Pennsylvania Department of Health
TRANSITIONS HEALTHCARE SHOOK HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TRANSITIONS HEALTHCARE SHOOK HOME
Inspection Results For:

There are 88 surveys for this facility. Please select a date to view the survey results.

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TRANSITIONS HEALTHCARE SHOOK HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights survey which ended on March 5, 2026, it was determined that Transitions Healthcare Shook Home 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, and Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

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.

§483.21(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 clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 16 residents reviewed (Resident 11).

Findings include:

Review of Resident 11's clinical record revealed diagnoses that included dementia (a chronic disorder of mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and hypertension (high blood pressure).

Review of Resident 11's current physician orders revealed an order for losartan potassium 50 milligram tablet give one tablet by mouth one time a day hold for systolic blood pressure less than 100 or blood pressure less than 100/60, dated October 15, 2025.

Review of Resident 11's Medication Administration Records from October 15, 2025, through March 4, 2026, revealed the following:
1) There was no documentation of Resident 11's blood pressure documented with each medication administration.
2) The losartan was coded as "5=Hold See Progress Notes" on November 2 and 7, 2025, and December 14, 2025. All other doses between October 15, 2025, and March 4, 2026, were documented as being administered.

Review of Resident 11's clinical record progress notes revealed the following:
1) November 2, 2025, at 10:26 AM, losartan was held due to a pulse of 56 (which was not one of the physician's provided parameters for holding the medication);
2) November 7, 2025, at 9:35 AM, losartan was held due to a pulse of 56 (which was not one of the physician's provided parameters for holding the medication); and
3) December 14, 2025, at 8:52 AM, losartan was held due to a blood pressure of 99/54.

Review of Resident 11's blood pressure documentation in the vitals tab of the clinical record revealed that Resident 11's blood pressure was documented on six occasions that could possibly coincide with the losartan medication administration (October 16, 17, and 18, 2025; December 3, 2025; January 8, 2026; and February 9, 2026).

Review of the Resident 11's clinical record revealed no evidence of blood pressures being taken consistently, prior to administration of medication with parameters.

During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on March 5, 2026, at 2:04 PM, the DON indicated that she could not say whether nurses consistently took Resident 11's blood pressure prior to administering the losartan. She said that the nurses may have just taken the blood pressure and wrote it on their report sheet instead of documenting it in the clinical record. She confirmed that there should have been a corresponding box with the medication administration for nurses to document Resident 11's blood pressure to reflect that the physician's ordered parameters were followed.

28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.9(a)(1) Pharmacy services.
28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 04/07/2026

1. Resident R11's order was updated to include a force function in the electronic medical record to take the blood pressure prior to medication administration.
2. A baseline audit will be completed to ensure that antihypertensive orders that require vitals prior to administration have a force function to obtain the blood pressure prior to administration.
3. Education will be provided by the DON or designee to the clinical staff on how to enter orders to include the force function vital component if the order requires monitoring vitals prior to administration.
4. An audit will be conducted by the DON or designee of antihypertensive medications requiring monitoring of vitals prior to administration weekly for 4 weeks then monthly x 2. Results will be taken to QAPI for review of findings and further interventions if indicated

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

§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 facility policy review, observations, facility documentation review, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen, in two of two kitchenettes, and a resident unit refrigerator (second floor upper-level unit).

Findings include:

Review of facility policy, titled "Food Storage," dated 2021, revealed, in part, "All stock must be rotated with each new order received. Rotating stock is essential to assure freshness and highest quality of all foods. Old stock is always used first. Food should be dated as it is placed on shelves if required by state regulation. All containers or storage bags must be legible and accurately labeled and dated. All refrigerator units should be kept clean and in good working condition at all times. Every refrigerator must be equipped with a thermometer. Refrigerators/freezers on nursing units should be supplied with thermometers. All [refrigerated] foods should be covered, labeled, and dated and routinely monitored."

Review of facility policy, titled "Food Brought in From Outside Sources and Personal Food Storage," dated 2021, revealed, in part, "Foods and beverages brought in from outside sources that require refrigeration or freezing should be labeled with the patient/resident's name and date stored in the refrigerator/freezer apart from facility food. Designated facility staff should be assigned to monitor individual room storage and refrigeration units for food or beverage disposal. All refrigeration units will have internal thermometers to monitor for safe food storage temperatures."

Review of facility policy, titled "Food Temperatures," dated 2023, revealed, in part, "All cold food items must be stored at a temperature of 41 degrees Fahrenheit or below. Temperatures should be taken periodically to assure cold foods stay below 41 degrees Fahrenheit. Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered into unit storage areas to maintain temperatures at or below 41 degrees Fahrenheit for cold foods."

Observation of the kitchen with Employee 6 (Director of Food Services) on March 2, 2026, at 10:03 AM, revealed the following:
1) in the dry storage room, there were two one-gallon containers of honey Dijon mustard dressing and a one-gallon container of ranch dressing with no dates indicated;
2) in the walk-in cooler there were three metal pans of broccoli and the clear wrap noted on top failed to completely cover the broccoli;
3) the drawer containing ladles had a dark colored substance along the edge of the drawer;
4) there was substantial grease residue noted on the floor near the deep fryer and Employee 6 indicated that they have not used the fryer in a long time;
5) Employee 7 (Cook) was noted to be using a scoop to remove carrots out of a large box that was lined with a plastic bag. She was not wearing gloves. She was observed using her right hand to hold the scoop and using her left hand to hold onto the plastic bag that was rolled out over the edge of the box. When she finished scooping the carrots, she rolled the bag back down inside the box. During an immediate interview with Employee 6, she confirmed that Employee 6 should have been wearing gloves;
6) on the bread rack there was a Ziploc bag containing five hamburger buns with no date indicated and a bag of opened hot dog rolls that contained nine rolls that were not dated;
7) in a single door refrigerator containing desserts for the lunch meal there was noted to food debris on the floor of the refrigerator; and
8) in the dish room there were two trays of cups stored upright, as well as stacks of plates that were stored upright.

Employee 6 acknowledged all findings observed during the tour. Employee 6 indicated that she expects the evening staff to clean the kitchen each day but indicated that she has no written protocols or cleaning logs that staff complete.

Observation of the first-floor kitchenette on March 2, 2026, at 10:35 AM, revealed in the single door reach in refrigerator there was spillage noted on the inside of the door at the bottom. There was food debris noted in the bottom of the side-by-side refrigerator/freezer. There was light food splatter in the microwave. There was spill of a dark colored substance noted in the cabinet where dry goods were stored. There were moderate crumbs noted in the crumb tray on the toaster. The plates and dome lids were noted to be stored upright and uncovered in preparation for lunch to be served.

Observation of the refrigerator on the upper-level rehabilitation unit on March 2, 2026, at 11:32 AM, revealed a bottle of Cinnabon International Delight coffee creamer, a squeeze bottle of Parkay butter, and two cans of soda with no names or dates indicated. There was no thermometer noted in the refrigerator.

Observation of the second-floor kitchenette on March 2, 2026, at 11:38 AM, revealed in the single door reach in refrigerator that was spillage noted on the inside of the door at the bottom and there was food debris in the bottom of the refrigerator. In the side-by-side freezer/refrigerator, the thermometer was noted to be broken in the refrigerator portion. The toaster was noted to have a moderate amount of crumbs in the crumb tray. The plates and dome lids were noted to be stored upright and uncovered in preparation for lunch to be served.

Review of food temperature logs from February 22-28, 2026, and March 1-3, 2026, revealed that staff do not consistently check the temperature of cold food items or beverages at point of service.

During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on March 4, 2026, at 1:29 PM, the NHA confirmed that he would expect foods to be labeled/stored properly, dishes to be stored properly, and that food temperatures would be checked according to policy. He also confirmed that he would expect staff to wear gloves when preparing food.

28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 211.6(f) Dietary services.

Plan of Correction - To be completed: 04/07/2026

1. At time of discovery, improperly stored or unlabeled food items were immediately discarded. Food storage areas (dry, refrigerated, and frozen) were cleaned and sanitized. Temperatures of food items including the cold items taken prior to serving

2. A baseline audit of all food storage areas was conducted to ensure compliance with safe storage, labeling, and dating requirements. Any items not aligned with the policy were removed and discarded at the time of discovery

3. A Cleaning schedule was developed by Dietary manager to include all areas of the main kitchen and serving kitchen areas in the dining rooms, assignments per shift were reviewed with staff.

4. The Dietary manager or designee will provide education on proper glove use, taking and recording temperatures of all food and fluids prior to service, proper labeling, dating and storage of all opened and prepared items reviewed with dietary staff, serving dishes, bowls, cups will be stored upside down to prevent contamination of surfaces, serving dishes, bowls, cups will be stored upside down to prevent contamination of surfaces, refrigerators and freezers will have thermometers inside and temperatures are obtained and recorded every day and the new cleaning schedule. Education will be provided to the dietary staff.

5. An audit will be conducted by the Dietary manager or designee weekly x2 then monthly for 2 months on proper glove use, food storage labeling and dating, temperature recording, and the cleaning schedule.

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

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

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

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

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

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

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

Observations:

Based on facility policy review, facility document review, observations, and resident and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for one of 16 residents reviewed (Resident 56).

Findings include:

Review of facility policy, titled "OPS-331 Resident Rights," dated February 6, 2025, revealed, in part, "The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life."

Review of facility provided information from their employee handbook, dated November 1, 2203, revealed, in part, "F. Dress Code Policy: Since the appearance of the staff is a reflection of the employee, the resident, and the Company, the dress code provides for a consistent professional appearance in the dress of the staff. Should an employee report to work improperly dressed or groomed, his/her supervisor may instruct the employee to return home to change. Employees will not be permitted to work when they are improperly dressed. For all employees in all departments: No sweatpants; blouses are to be non-revealing in cut."

In addition, the dress coded indicated for nursing department personnel was noted to be "a uniform or scrub suit" and that "the Charge Nurse, Nurse Supervisor, or Director of Nursing may determine the appropriateness of the uniform and has the right to verbally warn the employee or send the employee off duty to change the uniform."

Observation on the second-floor nursing unit on March 2, 2026, at 10:50 AM, Employee 2 (Licensed Practical Nurse) was observed to be dressed in sweatpants with Hello Kitty appliques noted on the leg and a short, blue and white striped shirt. Employee 2's abdomen was noted to be exposed. In addition, Employee 2 was not wearing a name tag.

During an immediate interview with Employee 2, she confirmed her identity, job role, and indicated that she was aware that she was to wear a nametag. She said it was possibly in her purse or on her jacket.

During a resident interview with Resident 56 in her room on March 2, 2026, at 1:10 PM, Employee 2 entered the room without knocking on the door. She was still dressed in sweatpants and the short shirt that exposed her abdomen, and she had no name tag. She did not identify herself to Resident 56. Employee 2 stated, "I have your medications."

During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 4, 2026, at 1:34 PM, the DON acknowledged that Employee 2 was not appropriately dressed and indicated that Employee 2 was a new employee and new nurse who cannot afford scrubs. The DON further indicated that she has now instructed Employee 2 to wear her school scrubs until she can afford to purchase her own scrubs. The NHA confirmed that he would expect staff to wear proper identification and to properly identify themselves prior to entering a resident's room. He further indicated that Employee 2 was provided with a name tag.

28 Pa Code 201.14(a) Responsibility of licensee.
28 Pa Code 201.18(b)(3) Management.
28 Pa Code 201.29(a) Resident rights.
28 Pa Code 211.11(d)(1)(2) Nursing services.

Plan of Correction - To be completed: 04/07/2026

Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law.

1. Employee E2 was counselled at the time the event occurred regarding wearing proper working attire and a name tag.

2. All other staff were in compliance with the dress code and name badge policy.

3. Education will be provided to facility staff by the NHA or designee on the dress code policy as well as the wearing of a name tag when on duty.

4. Any staff identified as violating dress code policy will receive a verbal warning on the dress code.

5. Education will be provided by the NHA/designee to facility staff on resident rights/dignity, which includes knocking on doors and identifying themselves when entering resident rooms.

6. An audit will be conducted by NHA or designee on staff attire and utilization of name badges weekly for 4 weeks then monthly x 2.

7. The NHA/designee will interview 5 residents a week for 4 weeks to receive their feedback on staff related to knocking on doors, identify themselves, and staff appropriately dressed.

8. Results will be taken to QAPI for review of findings and further interventions if indicated.

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 clinical record review, policy review, other resources, and staff interviews, it was determined that the facility antibiotic stewardship program allows for lapsed doses of antibiotic usage as determined by one of 19 residents reviewed (Resident 60).

Findings Include:

Review of the facility policy, titled "Antibiotic Stewardship- Order for Antibiotics," reviewed April 7, 2025, When a culture and sensitivity (C&;S) is ordered, it will be completed, and; lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on National Institute of Health Resource, dated December 11, 2025, "lapsed or missed doses particularly early in treatment are critical issues that reduce treatment efficacy, allow for the development of drug resistance, and may necessitate dose increases or adjustments."

Based on current Food and Drug Administration recommendations the treatment for Proteus mirabilis (Gram negative rod bacteria capable of causing symptomatic infections including cystitis [inflammation of the bladder] and pyelonephritis [kidney infection] and is present in cases of asymptomatic bacteriuria, particularly in the elderly), complicated urinary tract infections, the dosage should be 500 milligrams twice a day for 7 days.

Review of the clinical record for Resident 60 revealed diagnoses that included Parkinson's disease with dyskinesia (involuntary, erratic movements) and retention of urine (inability to empty the bladder completely).

Further review of the clinical record for Resident 60 revealed a diagnosis of urinary tract infection (UTI) was confirmed by a laboratory culture on November 28, 2026. The microbiology results revealed " > (greater than) 100,000 CFU/ml (colony-forming units per milliliter) Proteus mirabilis (Abnormal)."

On November 28, 2025, at 3:25 PM, the provider ordered Cipro (ciprofloxacin - a potent antibiotic used to treat serious bacterial infections, including urinary tract infections) 250 milligrams by mouth twice a day for 3 days. The antibiotic started on November 28, 2025, at 6:00 PM. Resident 60 received additional doses on November 29, 2025, at 6:00 AM and 6:00 PM; November 30, 2025, at 6:00 AM and 6:00 PM; and was stopped on December 1, 2025, at 6:00 AM.

The Provider's designated Registered Nurse visited Resident 60 and reported the Resident was without any UTI symptoms and the antibiotic was discontinued as ordered initially.

Resident 60 received a follow-up visit on December 3, 2025, and during the physical assessment Resident had suprapubic tenderness (pain or sensitivity in the lower abdomen just above the pubic bone) often signaling underlying bladder or pelvic issues like urinary tract infections or cystitis.

On December 3, 2025, the provider wrote new orders for Cipro 500 mg twice a day (1000 mg daily) for 7 days due to continued symptoms "related to a complicated UTI."

During an interview with Employee 9 (ICP-Infection Control Preventionist) on March 5, 2026, at 10:00 AM, Employee 9 stated that residents under the care of this Resident's provider are usually treated for 3 days with antibiotics when diagnosed with UTI with a positive culture. The Resident is evaluated by a Registered Nurse for symptoms and, if there are no symptoms, the antibiotic ends as scheduled. When the Provider reevaluates at the next visit if there are symptoms, the antibiotic is restarted.

During an interview with the Nursing Home Administrator (NHA) on March 5, 2026, at 10:45 AM, the NHA stated that antibiotic usage is referred to the provider.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 211.12(c)(d)(3) Nursing services

Plan of Correction - To be completed: 04/07/2026

1. The facility cannot go back in time on a medication order.
2. The facility will obtain a baseline audit on any current patients being treated for urinary tract infections empirically.
3. Education will be provided by the Medical Director or designee to the in-house providers on following the peer reviewed and recommended treatments protocols for uncomplicated bladder infections as identified in the JAMDA literature.
4. An audit will be conducted by the ICP weekly x 2 then monthly x 2 or designee on empiric treatments of uncomplicated urinary tract infections to ensure they are in line with the peer reviewed and recommended treatments as identified by JAMDA.Results will be taken to QAPI for review of findings and further interventions if indicated

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 observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of 19 residents observed on contact precautions (Resident 5).

Findings Include:

Review of facility policy, titled IC-Enhanced Barrier Precautions, revised April 1, 2024, revealed, Enhanced barrier precautions apply when: A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and contact precautions do not otherwise apply.

Review of Resident 5's clinical record revealed diagnoses that included pressure ulcer of sacral region, stage 3 (a severe, full-thickness wound where the true depth [Stage III or IV]) and diabetes (a chronic condition when the body cannot properly control blood glucose levels).[DEL] I feel the ulcer piece isn't finished

Observation of Resident 5's room door on March 2, 2025, at 10:30 AM, failed to reveal any signage that Resident 5 was on enhanced barrier precautions or that it was necessary to use personal protective equipment when caring for Resident 5.

Observation of Resident 5's room door on March 3, 2025, at 11:30 AM, failed to reveal any signage that Resident 5 was on enhanced barrier precautions or that it was necessary to use personal protective equipment when caring for Resident 5.

Observation of Resident 5's stage 3 pressure ulcer treatment on March 5, 2026, at 9:45 AM, revealed that Resident 5 had a stage 3 pressure ulcer on her sacrum that is healing but still an opening in her skin.

Review of Resident 5's wound team consult dated March 2, 2026, at 11:55 PM, revealed that Resident 5 had a stage 3 pressure ulcer on her sacrum.

Review of Resident 5's physician orders failed to reveal a physician's order for Resident 5 to be on enhanced barrier precautions.

Review of Resident 5's care plan failed to reveal any care plan dealing with Resident 5's need to be on enhanced barrier precautions.

Interview with the Director of Nursing on March 3, 2026, at 12:15 PM, revealed that she was under the impression that Resident 5's pressure ulcer had closed and that enhanced barrier precautions were no longer needed.

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

Plan of Correction - To be completed: 04/07/2026

F880

1. The facility cannot go back in time on a posting on enhanced barrier precautions.

2. Audit of current residents will be completed to ensure all residents who require EBP have an order, care plan, and PPE set up.

3. Education will be provided by the DON or designee to the ICP on following the CDC recommendations for Enhanced Barrier Precautions.

4. Ongoing, the ICP nurse reviews physician orders daily to identify new residents who require EBP set up and those who no longer need EBP.

5. An audit will be conducted by the ICP weekly x 2 then monthly x 2 or designee on following the CDC recommendations for EPB as it related to wound care.

6. Results will be taken to QAPI for review of findings and further interventions if indicated

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, facility policy, and staff interviews, it was determined that the facility failed to discard expired medications for one of one medication storage rooms observed (2nd floor), and failed to place "opened dates" on medications in one of two medication carts (2nd floor) and one of one medication storage rooms (2nd floor) observed.

Findings Include:

Review of facility policy, titled "Storage of Medications," last revised April 7, 2025, read, in part, "III. Expiration Dating (Beyond-Use Dating) 3. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency."

Observation of the second floor medication storage room on March 4, 2026 at 10:00 AM, revealed one open multidose vial of tuberculin solution with no open date label.

Further observation of the second floor medication storage room on March 4, 2026 at 10:00 AM, revealed one box of 25 gauge needles with an expiration date of February 28, 2026, and one open vial of insulin lispro labeled with an open date of January 17, 2026.

An interview with Employee 1 on March 4, 2026, at 10:00 AM, revealed that the tuberculin solution should be labeled with an open date when opened and expired medication and supplies should be discarded.

Observation of the second floor medication cart on March 5, 2026 at 11:15 AM, revealed one open bottle of liquacel with no open date label and one open Lantus insulin pen with no open date label.

An interview with Employee 1 on March 5, 2026 at 11:15 AM, revealed that liquacel bottles and insulin pens should be labeled with an open date when opened due to a shortened expiration date once opened.

During an interview on March 5, 2026, at 1:08 PM, with the Nursing Home Administrator and Director of Nursing, revealed that it was the facility's expectation that medications be labeled with open dates when opened and expired medications and supplies be disposed of.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1) Pharmacy services

Plan of Correction - To be completed: 04/07/2026

1. Identified medications or supplies were discarded at time of discovery.

2. A baseline audit will be conducted by the DON or designee on medication carts and medication storage areas to ensure that opened medications are dated and discarded per policy.

3. Education will be provided by the DON or designee to clinical staff on dating medications when opened and discarded by the expiration date.

4. An audit will be conducted by the DON or designee on medication carts and medication storage areas weekly for 4 weeks to ensure that opened medications are dated and discarded per policy.

5. The pharmacy consultant audits med rooms/carts on a monthly to monitor sustained resolution.

6. Results will be taken to QAPI for review of findings and further interventions if indicated.

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 facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for three of 19 residents reviewed (Residents 4, 56, and 60).

Findings include:

Review of the facility policy, titled "Care Plan-Comprehensive," last reviewed April 7, 2025, stated "Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change."

Review of Resident 4's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body).

Review of Resident 4's clinical record revealed that he was treated for the flu from January 30, 2026 -February 6, 2026.

Review of Resident 4's care plan revealed an active care plan focus for influenza, dated January 30, 2026.

During a staff interview with the Director of Nursing on March 5, 2026, at 10:20 AM, she confirmed that Resident 4's influenza was resolved in early February 2026, and that his care plan should have been revised at that time.

Review of Resident 56's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes, which causes memory loss in older adults) and hearing loss.

Review of Resident 56's clinical record revealed that she was treated for a urinary tract infection (UTI) from February 1-4, 2026.

Review of Resident 56's care plan revealed an active care plan focus for a UTI, dated February 1, 2026.

During a staff interview with the Nursing Home Administrator (NHA) on March 5, 2026, at 11:26 AM, the NHA indicated that the care plan should have been revised when the UTI resolved and that Resident 56's care plan has now been revised.

Review of the clinical record for Resident 60 revealed diagnoses that included Parkinson's disease with dyskinesia (uncontrolled, involuntary movement) and retention of urine (inability to fully empty the bladder).

Review of the clinical record for Resident 60 revealed resident had a UTI on November 1, 2025, that was resolved with treatment.

Review of Resident 60's care plan on February 4, 2026, revealed the UTI that occurred November 1, 2025, was still present on the care plan.

During an interview with the NHA on February 5, 2026, at 10:45 AM, he agreed that care plans should reflect the Resident's status.

28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/07/2026

1. Resident R 4 and R 56 care plans for flu and UTI were resolved at time of discovery.

2. A baseline audit will be conducted by the ICP or designee to ensure that resident care plans for acute infections are resolved.

3. The DON/designee will provide education to the IDT team and licensed staff on updating care plans with changes (new orders, discontinued orders, changes in condition).

4. The IDT team will update care plans with the MDS schedule and as needed.

5. The DON/designee will audit care plans on 5 residents a week for 4 weeks to ensure care plans are current and reflect orders/changes that have been resolved.

6. Results will be taken to QAPI for review of findings and further interventions if indicated

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

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

Observations:

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan to meet a resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one of 16 residents reviewed (Resident 3).

Findings include:

Review of facility policy, titled "Care Plan-Comprehensive," dated September 28, 2022, revealed, in part, "Each resident will have a comprehensive care plan that is individualized, includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflects the resident's cultural references, values, and practices. Each resident's care plan is designed to: d. reflect the resident's expressed wishes regarding care and treatment goals."

Review of Resident 3's clinical record revealed diagnoses that included muscle weakness and depression.

During a resident interview with Resident 3 on March 2, 2026, at 1:40 PM, he indicated that he does not get showers very often and described them as "few and far between."

Review of Resident 3's care plan revealed his bathing preference was to receive a shower once a week, dated January 14, 2024.

Review of Resident 3's shower/bath documentation from February 3, 2026 -March 4, 2026, revealed that he was documented as receiving a shower once on February 15, 2026, and received a bed bath all other times.

During a staff interview with the Director of Nursing (DON) on March 5, 2026, at 10:20 AM, she indicated that he does occasionally refuse a shower. She said Resident 3's autonomy of care is presumed because of his high level of cognition and that he could voice his concerns or requests to staff when care is being provided. The DON confirmed that Resident 3's preferences should have been care planned so all staff providing care could be aware and make efforts to accommodate them.

28 Pa. Code 201.24(e)(4) Admission policy.
28 Pa. Code 211.12(d)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/07/2026

1. Resident R 3's care plan was updated at time of discovery to reflect his showering preferences.

2. Care plan audit will be completed on current residents to ensure shower preferences are correct and on the care plan.

3. The DON/designee will provide education to the licensed staff on comprehensive care plan completions which includes preferences, new orders, and changes in condition.

4. The DON/designee will provide education on comprehensive care plan completion to the IDT team.

5. The DON/designee will audit 5 resident care plans a week for 4 weeks to ensure new orders/preferences/changes have been updated.

6. Results will be taken to QAPI for review of findings and further interventions if indicated

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the resident's medical record included a complete discharge summary for one of three closed records reviewed (Resident 67).

Findings Include:

Review of Resident 67's clinical record revealed diagnoses that included Crohn's disease (inflammatory bowel disease that causes chronic inflammation of the digestive tract) and anemia (lack of enough healthy red blood cell to transport oxygen to tissues).

Further review of Resident 67's clinical record revealed he was discharged from the facility on January 2, 2026, to the hospital and did not return to the facility.

Continued review of Resident 67's clinical record failed to reveal a discharge summary signed by the physician.

An interview on March 5, 2026, at 2:07 PM, with the Nursing Home Administration (NHA) and the Director of Nursing, revealed that the facility could not provide a discharge summary signed by the physician. The NHA stated that it was the expectation of the facility that physician signed discharge summaries be completed within 30 days of discharge.

Plan of Correction - To be completed: 04/07/2026

1. The facility had the physician complete and sign the discharge summary on resident R67.
2. A baseline audit will be completed on discharged residents within the last 30 days to ensure a signed discharge summary is in their medical record.
3. Education will be provided by the Medical Record consultant or designee to the medical records staff on the requirement of a signed discharge summary is obtained prior to final closure of the medical record chart.
4. An audit will be conducted by the Medical Record consultant or designee weekly x 4 then monthly x 2 to ensure that the signed discharge summary is obtained prior to closure of the medical record. Results will be taken to QAPI for review of findings and further interventions if indicated.

35 P. S. § 448.809b LICENSURE Photo Id Reg:

Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.

Observations:

Based on observations, facility document review, and staff interviews, it was determined that the facility failed to ensure its employees wear an identification badge that includes a recent photograph of the employee, the employee's first name, the employee's title, and the name of the health care facility or employment agency.

Findings include:

Review of facility provided information from their employee handbook dated November 1, 2023, revealed, in part, "K. Name Badges. All employees must prominently wear a name badge at all times so that residents can identify them."

Observation of Employee 2 (Licensed Practical Nurse) on March 2, 2026, at 10:50 AM, revealed that Employee 2 was not wearing a name badge.

During an immediate interview with Employee 2, she confirmed her identity and job role and indicated that she was aware that she was to always wear a name badge. She said it was possibly in her purse or on her jacket.

Observation of Employee 4 (Registered Nurse) on March 2, 2026, at 10:53 AM, revealed that Employee 4 was not wearing a name tag.

During an immediate interview with Employee 4, she confirmed her identity and job role and indicated her name tag was in her desk drawer. She proceeded to her office and retrieved her name badge from the desk drawer. Employee 4 indicated that she was aware that she was to always wear a name badge.

Observation of Employee 5 (Nurse Aide) on March 2, 2026, at 12:48 PM, revealed that Employee 5 was not wearing a name tag.

During an immediate interview with Employee 5, she confirmed her identity and job role and indicated she did not know where her name badge was.

Follow-up observations of Employee 2 on March 2, 2026, at 12:45 PM, and 1:10 PM, revealed that Employee 2 was still not wearing a name tag.

During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on March 4, 2026, at 1:33 PM, the NHA confirmed that he would expect staff to always wear their name badges.

Plan of Correction - To be completed: 04/07/2026

1. Employee E2 was counselled at the time the event occurred regarding wearing proper working attire and a name tag.
2. All other staff were in compliance with the dress code and name badge policy.
3. Education will be provided by the NHA or designee on the dress code policy as well as the wearing of a name tag when on duty.
4. An audit will be conducted by NHA or designee on staff attire and utilization of name badges weekly for 4 weeks then monthly x 2. Results will be taken to QAPI for review of findings and further interventions if indicated.

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