on 9/9/25, at 2:29p.m. the Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program foreleven of eleven months (September 2024, thru August 2025).

28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 10/14/2025

Facility will monitor and track use of antibiotics.
On 9/9/2025, DON educated E5, Infection Preventionist on mapping, antibiotic monitoring and antibiotic stewardship policies.
DON/Designee will complete audits to ensure appropriate monitoring and tracking of antibiotic is being completed weekly X 4 and monthly X2.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

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(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for four of eight residents (Residents R25, R81, R88 and R104).

Findings include:

Review of the facility policy " Self-Administration of Medication" last reviewed 4/1/25, indicated the facility, in conjunction with the interdisciplinary care team, should access and determine whether self-administration of medications is safe and clinically appropriate. The facility should ensure that orders for self-administration list the specific medication(s) the resident may self-administer. If a resident self-administers their medication the facility should routinely assess the residents cognitive, physical, and visual ability.

Review of the facility policy "General Dose Preparation and Medication Administration" last reviewed 4/1/25, indicated during medication administration facility staff observe the resident's consumption of the medication(s).

Review of the facility policy "Storage and Expiration Dating of Medications and Biologicals" last reviewed 4/1/25, indicated the facility should not administer/provide bedside medication or biologicals without a Physician/Prescriber order and approval by the interdisciplinary care team and facility administration. Facility should store bedside medications or biologicals in a locked compartment within the resident's room.

Review of the clinical record indicated Resident R25 was admitted to the facility on 2/8/19.

Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/9/25, indicated diagnoses of high blood pressure, diabetes (high sugar in the blood) and constipation.

Observation on 9/8/25, at 9:51 a.m. Resident R25 had a pill cup with one pink oblong pill and a white oblong pill in a medicine cup.

During an interview on 9/8/25, at 9:53 a.m. Registered Nurse, Employee E8 confirmed Resident R25 was left unattended with medications. RN, Employee E8 confirmed Resident R25 failed to have a care plan for self-administration of medications.

Review of the clinical record indicated Resident R81 was admitted to the facility on 9/26/24, and readmitted 1/16/25.

Review of Resident R81's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/14/25, indicated diagnoses of dementia (the loss of cognitive functioning -- thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), dependence on renal dialysis, and high blood pressure.

Observation on 9/8/25, at 9:44 a.m. a pill cup with four pills were left unattended at Resident R81's bedside.

During an interview on 9/8/25, at 9:47 a.m. the Assistant Director of Nursing (ADON), Employee E9 confirmed Resident R81's was left unattended with medications. The ADON confirmed Resident R81 failed to have a care plan for self-administration of medications.

Review of the clinical record indicated Resident R88 was admitted to the facility on 4/29/25.

Review of Resident R88's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/5/25, indicated diagnoses of anemia (low iron on the blood), diabetes (high sugar in the blood) and high blood pressure.

Observation on 9/8/25, at 10:32 a.m. a tube of Voltaren gel (topical pain reliever) was sitting on Resident R88's over the bed table, a tube of Aspercream (topical medication for minor aches and pains) was on her lap in bed.

During an interview completed on 9/8/25, at 10:38 a.m. Registered Nurse (RN) Employee E4 confirmed the topical medications were in Residents R88's room. RN Employee E4 removed the items from the room. Upon asking RN Employee E4 concerning the topical medications stated, "I haven't seen an order for the Aspercream, I believe there is one for the Voltaren".

Review of Resident R88's physician orders on 9/8/25, at 10:46 a.m. failed to reveal orders for the Voltaren or Aspercream.

During an interview completed on 9/10/25 at 12:14 p.m. the Director of Nursing confirmed no orders were in place for Resident R88's Voltaren gel or Aspercream and an assessment for medication self-administration was not completed.

Review of the clinical record indicated Resident R104 was admitted to the facility on 1/30/25.

Review of Resident R104's MDS dated 6/30/25, indicated diagnosis of diabetes (high sugar in the blood), hyperlipidemia (high fats in the blood) and high blood pressure.

Observation on 9/8/25, at 9:51 a.m. Resident R104's bedside stand had a bottle of Flonase nasal spray (reduces inflammation and allergic symptoms) sitting on it.

During an interview completed on 9/8/25, at 10:14 a.m. RN Employee E2 confirmed the Flonase was on Resident R104's bedside stand and stated," I gave it to him, he was finishing breakfast, so I left it in room for him to use later".

During an interview on 9/8/25, at 3:15 p.m. the Director of Nursing confirmed the facility failed to determine the ability to self-administer medications for four of eight residents (Residents R25, R81, R88 and R104).

28 Pa code: 211.12 (d) (1) (5) Nursing services.

Plan of Correction - To be completed: 10/14/2025

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

On 9/8/2025, R25 medication cup was removed from bedside.
R25 at baseline.
On 9/8/2025 DON educated E8 on self-administration of medication policy.
On 9/8/2025, R81 medication cup removed.
R81 at baseline.
On 9/8/2025, DON educated E9 on self-administration of medication policy.
On 9/08/2025, Voltaren Gel and Aspercream were removed from bedside.
R88 at baseline.
On 9/10/2025, DON educated E4 on self-administration of medication policy and Physician order policy.
On 9/8/2025, Flonase was removed from bedside.
R104 at baseline.
On 9/8/2025, DON educated E8 on self-administration of medication policy.
On 9/8/2025, ADON and RN did room to room sweep to ensure no other medications were at bedside.
DON/designee will educate all licensed staff on medication self-administration policy and physician order policy.
Don/Designee will complete 3 random room audits to ensure medication is not left at bedside, weekly X4, Monthly X2.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement COVID monitoring, isolation, tracking, and testing for one of two residents (Resident R31), failed to prevent cross contamination during a dressing change for one of three residents (Resident R86), and failed to ensure enhanced barrier precautions were implemented for one of three residents (Resident R131). The facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for eleven of twelve months (September 2024, thru August 2025).

Findings include:

Review of the facility "Enhanced Barrier Precautions (EBP) Policy" last reviewed 4/1/25, revealed enhanced barrier precautions are intended to prevent transmission of multi-drug resistant organisms (MDROs) via contaminate hands and clothing of healthcare workers to high risk residents during high contact activities. Staff engaging in high-contact activities will don both gloves and gown before initiating the activity.

Review of the facility policy "Hand Hygiene/Handwashing" last reviewed 4/1/25, indicated hand hygiene is the most important component for preventing the spread of infections. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications that include but not inclusive to after contact with blood, body fluids, or contaminated surfaces.

Review of the facility policy "Infection Prevention and Control Program" last reviewed 4/1/25, indicated to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contracted healthcare workers; to conduct surveillance of communicable disease and infectious outbreaks; and to monitor employee health. The infection preventionist responsibilities for infection control include but not limited to: Conducts surveillance of staff and residents for the facility-associated infections and/or communicable disease. Infection prevention and control provide education, based on surveillance findings, outbreak analyses or changes in scientific knowledge/guidelines in the areas of infection prevention and control to employees, residents and families.

During a review of the infection control program documentation on 9/9/25, it was revealed that no surveillance of infections was completed for eleven of twelve months (September 2024, thru August 2025). Upon asking Infection Preventionist Licensed Practical Nurse (LPN) Employee E5 concerning mapping of infections presented a blank map of the facility rooms and stated we don't use the maps"

During an interview completed on 9/9/25, at 2:00 p.m. Infection Preventionist LPN Employee E5 confirmed that no surveillance of infections was completed for eleven of twelve months (September of 2024 thru August of 2025).

Review of the clinical record indicated Resident R31 was admitted to the facility on 6/12/24, with diagnoses dementia (the loss of cognitive functioning - thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), and high blood pressure.

Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/16/25, indicated diagnoses were current.

Review of Resident R31's progress note dated 9/3/25, at 1:03 a.m. revealed the resident was short of breath, with wheezing noted. The residents oxygen saturation was 60-70%. Oxygen was applied, and breathing treatment was administered. Resident continued to have wheezing and rhonchi in bilateral lungs. The physician was notified. There was no evidence the resident was tested for COVID. The facility failed to implement droplet precautions upon identification of any COVID-19 symptoms such as cough and shortness of breath.

Review of Resident R31's progress note dated 9/3/25, at 7:14 a.m. revealed the resident was observed coughing and wheezing. The residents oxygen saturation was 60-70%. Oxygen was applied, and the resident's pulse saturation went to 97%. The RN supervisor was notified and assessed the resident. The physician was notified. A breathing treatment and cough medication was administered. There was no evidence the resident was tested for COVID. The facility failed to implement droplet precautions upon identification of any COVID-19 symptoms such as cough and shortness of breath.

Review of Resident R31's progress note dated 9/3/25, at 10:30 a.m. revealed the resident was seen in follow up to recent reported cough and congestion symptoms. Resident was started on DuoNeb three time a day and as needed Guaifenesin (cough medication) along with supplemental oxygen due to hypoxia on room air. It was documented the resident refused labs and nasal swabs. The facility failed to implement droplet precautions upon identification of any COVID-19 symptoms such as cough and shortness of breath.

Review of Resident R31's clinical record failed to include evidence the resident was tested for COVID on Day 1 (9/4/25), Day 2 (9/6/25), and Day 3 (9/8/25).

During an observation on 9/9/25, at 11:45 a.m. Resident R31 was observed receiving a breathing treatment with the door open. There were no isolation precautions implemented.

During an interview on 9/9/25, at 11:49 a.m. Licensed Practical Nurse, Employee E31 stated "I am unaware" if Resident R31 was tested for COVID. LPN, Employee E31 indicated they were in training, and this was their second day.

During an observation of Resident R31's clinical record on 9/11/25, at 10:10 a.m. failed to include an order for isolation.

During an observation on 9/11/25, at 10:11 a.m. Resident R31's was observed wheeling in their wheelchair throughout the unit. No mask was observed on the resident.

During an interview on 9/11/25, at 10:11 a.m. Registered Nurse, Employee E2 confirmed Resident R31 failed to have an order for droplet precautions. RN, Employee E2 stated if a resident developed COVID-like symptoms such as cough, fever, or fatigue the next steps would be to isolate, notify physician, and test for COVID using the standing order. If negative, then the resident would be tested every two days until Day 5. During the testing period, the resident must stay in isolation and if they come out of the room, they should wear a mask.

During an interview on 9/11/25, at 10:22 a.m. the Director of Nursing confirmed residents should be tested on Day 1, Day 3, and Day 5. The DON confirmed the facility failed to implement COVID monitoring, isolation, tracking, and testing in accordance with state and federal guidance for one of two residents (Resident R31).

Review of Resident R86's clinical record indicated admission to the facility on 8/7/23.

Review of Resident R86's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/25, indicated diagnoses of anxiety, depression and high blood pressure.

Review of Residents R86's physician orders dated 8/12/25, indicate to cleanse sacrum with wound cleanser, pack with quarter strength Dakin's-soaked packing strips and cover with dry dressing daily.

During an observation on 9/10/25, at 10:00 a.m. Licensed Practical Nurse (LPN) Employee E16 entered Resident R86's room to complete dressing change. After completing the dressing change LPN Employee E16 continued on and picked up the bottle containing the packing strip and pushed the packing that was out of the bottle back into the bottle, applied the lid, picked up the bottle of Dakins solution and repositioned it on the over bed tray table. LPN Employee E16 then removed gloves and completed hand hygiene.

During an interview completed on 9/10/25, at 2:30 p.m. LPN Employee E16 confirmed not removing gloves and completing hand hygiene prior to replacing the packing strip into the bottle, applying the lid and repositioning the bottle of Dakins solution on the over bed tray table.

Review of the clinical record indicated Resident R131 was admitted to the facility on 9/4/25, with diagnoses of left femur fracture, severe protein-calorie malnutrition, and flaccid neuropathic bladder (a condition that disrupts normal bladder function due to nerve damage. This can lead to problems with bladder control, resulting in either an overactive bladder or difficulty emptying the bladder).

Review of Resident R131's physician order dated 9/5/25, revealed an order for enhanced barrier precautions.

During an observation on 9/8/25, Licensed Practical Nurse, Employee E15 was observed flushing Resident R131's nasogastric tube without a gown.

During an interview on 9/8/25, at 10:38 a.m. Licensed Practical Nurse, Employee E15 confirmed they failed to implement enhanced barrier precautions while flushing Resident R131's nasogastric tube.

28 Pa. Code: 211.10(d) Resident Care Policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing Services.

Plan of Correction - To be completed: 10/14/2025

R31 is at baseline.
R86 is at baseline.
R131 at baseline.
Facility will maintain surveillance of infections through the mapping process.
DON educated Infection Preventionist on surveillance, mapping and monitoring of facility infections.
Current residents that display symptoms of COVID 19, i.e cough and shortness of breath, will have MD notified and tested if ordered
Identified residents will be placed in droplet precautions.
On 9/29/2025, DON educated E16 on proper handwashing with dressing changes.
On 9/8/2025, Infection Preventionist educated E15 on enhanced barrier precautions.
All licensed staff will be educated on enhanced barrier precautions
All licensed staff will be educated monitoring for symptoms of COVID 19 and on handwashing with dressing changes.
DON/designee will complete audits to ensure proper identification of COVID 19 symptoms, testing and isolation weekly X4, monthly X2.
DON/Designee will complete audits to ensure appropriate monitoring and tracking of antibiotic is being completed weekly X 4 and monthly X2.
DON/Designee will complete audits to ensure Enhance barrier precautions are being utilized on 3 rooms weekly X4, monthly x 2.
DON/designee will complete audits on 1 dressing change per day to ensure proper handwashing weekly x4 and monthly X2.

483.70(m)(1)(2)(i)(ii)(3)-(5) REQUIREMENT Entering into Binding Arbitration Agreements:

§483.70(m) Binding Arbitration Agreements
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

§483.70(m)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(m)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;

§483.70(m)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

§483.70(m)(4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(m)(5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k).

Observations:

Based on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure resident's had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for two of three residents (Resident R82, CR315).

Findings include:
Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment.

Review of the admission record indicated Resident R82 was admitted to the facility on 1/15/25.

Review of Resident R82's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/21/25, indicated the diagnoses of unspecified intellectual disabilities, diabetes mellitus and chronic kidney disease. Resident R82's MDS assessment section C0200 BIMS score was a four, indicating severe impairment.

Review of Resident R82s Binding Arbitration Agreement indicated that the resident signed the document on 1/29/25, with a severe cognitive impairment.

Review of the admission record indicated Resident CR315 was admitted to the facility on 2/16/25.

Review of Resident RCR315's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/22/25 indicated the diagnoses of diabetes mellitus, dementia (group of brain disorders that cause a decline in cognitive functions, such as memory, thinking, reasoning, and judgment) and major depressive disorder. Resident CR315's MDS assessment section C0200 BIMS score was a zero, indicating severe impairment.

Review of Resident CR315's Binding Arbitration Agreement indicated that the resident signed the document on 2/28/25, with a severe cognitive impairment.

During an interview on 9/10/25, at 11/15 a.m. the Admission Director Employee E10 confirmed the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for two of three residents (Resident R82, CR315).

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

Plan of Correction - To be completed: 10/14/2025

R82 and CR315's arbitration agreement will be voided. A Representative from the facility will contact responsible party and agreement will be explained. Responsible party will be given an opportunity to sign agreement but is in no way a condition of continued stay. Representative will be afforded an additional 30 days to rescind the agreement.
Complete in house audit completed to ensure only residents that have the capability to sign have signed the arbitration agreement.
Residents that are cognitively intact based on initial admission assessment may sign their own arbitration agreement.
NHA educated Admissions Director on need to verify with RN/designee on unit to determine resident's capacity to sign paperwork based on initial nursing admission assessment.
NHA/designee will audit arbitration agreements weekly X 4 monthly X2 to ensure residents who lack the capacity to sign their paperwork will be signed by responsible party.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on review of clinical records, facility policy and staff and interviews it was determined the facility failed to make certain consistent dialysis communication was maintained for two of two residents (Residents R14 and R81), and failed to ensure resident's receiving dialysis received care and treatment as ordered and ensured fluid restrictions were maintained for one of two residents (Resident R81)

Findings include:

Review of facility "Fluid Balance Policy" dated 4/1/25, indicated the facility will track intake and/or output with a provider order. The amount of fluid allowed in a 24-hour period will be specified in the provider order. The Nursing and Nutrition Services Team will work together to distribute the restricted fluid amount daily. An allocation for each department will be developed for each level of limitation and will be included in the order.

Review of the facility policy "Hemodialysis Care Policy" last reviewed 4/1/25, indicated licensed staff with demonstrated competence will care for residents who require hemodialysis. Communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed. Pre-dialysis process: Document assessment in the dialysis communication tool. Assessment includes but not inclusive to vital signs, medications administered before treatment, time of last meal, fluid intake and any additional alerts or information. Post dialysis process: Receive report from the dialysis provider or review the dialysis communication tool documentation by the dialysis provider. Information post- dialysis will include but not inclusive to vital signs, lab draws and/or results, medication administered after treatment, any new orders additional alerts or information.

Review of the admission record indicated Resident R14 was admitted to the facility on 7/14/25.

Review of Resident R14's MDS dated 7/16/25, indicated diagnoses of heart failure (heart doesn't pump blood the way it should), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids) and high blood pressure.

Review of Resident R14's physician orders dated 9/12/25, indicated dialysis: Monday, Wednesday, and Friday at dialysis vendor. Chair time at 12:00 p.m.

Observation completed on 9/10/25, at 1:25 p.m. Resident R14's dialysis communication forms indicated the following:
-8/6/25, incomplete form.
-9/3/35, incomplete form.
-9/8/25, incomplete form.

During an interview completed on 9/10/25, at 1:41 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the communication sheets failed to be complete as required.

Review of the clinical record indicated Resident R81 was admitted to the facility on 9/26/24, and readmitted 1/16/25.

Review of Resident R81's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/14/25, indicated diagnoses of dementia (the loss of cognitive functioning -- thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), dependence
on renal dialysis, and high blood pressure.

Review of Resident R81's care plan dated 9/29/24, revealed the resident requires dialysis and receives treatment on Tuesday, Thursday, and Saturday. Interventions included to monitor intake and output.

Review of Resident R81's physician's order dated 1/16/25, revealed the resident was ordered a 1000 milliliters (ml) daily fluid restriction. Dietary to give a total of 600 ml and nursing to give up to 400 ml in 24 hours.

Review of Resident R81's clinical record revealed the facility failed to adhere to the resident's fluid restriction on the following days:
8/11/25-1,160 ml
8/17/25-1,040 ml
8/18/25-1,070 ml
8/23/25-1,040 ml
8/26/25-1,160 ml
8/28/25-1,080 ml
8/30/25- 5,560 ml
9/8/25- 1,190 ml

Review of Resident R81's dialysis communication binder on 9/10/25, at 12:07 p.m. failed to revealed evidence Resident R81's communication sheets were completed for 9/4/25, 9/6/25, and 9/9/25.

During an interview on 9/10/25, at 12:08 p.m. Licensed Practical Nurse (LPN), Employee E1 confirmed there was no evidence Resident R81's dialysis communication sheets were completed for 9/4/25, 9/6/25, and 9/9/25.

During an interview on 9/10/25, at 12:19 p.m. the Director of Nursing confirmed the facility failed to ensure Resident R81 fluid restriction were maintained as ordered and that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents (Resident R81) and failed to make certain consistent dialysis communication was maintained for two of two residents (Residents R14 and R81).

28 Pa. Code: 201.14(a) Responsibility of licensee.
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: 10/14/2025

R14 at baseline.
R81 at baseline
ADON and RN supervisor completed audit on other dialysis residents to ensure residents had communication books and were completed.
On 9/11/2025, dialysis communication sheets added to communication book, nursing completed and call placed to dialysis unit for communication from dialysis unit to facility is completed.
On 9/11/2025, audit completed by RN on residents with fluid restriction in place, no further findings.
All licensed staff will be educated on use of dialysis communication books and documentation of fluid restrictions.
DON/Designee will complete audits weekly X4, monthly X 2 on dialysis communication books to ensure completion and on residents with a fluid restriction to ensure proper documentation.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

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.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:

Based on clinical records, an observation and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of six residents (Resident R19).

Findings include:

Review of the clinical record indicated Resident R19 was admitted to the facility on 6/9/25.

Review of Resident R19's MDS dated 6/15/25, indicated diagnoses of depression, macular degeneration (an eye disease that affects central vision. This means that people with macular degeneration cant see things directly in front of them.), and muscle wasting. Section B100. Vision was entered as 0, which indicated Resident R19 ability to see in adequate light (with glasses or other visual appliances) was adequate (sees fine detail, such as regular print in newspapers/books.)

During an interview on 9/8/25, at 9:58 a.m. Resident R19 stated he was visually impaired and cannot see much.

During an observation on 9/9/25, at 12:12 p.m. Resident R19 was sitting in front of their lunch tray and stated "I don't know what I have, no one had told me."

During an interview on 9/10/25, at 11:13 a.m. Registered Nurse Assessment Coordinator (RNAC), Employee E11 confirmed that the facility failed to ensure that MDS assessments accurately reflected the resident's status for Resident R19.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 211.5(f) Medical records.

Plan of Correction - To be completed: 10/14/2025

On 9/10/2025, R19's MDS was modified to accurately reflect visual impairment.
No other like residents noted, audit completed.
On 9/23/2025, DON educated RNAC and LPNAC X 2 on accuracy when completing assessments.
RNAC/Designee will audit complete audits weekly X 4 and monthly X 2 to note accuracy of visual impairments on MDS.

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

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

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

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

Observations:

Based on review of clinical records, staff and interviews, it was determined that the facility failed to develop and implement a baseline care plan for one out of three residents (Resident R131).

Findings include:

Review of the facility's "Interim/Baseline Care Planning Policy" last reviewed 4/1/25, revealed the facility will develop a baseline care plan within 48 hours of admission. The baseline care plan will include the minimum healthcare information necessary to care for a resident.

Review of the clinical record indicated Resident R131 was admitted to the facility on 9/4/25, with diagnoses of left femur fracture, severe protein-calorie malnutrition, and flaccid neuropathic bladder (a condition that disrupts normal bladder function due to nerve damage. This can lead to problems with bladder control, resulting in either an overactive bladder or difficulty emptying the bladder).

Review of Resident R131's progress note dated 9/5/25, revealed on 9/4/25, Resident R131 was admitted to the facility with a new nasogastric tube placement.

Review of Resident R131's clinical record revealed a "Foley Catheter Justification" assessment was completed on 9/5/25. The resident was assessed to have a foley catheter due to acute urinary retention or bladder outlet obstruction and the resident had a diagnosis of neurogenic bladder. It was indicated the catheter was maintained.

During an interview on 9/11/25, at 10:55 a.m. Registered Nurse Assessment Coordinator (RNAC), Employee E11 confirmed the facility failed to ensure Resident R131's baseline care plan included their catheter and nasogastric tube.

28 Pa. Code: 211.11 (a)(c)(d) Resident care plan.
28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Plan of Correction - To be completed: 10/14/2025

R131 Foley catheter and nasogastric tube care plans in place and care of both maintained. R131 at baseline.
No other like residents.
DON/designee to educate all licensed staff to incorporate specialized treatment in the baseline care plan upon admission.
DON/Designee will complete audits weekly X4, monthly X2 to ensure specialty care is placed on baseline care plans.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one out of two residents (Resident R19).

Findings include:

Review of the facility "Morning Care/AM Care" policy last reviewed 4/1/25, revealed morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general well-being.

Review of the clinical record indicated Resident R19 was admitted to the facility on 6/9/25, with diagnoses of depression, macular degeneration (an eye disease that affects central vision. This means that people with macular degeneration cant see things directly in front of them.), and muscle wasting.

Review of Resident R19's MDS dated 6/15/25, revealed Section GG- Functional Abilities revealed the resident required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene and personal hygiene. The resident requires setup or clean-up assistance with eating.

Review of Resident R19's care plan dated 8/15/25, indicated to provide assistance with meals as needed to encourage intake.

Review of Resident R19's care plan dated 8/26/25, revealed the resident has limited ability to dress/undress self due to weakness. Interventions included to provide assistance for dressing.

During an interview on 9/8/25, at 9:58 a.m. Resident R19 stated he was visually impaired and cannot see much. Resident R19 stated some staff can be unprofessional and they can be disrespectful.

During an observation on 9/8/25, at 1:57 p.m. Resident R19 call light was on.

During an observation on 9/8/25, at 1:59 p.m. Housekeeper, Employee E13 entered Resident R19's room. Resident R19 asked Housekeeper, Employee E13 if they were Nurse Aide (NA), Employee E14. Resident R19 stated "I am legally blind, the nurse aide said I'll be back in ten minutes, that was at 11 a.m."

During an interview on 9/8/25, at 2:00 p.m. Resident R19 indicated they put on their call light at 11 a.m. and at 11:20 a.m. NA, Employee E14 answered the call light and stated they would be back. A total of four hours ago. Resident R19 stated the facility is understaffed, and indicated I will need assistance to get on the toilet.

During an interview and observation on 9/8/25, at 2:02 p.m. NA, Employee E14 entered Resident R19's room and confirmed they were aware Resident R19 needed assistance earlier in the morning around 11 a.m. NA, Employee E14 told the resident they would return. Resident R19 asked "what happened, you told me ten minutes?" NA, Employee E14 stated "I kind of got caught up, I was on my break." NA, Employee E14 was observed to be argumentative with Resident R19.

During an interview on 9/8/25, at 2:05 p.m.. The Director of Nursing was notified the facility failed to provide Activity of Daily Living (ADL) assistance for one out of two residents (Resident R19).

During an observation on 9/9/25, at 12:12 p.m. Resident R19 was sitting in front of their lunch tray and stated "I don't know what I have, no one had told me."

During an interview on 9/9/25, at 12:13 p.m. Registered Nurse, Employee E14 confirmed the facility failed to assist Resident R19 with meal set up.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(2.1) Management.

Plan of Correction - To be completed: 10/14/2025

R19 at baseline.
On 9/29/2025, DON educated E14 on AM care and assisting with meal set up for identified visually impaired residents.
DON/designee will educate all Licensed and certified staff on offering AM care and assisting with meal set up for identified visually impaired residents.
DON/designee will complete audits to ensure AM care is offered daily on 3 residents and assisting with meal set up on 1 identified visually impaired resident weekly X4 and monthly X2.

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 facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and carefor a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart)in accordance with professional standards of practice for one of three residents (Resident R84).

Findings include:

Review of the facility policy "Administration of an Intermittent Infusion" last reviewed 4/1/25, indicated am intermittent infusion allows the patient to be disconnectedfrom the infusion/administration set between medication doses. Label medication/solution container and administration set with date, time and nurses initials.

Review of the facility policy "Midline Catheter Dressing Change" last reviewed 4/1/25, indicated a sterile dressing change using a transparent dressing is performedupon admission. If transparent dressing is dated, clean, dry and intact the admission dressing change may be omitted and scheduled for seven days from the date on thedressing label.

Review of the clinical record indicated Resident R84 was admitted to the facility on 8/29/25.

Review of Resident R84 's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/4/25, indicated diagnoses of infection and inflammatory reaction due to
internal right knee prosthesis, atrial fibrillation (irregular and rapid heart rhythm) and high blood pressure.

Review of Resident R84's physician orders dated 8/29/25, indicated Cefazolin Solution Reconstituted 2 gram (GM) Use 1 vial intravenously (IV) every eight hours.

Review of Resident R84's care plan dated 9/4/25, focus indicates IV Medications/Fluids. The resident is on IV Medications related to infection of internal right knee prothesis and bacterial arthritis. Check dressing at site daily. Monitor/document/report to physician as needed signs and symptoms of infection at the site: drainage, inflammation, swelling,redness, warmth. Change PICC dressing weekly and as needed for soiling or dislodgement

During an observation and interview on 9/8/25, at 10:47 a.m. Resident R84's right arm PICC site dressing was labeled with the date of 8/29/25, a large piece of tape wasnoted on the right side of the dressing with a date of 9/8/25. Resident R84 stated the tape was placed "to hold the dressing down". An IV medication solution container was hanging on an IV pole, next to Resident R84's bed the medication solution container failed to be labeled with a date or time.

During an interview completed on 9/8/25, 10:50 a.m. Registered Nurse (RN) Employee E3 confirmed the dressing to Resident R84's PICC site was dated 8/29/25 and wasreinforced with a piece of tape dated 9/8/25. RN Employee E3 also confirmed the IV medication solution container was not labeled with a date and time andthat the facility failed to provide adequate treatment and care for a PICC in accordance with professional standards of practice for one of three residents (Resident R84).

28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services.
28 Pa. Code: 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 10/14/2025

On 9/8/2025, R84 right arm PICC line dressing changed and IV medication thrown away. R84 at baseline.
On 9/8/2025, verified all residents IV medications were dated and PICC dressings were changed. No other issues were found.
All licensed staff will be educated on IV dressing change policy and dating of IV medication.
DON/Designee will complete audits on PICC lines and IV medications weekly X4, monthly X2 to ensure dressing changes are completed and IV medications are dated.

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.

Plan of Correction - To be completed: 10/14/2025

On 9/9/2025, Lovenox syringe, Lispro pen X 2, Lantus pen and timolol were removed from medication cart and umbrellas and sweater were removed from oxygen tank holder.
On 9/9/2025, all medication carts and medication rooms were audited by RN to ensure medications were labeled and stored properly and that medication rooms did not have personal items stored within them. No further findings were noted.
On 9/10/2025, all medications that were noted in gray tote were returned to Omnicare pharmacy via electronic scanning and returned with delivery driver.
On 9/15/2025, all gray totes were labeled for discontinued medications and will continue to be locked securely in medication room until picked up from Omnicare.
DON/designee will educate all nurses on labeling and storage of drugs and biologicals and medication return policies.
DON/designee will complete audits on one medication room and one medication cart weekly X4, monthly X2 to ensure proper labeling and storage of drugs and biologicals and to ensure no personal belongings are in the medication rooms.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:

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

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;

Observations:

Based on review of clinical records, observations, staff, and resident interviews, it was determined that the facility failed to provide residents food products based on their preferences for one out of four residents (Resident R19).

Findings include:

Review of the clinical record indicated Resident R19 was admitted to the facility on 6/9/25, with diagnoses of depression, macular degeneration (an eye disease that affects central vision. This means that people with macular degeneration cant see things directly in front of them), and muscle wasting.

Review of Resident R19's MDS dated 6/15/25, revealed the diagnoses were current.

During an observation on 9/9/25, at 12:12 p.m. Resident R19 was sitting in front of their lunch tray and stated "I don't know what I have, no one had told me." A biscuit was observed on Resident R19's plate. The resident's meal ticked said "NO BREAD/NO PASTA." Resident R19 expressed frustration that the facility continuously fails to honor their food preferences of having no bread products.

During an interview on 9/9/25, at 12:13 p.m. Registered Nurse, Employee E14 confirmed the facility served food products with bread. RN, Employee E14 confirmed the facility failed to follow Resident R19's food preferences.

During an interview of 9/9/25, at 3:15 p.m. the Director of Nursing confirmed the facility failed to provide residents food products based on their preferences for one out of four residents (Resident R19).

Pa Code: 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 10/14/2025

Resident R19 food preferences updated to list dislikes of ALL specific bread products. R19 at baseline.
On 10/1/2025, an audit was completed by dietary manager to ensure that all resident preferences are noted, reviewed and being honored.
Dietary manager/designee will educate all dietary staff on honoring bread product food preferences.
Dietary manager/designee will complete audits on 5 random trays weekly X 4, monthly X 2 to be ensure bread product food preferences are being honored.

§ 201.14(a) LICENSURE Responsibility of licensee.:

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

Observations:

Based on state regulations, staff interview, and review of the facility's Infection Control Committee Meeting attendance records, it was determined that the facility failed to ensure that all of the required nine multidisciplinary members were present at the Infection Prevention Subcommittee meetings (laboratory personnel) for one of four quarters (Quarter 2, April 2025, May 2025 and June 2025).

Findings include:

Review of the facility's Infection Control Meeting attendance records for Quarter 2 (April 2025, May 2025 and June 2025) failed to reveal that laboratory personnel were in attendance.

During an interview completed on 9/11/25, at 10:31 a.m. the Director of Nursing confirmed that the facility failed to ensure that all of the required nine multidisciplinary members were present at the Infection Prevention Subcommittee meetings (laboratory personnel) for one of four quarters (Quarter 2, April 2025, May 2025 and June 2025).

Plan of Correction - To be completed: 10/14/2025

DON educated lab provider that attendance to infection control meeting is required quarterly.
Facility will ensure that lab is present for quarterly infection control meetings.
NHA/designee will monitor for lab personnel signature quarterly.

All audits will become part of QAPI process as needed.

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