Pennsylvania Department of Health
COMMUNITIES AT INDIAN HAVEN, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

COMMUNITIES AT INDIAN HAVEN, THE
Inspection Results For:

There are 81 surveys for this facility. Please select a date to view the survey results.

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COMMUNITIES AT INDIAN HAVEN, THE - 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 a complaint survey completed on January 30, 2026, it was determined that Communities at Indian Haven 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:

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

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.

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

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

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

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

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

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

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

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

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

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

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

Observations: Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the ombudsman of the transfer to the hospital, for three of 32 residents reviewed (Residents 1, 4, 7). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 9, 2026, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs and had diagnoses that included heart failure and renal failure. A nursing note, dated September 26, 2025, at 2:45 a.m. revealed that Resident 1 had a decline in condition, had a fever of 101 degrees Fahrenheit (F), was sweating through her clothing, had crackles (lung sounds that indicate the presence of fluids or secretions in the airways) and occasional moist cough, and her oxygen saturation (percentage of oxygen in blood) dropped to into the 70's with 2 liters of oxygen on. The physician was notified and an order was received to transfer the resident to the emergency room for evaluation. She was admitted to the hospital with a diagnoses of pneumonia. There was no documented evidence that the ombudsman was notified of Resident 1's transfer to the hospital as required. A quarterly MDS assessment for Resident 4, dated December 19, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included sepsis (serious condition in which the body responds improperly to an infection). Physician's note for Resident 4 dated September 1, 2025, at 1:28 p.m. revealed that the resident was seen by the physician and had an elevated temperature and heart rate. The physician gave orders to send the resident to the hospital emergency room for evaluation. A nurse's note dated September 1, 2025, at 5:56 p.m. revealed that the resident was admitted to the hospital with a diagnosis of urinary tract infection and heart failure. A nurse's note for Resident 4 dated October 22, 2025, at 5:24 p.m. revealed that the resident's daughter was in the facility to visit the resident and requested that the resident be sent to the hospital emergency room for evaluation. The physician was agreeable and the resident was transferred to the hospital. A nurse's note dated October 23, 2025, at 5:57 a.m. revealed that the resident was admitted to the hospital with a diagnosis of sepsis. There was no documented evidence that the ombudsman was notified of Resident 4's transfers to the hospital as required. A quarterly MDS assessment for Resident 7, dated July 9, 2025, indicated that the resident was cognitively intact and required assistance from staff for her daily care needs. A nursing note, dated July 16, 2025, at 9:25 a.m., revealed that Resident 7's right hip incision had more swelling and was causing increased pain. At 7:06 p.m. a physician's order was received to send the resident to the emergency room for evaluation of her right hip abscess. The resident was admitted to the hospital and was awaiting a general surgery consult. Interview with the Nursing Home Administrator on January 30, 2026, at 11:51 a.m. confirmed that there was no documented evidence that the ombudsman was notified regarding the hospitalizations for Residents 1, 4, and 7. 28 Pa. Code 201.29(j) Resident Rights.

Plan of Correction - To be completed: 03/08/2026

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Communities at Indian Haven agrees with the allegations and citations listed on the statement of deficiencies. Communities at Indian Haven maintains that the alleged deficiencies do not, individually, and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Communities at Indian Haven's written credible allegation of compliance. By submitting this plan of correction, Communities at Indian Haven does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Communities at Indian Haven reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

The facility is unable to correct the observations for Residents 1, 4, and 7 as these are past events.

An audit of Ombudsman notification of residents transferred or discharged to the hospital in the past 30 days will be completed to ensure that notification of the transfer/discharge was completed.
The Social Service Director will receive education from the Administrator or designee regarding the requirement to complete notification to the Ombudsman of resident transfers/discharges to the hospital.

Random audits will be completed monthly for 3 months by the Administrator or designee to assure that the Ombudsman is notified monthly of resident transfers/discharges to the hospital. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

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 review of the Resident Assessment Instrument User's Manual and clinical records and staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for two of 32 residents reviewed (Residents 12, 68). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that for admission MDS assessments, the assessment completion date, and the Care Area Assessment (CAA - the process of completing an in-depth assessment of triggered, potentially problematic care areas) completion date (Item V0200B2) were to be no later than the resident's admission date plus 13 calendar days and there must be an MDS every 92 days. A comprehensive MDS assessment for Resident 12 revealed that the ARD was September 30, 2025, however, there was no prior MDS assessment in the last 366 days. A comprehensive MDS assessment for Resident 68 revealed that the ARD was November 19, 2025, however, there was no prior MDS assessment in the last 366 days. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on January 30, 2026 at 10:19 a.m. confirmed that the above referenced MDS assessments were not completed in the required time frames. 28 Pa. Code 211.5(f) Clinical records.

Plan of Correction - To be completed: 03/08/2026

The facility is unable to correct the observations for Residents 12 and 68 as they are past events.

A random audit of comprehensive Minimum Data Set (MDS) assessments completed in the past 14 days will be reviewed to assure that the Care Area Assessment process of comprehensive assessments and comprehensive assessments were completed in the required timeframe.

The Registered Nurse Assessment Coordinator (RNAC) will receive education an MDS Consultant or designee regarding completion of the Care Area Assessment process and comprehensive assessments within the required timeframe.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Administrator or designee to assure that the Care Area Assessment process and comprehensive assessments are completed within the required timeframe Audit results will be reported to the Quality Assurance Performance Improvement Committee.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:

§483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Observations: Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for 2 of 32 residents reviewed (Residents 37, 40). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 37 had an ARD of October 31, 2025, which was more than 92 days after the last assessment. A quarterly MDS assessment for Resident 40 had an ARD of October 30, 2025, which was more than 92 days after the last assessment. Interview with the Registered Nurse Assessment Coordinator Consultant (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on January 30, 2026 at 10:19 a.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames. 28 Pa. Code 211.5(f) Clinical records.

Plan of Correction - To be completed: 03/08/2026

The facility is unable to correct the observations for Residents 37 and 40 as they are past events.

A random audit of quarterly Minimum Data Set (MDS) assessments completed in the past 14 days will be reviewed to assure that the quarterly MDS assessments were completed in the required timeframe.

The Registered Nurse Assessment Coordinator (RNAC) will receive education from an MDS Consultant or designee regarding completion of the quarterly MDS assessments within the required timeframe.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Administrator or designee to assure that the quarterly MDS assessments are completed within the required timeframe. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

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

§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 a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for six of 32 residents reviewed (Residents 1, 11, 12, 13, 16, 38). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section N0415E1 Anticoagulant was to be checked if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 1, dated October 3, 2025, included an order for the resident to receive 15 milligram (mg) of Rivaroxaban (anticoagulant) at bedtime for chronic atrial fibrillation (irregular heart rhythm). Review of the Medication Administration Record (MAR) for Resident 1, dated January 2026, revealed that staff administered the 15 mg of Rivaroxaban at bedtime every morning from January 1 through 29, 2026. However, a quarterly MDS assessment for Resident 1, dated, January 9, 2026, revealed that Section NO415E1 was not checked, indicating that the resident did not receive an anticoagulant medication during the seven-day look-back assessment period. The RAI User's Manual, dated October 2025, revealed that Section N0415A1 Antipsychotic was to be checked if the resident took the medication during the seven-day look-back period and Section N0450A Antipsychotic Medication Review was to be coded (1) Yes, if the resident took an antipsychotic medication routinely since admission/entry or re-entry or the prior OBRA assessment, whichever was most recent. If the resident took an antipsychotic routinely, then Section N0450B, has a gradual dose reduction been attempted?, was to be coded (0) for no, and (1) yes, and if (1) yes was coded, then staff were to include the date that the gradual dose was attempted. A psychiatry note for Resident 11, dated November 20, 2025, indicated that the resident was doing well with the decrease in Zyprexa (antipsychotic) and to decrease the Zyprexa from 10 mg at bedtime to 5 mg at bedtime. Physician's orders, dated November 20, 2025, included an order for the resident's Zyprexa be decreased from 10 mg at bedtime to 5mg at bedtime. Review of the Medication Administration Record (MAR) for Resident 11, dated November 2025, revealed that staff administered the 5 mg of Zyprexa at bedtime starting November 20, 2025. A quarterly MDS assessment for Resident 11, dated, December 16, 2025, revealed that Section NO415A1 was checked to indicate that the resident received an antipsychotic medication during the seven day look back period and Section N0450A was coded (1) yes, to indicate that the resident received an antipsychotic medication routinely since admission/entry or re-entry or the prior OBRA assessment; however Section 0450B was coded (0) No, indicating that the resident did not receive a gradual dose reduction. Physician's orders for Resident 12, dated September 1, 2024, included an order for the resident to receive 80 mg of Ziprasidone (antipsychotic) one time a day for schizoaffective disorder (mental health condition characterized by the combination of schizophrenia symptoms, including hallucinations, delusions, and disorganized speech, and a mood disorder). Review of the MAR for Resident 12, dated December 2025, revealed that staff administered 80 mg of Ziprasidone one time a day during the month of December 2025. A quarterly MDS assessment for Resident 12, dated December 30, 2025, revealed that Section NO415A1 was checked, indicating that the resident received an antipsychotic medication during the seven-day look-back period; however, Section N0450A was coded (0) No, indicating that the resident did not receive an antipsychotic medication routinely since admission/entry or re-entry or the prior OBRA assessment. Physician's orders for Resident 13, dated September 9, 2024, included an order for the resident to receive 5 mg of Aripiprazole (antipsychotic) one time a day and 10 mg of Aripiprazole at bedtime for bipolar disorder (chronic mental health condition that causes significant fluctuations in mood, energy, activity levels, and the ability to think clearly). Review of the MAR for Resident 13, dated November 2025, revealed that staff administered 5 mg of Aripiprazole one time a day and 10 mg of Aripiprazole at bedtime November 1 through 20, 2025. A quarterly MDS assessment for Resident 13, dated, November 27, 2025, revealed that Section NO415A1 was checked, indicating that the resident received an antipsychotic medication during the seven day look back period; however Section N0450A was coded (0) No, indicating that the resident did not receive an antipsychotic medication routinely since admission/entry or re-entry or the prior OBRA assessment. Interview with the Nursing Home Administrator on January 30, 2026, at 3:23 p.m. confirmed that the MDS assessments for Residents 1, 11, 12, and 13 were coded incorrectly. The RAI User's Manual, dated October 2025, revealed that Section J0100A was to be marked yes if the resident received scheduled pain medication regimen at any time in the last 5 days of the look-back period. Physician's orders for Resident 16 dated May 21, 2026, included that the resident receive 15 mg of oxycodone (pain medication) three times a day for chronic pain. Review of the MAR for Resident 16 dated November 2025 revealed that the resident received 15 mg of oxycodone three times of day every day during the period of November 1-13, 2025. However, a quarterly MDS for Resident 16 dated November 13, 2025, revealed that Section J0100A was checked not to indicate that resident was not on a scheduled pain medication regimen. The RAI User's Manual, dated October 2025, revealed that Section O0110K1B was to be marked yes if the resident was receiving hospice services during the seven-day look-back period. Nurse's note for Resident 38 dated November 29, 2025, revealed that the resident was admitted to hospice services. However, a significant change MDS assessment dated November 29, 2025, revealed that Section O0110K1B was coded no, indicating that the resident was not receiving hospice services. Interview with the Nursing Home Administrator on January 30, 2026, at 11:51 a.m. confirmed that MDS assessments for Residents 16 and 38 were coded incorrectly. 28 Pa. Code 211.5(f) Medical records

Plan of Correction - To be completed: 03/08/2026

Modifications will be made to the Minimum Data Set Assessments for Residents 1, 11, 12, 13, 16, and 38 to reflect correct coding for these items.

A random audit of Minimum Data Set (MDS) assessments completed in the past 14 days will be reviewed to assure that the MDS assessments were coded accurately for Sections J, N, and O.

The Registered Nurse Assessment Coordinator (RNAC) will receive education from an MDS Consultant or designee regarding accurate coding of MDS Sections J, N, and O.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Administrator or designee to assure that MDS Sections J, N, and O are coded accurately. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

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

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

Plan of Correction - To be completed: 03/08/2026

The care plan for Resident 4 will be updated to reflect antidepressant use. The care plan for Resident 16 will be updated to reflect presence of back pain and use of pain medications. Resident 18's care plan will be updated to address antidepressant and anticoagulant use. Resident 47 no longer resides at the facility. Resident 75's care plan will be updated to address care needs related to bowel and bladder incontinence. Resident 84's care plan will be updated to address anticoagulant use. The observations for Residents R3 and R 85 care plans conditions related to COVID infections are resolved conditions, and therefore were not added, as they are past events.

A random audit of care plans in the past 14 days will be reviewed to assure that the care plans for residents receiving antidepressants, anticoagulation medications, bowel and bladder incontinence, and COVID infections are reflective of these treatments/conditions.

The Registered Nurse Assessment Coordinator (RNAC) will receive education from the Administrator or designee regarding assuring that care needs are care planned for residents receiving antidepressant medications, anticoagulants, individuals with bowel and bladder incontinence, back pain with use of pain medication, and COVID infections.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Director of Nursing or designee to assure that that care needs are care planned for residents receiving antidepressant medications, anticoagulants, individuals with bowel and bladder incontinence, back pain with use of pain medication, and COVID infections. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations: Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 32 residents reviewed (Residents 44, and 53). Findings include: The facility's policy regarding plans of care, dated April 15, 2025, indicated that resident assessments were ongoing and care plans were revised as information about the resident and their condition changed. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44, dated December 24, 2025, revealed that the resident was cognitively impaired, required staff assistance with daily care needs, was frequently incontinent of bowel and bladder, was at risk for developing pressure ulcers, and had no unhealed pressure ulcers. Physician's orders, dated February 12, 2025, included orders for the resident to have an alternating pressure mattress (mattress that utilizes a system of air cells to redistribute pressure across the body). A nursing note, dated August 13, 2025, revealed that the alternating pressure mattress was discontinued due to low risk and no current pressure injuries. The resident's current care plan included that an alternating pressure mattress was being used. Observations of Resident 44 on January 30, 2026, at 8:16 a.m. revealed the resident was sitting on the side of his bed eating breakfast and there was no alternating pressure mattress in place. Interview with the Director of Nursing on January 30, 2026, at 3:50 p.m. confirmed that Resident 44's care plan was not revised to reflect that the alternating pressure mattress was discontinued on August 13, 2025. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated October 28, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included obstructive neuropathy ( functional or structural blockage of the urinary tract that prevents normal urine flow). Care plan for resident 53 dated December 5, 2024, indicated that the resident was receiving anti-anxiety medication for anxiety disorder. Review of the Medication Administration Record (MAR) for Resident 53 dated January 2026 revealed that the resident did not receive any anti-anxiety medication during the month of January. Interview with the Nursing Home Administrator on January 30, 2026, at11:51 a.m. confirmed that Resident 53's care plan was not revised to reflect that she was not receiving an anti-anxiety medication and it should have been. 28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 03/08/2026

The care plan for Resident 44 will be updated to address discontinuation of the alternating pressure mattress. The care plan for Resident 53 will be updated to reflect the discontinuation of anti-anxiety medication.

A random audit of care plans in the past 14 days will be reviewed to assure that the care plans for residents with discontinued physician orders for alternating air mattresses and anti-anxiety medications are reflective of these changes.

The Registered Nurse Assessment Coordinator (RNAC) will receive education from the Administrator or designee regarding assuring that care needs are updated on the care plan for residents with discontinued physician orders for alternating air mattresses and anti-anxiety medications.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Director of Nursing or designee to assure that that care needs are care planned for residents with discontinued physician orders for alternating air mattresses and anti-anxiety medications. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations: Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of 32 residents reviewed (Resident 90). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The facility's policy regarding change in condition, dated April 15, 2025, indicated that the resident would be assessed following a change in condition. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 90, dated December 26, 2025, revealed that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note, dated December 28, 2025, revealed that the resident was experiencing auditory and visual hallucinations, was seeing and having conversations with her father in law who passed away several years ago, and knowing that these conversations are not real. There was no documented history of hallucinations in the resident's clinical chart. There was no documented evidence in the clinical record to indicate that Resident 90 was assessed by a registered nurse when she began having auditory and visual hallucinations. Interview with the Nursing Home Administrator on January 30, 2026 at 12:03 p.m. confirmed there was no documented evidence of a registered nurse assessment at the time of Resident 90's new hallucinations, and there should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/08/2026

The observation for Resident 90 cannot be corrected, as it is a past event.

A random audit of resident progress notes in the past 14 days will be reviewed to assure that residents experiencing a change in condition were assessed by a Registered Nurse.

Licensed Nursing Staff will receive education from the Director of Nursing or designee regarding the requirement for a Registered Nurse to complete an assessment of a resident after a change in condition.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Director of Nursing or designee to assure that residents are assessed by a Registered Nurse after a change in condition. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

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 facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 32 residents reviewed (Resident 75). Findings include: The facility policy for the procedure for bathing a resident in a tub or shower dated April 15, 2025, indicated that the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation after a tub or shower should include the date and time the shower/tub was performed, the name of the individual who assisted with the bath, how the resident tolerated the shower/tub bath, and if the resident refused the shower/tub, the reason why and the intervention taken. Staff should notify the supervisor if the resident refuses the shower/tub bath. A quarterly MDS assessment for Resident 75, dated December 1, 2026, revealed that the resident had moderate cognitive impairment, was dependent on staff for bathing or showering, and had diagnosis that included stroke and dementia. Care plan for Resident 75 dated August 27, 2025, indicated that that the resident had a self-care deficit because of a right sided hemiplegia (paralysis affecting one side of the body,) after a stroke, and identified her preferred bathing type as a shower. A review of the nurse aide bathing documentation for Resident 75 dated January 2026, revealed that the Resident received a sponge bath and did not receive a shower from January 6-28, 2026, a total of 23 days. An interview with Nurse Aide 1 on January 30, 2026, at 1:13 p.m. revealed that there is no reason why Resident 75 could not get a shower and to her knowledge, she was supposed to receive showers. Interview with the Nursing Home Administrator on January 30, 2026, at 11:51 p.m. revealed there was no documented evidence that Resident 75 was showered according to her care planned preference during the 23 days of January 6- 28, 2026. 28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 03/08/2026

The observation for Resident 75 cannot be corrected, as it is a past event.

A random audit of resident bathing/shower records in the past 14 days will be reviewed to assure that residents received bathing/showers as scheduled.

The Licensed Nursing Staff and Nursing Assistants will receive education from the Director of Nursing or designee regarding the requirement to bathe/shower residents as scheduled.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Director of Nursing or designee to assure that residents are bathed/showered as scheduled. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations: Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of eight residents reviewed (Resident 4). Findings include: The facility policy for administering medication dated April 15, 2025, included that medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must initial the resident's Medication Administration Record (MAR) on the appropriate area after giving each medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated December 19, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included heart failure and diabetes. Physician's orders for Resident 4, dated September 6, 2025, included an order for the resident to receive two grams of Ceftriaxone ( an antibiotic) intravenously (way of giving a medication through a needle or tube inserted into a vein) every 24 hours for a urinary tract infection. Review of the MAR for Resident 4, dated September 2025, revealed that two grams of Ceftriaxone was documented as U-SA on September 6 and September 7, 2025. Two grams of Ceftriaxone was documented as administered on September 8-12, 2025. Interview with the Director of Nursing on January 29, 2026, at 11:54 a.m. revealed that U-SA was an abbreviation meaning unknown-self-administered, and he was unsure why the medication was documented as U-SA on September 6 and September 7 or if the medication was administered on those two days. Interview with the Nursing Home Administrator on January 30, 2026, revealed there was no documented evidence that the resident received two grams of Ceftriaxone for seven days as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Plan of Correction - To be completed: 03/08/2026

The observation for Resident 4 cannot be corrected, as it is a past event. No negative resident outcome was experienced as a result of this observation.

A random audit of residents receiving intravenous (IV) antibiotics in the past 14 days will be completed to assure that residents Medication Administration Record (MAR) reflects administration of doses of IV antibiotics as ordered.

Licensed Nursing Staff will receive education from the Director of Nursing or designee regarding the requirement of documentation of administration of each dose of IV antibiotics on the resident's MAR.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Director of Nursing or designee to assure that documentation of administration of each dose of IV antibiotics is completed by Licensed Nursing Staff on the resident's MAR. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

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.

Plan of Correction - To be completed: 03/08/2026

Resident 53 and 75 physicians were notified of the identified weight losses following this observation.

A random audit of residents with identified weight losses in the past 14 days will be completed to assure that resident reweights were completed if indicated and physician notification occurred regarding weight loss.

Licensed Nursing Staff and Nursing Assistants will receive education from the Director of Nursing or designee regarding the weight policy, including obtaining reweights. The Registered Dietician and Registered Nursing staff will receive education from the Director of Nursing or designee regarding the requirement to notify the physician of identified weight loss.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Director of Nursing or designee to assure that reweights are completed when needed and physician notification is completed for identified weight losses. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

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

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations: Based on observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly stored for one of 32 residents reviewed (Resident 4). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated December 19, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, received an antidepressant medication, anticoagulant medication, and anti-convulsant medication. Resident 4 had diagnoses that included heart failure and diabetes. Observation of Resident 4 on January 28, 2026, at 9:53 a.m. revealed the resident was sitting in her wheelchair beside her bed and an unsupervised medicine cup containing 7 unlabeled clean and dry pills was sitting on her overbed table. Interview with Resident 4 at that time revealed that they were her morning medications that the nurse left for her to take. Interview with Licensed Practical Nurse 2on January 28, 2026, at 9:57 a.m. revealed that she believed that Resident 4 had taken her morning medications when she was in the room administering them, and that Resident 4's medications should not have been left unlabeled and unsupervised on her bedside table. An interview with the Nursing Home Administrator on January 28, 2026, at 4:52 p.m. confirmed that Resident 4 medications should not have been left unsupervised and unlabeled at the bedside. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Plan of Correction - To be completed: 03/08/2026

The observation for Resident 4 cannot be corrected, as it is a past event. No negative outcome was experienced by the resident as a result of this observation.

A random audit of medication passes will be completed by the Director of Nursing or designee to ensure that medications are properly stored evidenced by no unlabeled or unsupervised medications in resident rooms.

Practical Nurse 2 received reeducation regarding storage and supervision of medications following this observation. Licensed Nursing Staff will receive education from the Director of Nursing or designee regarding proper storage of medications and requirement for medications to be labeled and supervised in resident rooms.

Random audits will be completed weekly for 4 weeks and monthly for 2 months by the Director of Nursing or designee to assure that medications are stored properly evidenced by no unlabeled or unsupervised medications in resident rooms. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

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

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

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

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

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

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

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

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

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

§483.75(e) Program activities.

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

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

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

§483.75(g) Quality assessment and assurance.

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

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

Observations: Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of corrections for an annual survey ending February 5, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 30, 2026, identified repeated deficiencies related to a failure to accurately complete MDS assessments, failure to create individualized care plans, quality of care, and infection control. The facility's plan of correction for a deficiency regarding accurate MDS assessments, cited during the survey ending February 5, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's MDS assessments were completed accurately. The facility's plan of correction for a deficiency regarding development of care plans, cited during the survey ending February 5, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's care plans were developed/implemented timely. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 5, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that quality care was provided. The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending February 5, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that there was appropriate infection control. Refer to F641, F656, F684, F880. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Plan of Correction - To be completed: 03/08/2026

The facility is unable to retroactively correct these observations related to Quality Assessment and Assurance (QA&A) programs.

Re-evaluation of the Quality Assurance process resulted in a reorganization of the current Performance Improvement Plans.

The facility has developed plans of correction for the observations of this survey related to F641, F656, F 658, F684, and F880.

Plans for auditing have been established to monitor compliance for F641, F656, F684, and F880. The audit results will be reviewed by the facility's Quality Assurance Performance Improvement Committee to monitor effectiveness of the plans of correction and additional monitoring will be initiated if indicated.

The Quality Assurance Performance Improvement Committee reviews these results and develops audits to monitor compliance where necessary. Administrator will monitor for compliance.

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

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

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

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

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

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

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

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

Observations: Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during the administration of a treatment for one of 38 residents reviewed (Residents 48). Findings include: The facility policy regarding nephrostomy tubes dated April 15, 2025, indicated that the steps in completing nephrostomy tube dressing changes and irrigation include to wash and dry your hands, open a sterile (completely free from germs/microorganisms (like bacteria) ) drape and create a sterile field (a designated, microorganism-free area prepared to prevent contamination during procedures), open several packages of gauze pads, open several packages of povidone-iodine swabs, and open the disposable waste bag and place it away from the sterile field. The steps for the dressing change include to position resident on their side opposite of the tube, place a pad under the resident, wash your hands and put on clean gloves, careful remove the wet or soiled dressing, discard the dressing in the disposable waste bag, wash and dry hands, put on sterile gloves, with iodine , or a four inch by four inch gauze dipped in Normal Saline Solution ( NSS-sterile saltwater), cleanse the nephrostomy tube site in outward circles form the insertion site. Discard the swabs or gauze in the disposable waste bag, place one to two sterile drain dressings on the nephrostomy tube site and secure with tape. Remove your gloves and wash your hands. The procedure for irrigation includes to open gauze pads, iodine or alcohol swabs, and pre-filled syringe, wash your hands and put on sterile gloves before performing the procedure. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated October 28, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling catheter (or nephrostomy tube), and diagnosis that included obstructive neuropathy ( functional or structural blockage of the urinary tract that prevents normal urine flow). Physician orders for Resident 53 dated June 13, 2025, included for staff to cleanse the nephrostomy tube site with NSS and dry well, apply silicone tape (a skin-friendly, flexible adhesive) under the tubing to prevent it from touching skin, apply OPTILOCK dressing (brand of super-absorbent wound dressing), secure with silicone tape, and assure STAT lock (device to secure tubing in place) is in place every day shift every Monday, Wednesday, and Friday. Physician's orders dated January 13, 2026, include to flush the resident's nephrostomy with 10 ml of normal saline every shift. Observations of a nephrostomy tube dressing change and flush for Resident 53 on January 30, 2026, at 1:28 p.m. revealed that Licensed Practical Nurse 3 assembled all the supplies she needed for the procedure and placed them on the resident's bedside table and on the resident's bed without pacing a clean or sterile field. After removing the resident's soiled nephrostomy dressing and discarding it into a waste bag, she proceeded to open a bag of gauze that was laying on the resident's bed, pour NSS onto the nephrostomy site area and wipe the exposed nephrostomy tube site area with gauze without removing her soiled gloves, performing hand hygiene and applying sterile gloves. Licensed Practical Nurse 3 then removed the tape that was on the nephrostomy tubing and applied new tape. At that time, she removed her gloves and completed hand hygiene. She applied sterile gloves and then proceeded to open a package of sterile gauze that was lying on the resident bed, touching the packaging which contaminated her sterile gloves, and wiped the nephrostomy tube insertion site area, she then opened the Optilock dressing that was laying on the resident's bed and applied it to the nephrostomy site and applied tape to secure it. She then proceeded to flush the resident's nephrostomy tube with the same sterile gloves she applied the nephrostomy dressing with. She did not remove her gloves, perform hand hygiene and apply clean sterile gloves after completing the dressing change and before flushing the nephrostomy tube. Interview with Licensed Practical Nurse 3 on January 30, 2026, at 1:57 p.m. confirmed that she did not maintain a sterile field while providing a nephrostomy tube dressing change and while flushing the nephrostomy, stating she was not sure if it was supposed to be a sterile procedure, but she used sterile gloves because she likes to use sterile gloves when she applies clean dressings to any wound or other treatments. An interview with the Nursing Home Administrator on January 30, 2026, at 3:24 p.m. confirmed that Licensed Practical Nurse 3 should have completed Resident 53's nephrostomy site dressing change and flush using sterile procedures. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 03/08/2026

The facility is unable to correct the observation for Resident 48 as it is a past event. No negative outcome was experienced by Resident 48 as a result of this observation.

No other residents were affected.

Practical Nurse 1 received reeducation regarding nephrostomy tube site dressing changes and sterile procedure following this observation. Licensed Nursing staff will receive reeducation from the Director of Nursing or designee regarding nephrostomy tube site dressing changes and sterile technique.

Random audits of nephrostomy tubing site dressing changes following sterile technique will be completed by the Director of Nursing or designee weekly for 4 weeks and monthly for 2 months to assure correct completion of nephrostomy tubing site dressing changes following sterile technique. Audit results will be reported to the Quality Assurance Performance Improvement Committee.

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