Pennsylvania Department of Health
JULIA RIBAUDO EXTENDED CARE CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

JULIA RIBAUDO EXTENDED CARE CENTER
Inspection Results For:

There are 121 surveys for this facility. Please select a date to view the survey results.

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


JULIA RIBAUDO EXTENDED CARE CENTER - 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 Compliance survey, on June 16, 2026, it was determined that Julia Ribaudo Extended Care Facility was not in compliance with the following requirements of 42 Part 483 Subpart B Requirements for Long-Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

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

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

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

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

Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain sanitary food storage, dishwashing, and ice machine sanitation practices in the food and nutrition services department. These failures had the potential to contaminate food and ice served to residents and increased the risk of foodborne illness.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that encounters food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

During the initial tour of the food and nutrition services department on June 14, 2026, at 9:15 AM, in the presence of Employee 3, Cook/Dietary Aide observation revealed the following food storage concerns with the potential to increase the potential for food-borne illnesses:

Cardboard food containers stored on metal shelving were wet and covered with freezer burn. A large accumulation of ice was observed on the ceiling, shelving beneath the exhaust fans, storage shelves, food containers, the floor, and the door threshold.

At the time of the observation, the freezer temperature measured 9 degrees Fahrenheit. Commercial freezers are generally maintained at 0 degrees Fahrenheit or below to keep food frozen, preserve food quality, and minimize conditions that could contribute to food deterioration. Excessive ice accumulation and elevated freezer temperatures may indicate that the freezer is not functioning effectively and may compromise the safe storage of food.

During the observation, the Certified Dietary Manager was unable to state whether the freezer had been consistently maintained at acceptable temperatures to ensure safe food storage or prevent the excessive ice accumulation observed throughout the freezer.

Observation on June 14, 2026, at 9:15 AM revealed Employee 3, dietary aide, loaded soiled dishes into the dishwasher while wearing gloves that had contacted dirty dishware. After the wash cycle was completed, Employee 3 removed clean dishes from the dishwasher using the same gloves without removing the gloves or performing hand hygiene. The use of the same gloves for both dirty and clean dishware created the potential for cross-contamination by transferring microorganisms from soiled surfaces to cleaned and sanitized items.

A second observation on June 15, 2026, at 9:30 AM revealed Employee 4, dietary aide, loaded soiled dishes into the dishwasher while wearing gloves and subsequently removed clean dishes from the dishwasher using the same gloves without changing gloves or performing hand hygiene. This practice also created the potential for cross-contamination between dirty and clean dishware.

Observation of the ice machine located in the AB dining room/activity room on June 14, 2026, at 10:00 AM revealed a heavy accumulation of lint on the external filter. The exterior chrome surfaces contained dried liquid residue. The floor beneath and behind the machine contained paper debris, plastic debris, liquid stains, and dirt. The plastic drainpipe connected to the machine contained a large accumulation of brown sticky residue. The floor drain located two inches below the drainpipe contained a similar brown sticky substance. Additional plastic piping located at the rear of the machine near the floor contained numerous black spots throughout the length of the pipe. (Ice is considered food and must be protected from contamination during production, storage, and dispensing. Unsanitary conditions on and around ice machines and drainage systems may contribute to contamination of ice intended for resident consumption)

Observation of the ice machine located in the CD dining room/activity room on June 14, 2026, at 10:30 AM revealed paper debris, plastic debris, liquid stains, and dirt on the floor beneath and behind the machine. The plastic drainpipe connected to the machine was then connected directly into the drainpipe. The drainpipe contained brown sticky residue, visible dirt, and staining. The surrounding floor area also contained brown residue, dirt, and liquid staining.

Interview with the Nursing Home Administrator on June 15, 2026, at 12:00 PM confirmed the facility was expected to maintain safe food storage practices and sanitary conditions for equipment used in the preparation and service of food and ice.

Cross refer F 908

28 Pa. Code 201.18 (e)(1) Management.

28 Pa. Code 211.6 (f) Dietary.

Plan of Correction - To be completed: 07/16/2026

All food was removed from freezer on 6/14/26 and discarded, Freezer cleaned and serviced on 6/14/26. Dietary aide was educated on proper handwashing and dishwashing procedures

To identify like resident's that could have been affected, all residents had the potential to be affected by this deficient practice

To prevent reoccurrence the Regional Dietary manger will educate the Dietary Manager and staff on maintaining sanitary food storage, dishwashing and ice machine sanitation practices

To monitor and maintain compliance NHA/designee will audit the dietary department weekly to ensure they are maintaining sanitary food storage, dishwashing and ice machine sanitation practices weekly x4 and then monthly x2. Results will be reviewed at QAPI

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:

§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Observations:

Based on observation and staff interview, it was determined the facility failed to ensure that essential equipment was in safe operating condition in the facility's food and nutrition area.

Findings include:

A review of a policy for Freezers and Refrigerators, last reviewed June 5, 2026, revealed the facility will ensure safe refrigerator and freezer maintenance and sanitation. The food and nutrition services director will inspect refrigerators and freezers monthly for gasket, fan condition, the presence of rust, excess condensation and any other damage or maintenance issues. Necessary repairs will be initiated immediately.

A tour of the facility's main kitchen area on June 14, 2026, at approximately 9:30 AM revealed the walk in freezer with a large ice buildup on the ceiling, double exhaust fans, walls and floor.

The pipe located under the exhaust fans (to remove the condensation/water from inside the unit to the outside of the building was missing, leaving an exposed hole in the freezer to the outside of the building. The freezer was located on an outside wall of the kitchen.

The metal shelving unit located under the exhaust fans had two large plastic containers with individual ice cream cups encased in ice. These plastic containers were frozen to the metal shelves. There were multiple metal shelving units on either side of the freezer with wet cardboard boxes containing food. The cardboard boxes fell apart when moved.

Several boxes of food, including two cakes, were noted to be freezer burned with ice on the food.

A review of the freezer temperature logs at the time of the tour revealed the temperature inside the freezer was 9 degrees Fahrenheit.

A review of a service order from the freezer repair company dated June 3, 2026 revealed that a technician was in the building on that date and inspected the freezer unit in the kitchen. He noted on the invoice that the walk in freezer needed a drain pipe, it was coming off the fan inside the unit. The technician left the building stating he needed to get parts to repair the unit.

The service order noted that the technician was again in the building June 5, 2026, to make additional repairs to additional machines in the kitchen. The freezer was not repaired at that time.

The repair company was contacted by the facility staff on June 14, 2026, after the survey team identified the issue with the walk in freezer.

During an interview on June 15, 2026, at 10:00 AM, the Certified Dietary Manager (CDM) stated the pipe under the exhaust fans in the freezer had broken off two weeks ago. He stated the repair company was contacted and came out to the facility at that time but didn't have the needed part to fix the issue. As of the time of the start of the survey, June 14, 2026 the walk in freezer remained broken.

An interview with the Nursing Home Administrator (NHA) on June 15, 2026, at 10:00 AM confirmed the facility failed to ensure that essential equipment was in safe operating condition.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(3)(e)(2.1) Management.

Plan of Correction - To be completed: 07/16/2026

All food was removed from freezer on 6/14/26 and discarded, Freezer cleaned and serviced on 6/14/26.

To identify like resident's that could have been affected, all residents had the potential to be affected by this deficient practice. All food from freezer was discarded on 6/14/26

To prevent reoccurrence the Regional Dietary manger will educate the Dietary Manager and staff on Freezer and Refrigeration Policy.

To monitor and maintain compliance NHA/designee will audit the dietary department weekly to ensure that essential equipment is maintained in safe operating condition weekly x4 and then monthly x2. Results will be reviewed at QAPI

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

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

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

Observations:

Based on review of facility infection control records, clinical records, facility policy, and staff interview, it was determined that the facility failed to implement and maintain an antibiotic stewardship program and conduct and document antibiotic stewardship monitoring for eight of 8 months reviewed (November 2025 through June 2026) and failed to follow its antibiotic stewardship process for 1 of 20 residents reviewed (Resident 97).

Findings include:

A review of the facility policy titled "Antimicrobial Stewardship Program," last updated June 5, 2026, revealed the program focuses on improving antimicrobial use by avoiding inappropriate or unnecessary antimicrobials. The policy stated antimicrobial use would be reviewed through monitoring and tracking of antimicrobial prescribing, use, and resistance to promote optimal antimicrobial use within the facility.

The policy required the use of an antimicrobial tracking form or system to track and trend infections by site and organism. The policy also required monthly review of antimicrobial utilization reports from the pharmacy, including the type of drug prescribed, number of days of treatment, and number of new antimicrobial starts.

The policy further required monthly antimicrobial use surveillance, including monitoring, tracking, and trending for patterns, trends, and clusters, and required clinical and diagnostic testing for specific infections.

In addition, the policy required antimicrobial use protocols to address prescribing practices, documentation of the indication, dose, and duration of antimicrobial therapy, review of laboratory reports to determine whether antimicrobial therapy was indicated or required adjustment, completion of an infection assessment prior to prescribing, and monitoring of antimicrobial use through antimicrobial utilization reports, antimicrobial resistance reports, and current McGeer Criteria. McGeer Criteria are standardized surveillance definitions used in long-term care facilities to identify infections based on specific clinical signs, symptoms, and laboratory findings.

The policy further stated that antibiotics would be prescribed and administered under the guidance of the facility's antibiotic stewardship program, which was established to monitor antibiotic use among residents.

A review of the facility's infection control surveillance records from November 2025 through June 2026 revealed no documentation that antibiotic stewardship monitoring, tracking, trending, or utilization review activities had been completed during any of the eight months reviewed.

A review of Resident 97's clinical record revealed the resident was admitted on October 9, 2023, with diagnoses that included epilepsy (a neurological disorder characterized by recurrent seizures) and Parkinsonism (a group of neurological disorders that cause symptoms such as tremors and slowed movement).

A review of a physician's order dated April 27, 2026, revealed Macrobid 100 mg (an antibiotic used to treat urinary tract infections) was ordered twice daily for five days for a urinary tract infection (UTI, an infection involving the urinary system).

A review of the April 2026 Medication Administration Record revealed Resident 97 received four doses of Macrobid.

A review of Resident 97's clinical record revealed no documentation that a McGeer Criteria assessment had been completed prior to initiation of the antibiotic. Further review failed to identify documentation supporting the clinical signs or symptoms used to determine whether the resident met the facility's criteria for antibiotic treatment.

A review of a urinalysis with culture report dated April 27, 2026, at 3:40 PM revealed minimal bacterial growth consisting of mixed normal urogenital flora (bacteria commonly found on the skin and surrounding areas that do not necessarily indicate infection).

Documentation revealed the laboratory results were reviewed by the provider on April 30, 2026. Following review of the culture results, which did not identify evidence of a urinary tract infection, the antibiotic was discontinued.

During an interview on June 15, 2026, at 11:00 AM, the Infection Preventionist stated Resident 97 met McGeer Criteria for antibiotic treatment. However, the facility was unable to provide documentation identifying the clinical findings that met the criteria or a completed McGeer Criteria assessment supporting initiation of the antibiotic.

During an interview on June 16, 2026, at 1:00 PM, the Director of Nursing confirmed the facility had not completed antibiotic stewardship monitoring as required and acknowledged the facility's antibiotic stewardship process had not been followed.
Cross refer F 757

28 Pa. Code: 211.10(c)(d) Resident care policies.

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

Plan of Correction - To be completed: 07/16/2026

The facility is unable to retroactively correct resident 97 not having the antibiotic surveillance and tracking and trending completed

To identify like resident's that could have been affected an audit was completed on all residents ordered on antibiotics within the last 30 days to ensure that surveillance, tracking and trending was completed per policy

To prevent reoccurrence the DON/designee will educate the Licensed Staff on Antibiotic Stewardship

To monitor and maintain compliance DON/designee will audit 5 residents on antibiotics per week to ensure that surveillance, tracking and trending has been completed weekly x4 and then monthly x2. Results will be reviewed at QAPI

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and interview, it was determined the facility failed to maintain a clean, comfortable and homelike environment for residents on five of 5 resident units. (Units A,B,C,D and E )

Findings include:

An environmental tour conducted on June 14, 2026, at 9:30 AM revealed that the floor on all resident hallways (A,B,C,D and E) had a thick, yellow sticky substance around the perimeter to include in front of resident rooms and ancillary rooms.

The high back upholstered chairs in the A,B activity/dining room had food and dried liquid stains on them. The floor was dirty with dirt and liquid stains.

The floor under the ice machine had a black sticky substance on it as well as a large amount of dirt, paper and dried liquid stains.

The C/D activity/dining room floor was dirty with dried food debris, dirt and dried liquid stains. The floor behind the ice machine was dirty with paper and plastic debris, dried liquid stains and visible dirt. The high back upholstered chairs had food and dried liquid stains on them.

There was a large, uncovered bin with bagged dirty linen as well as a large, uncovered bin with bagged garbage on the patio outside the laundry area.

During a Resident council meeting held June 15, 2026, at 10:00 AM, revealed six out of 6 residents (Resident 33, 39, 48, 69, 75, and 95) complained of the shower rooms. Three out of 7 residents reported that the D Hall shower room has a mold like substance around the edges of the showers. Resident 75 and Resident 39 revealed the shower room was frequently full of wheelchairs, garbage cans, and other stored items, that limit the amount of room the residents have to take their showers. Six out of 6 residents revealed that staff do not clean the showers prior to showering residents, six out of 6 residents stated that when going to the shower there are dirty clothes, towels, and even dirty briefs, from the previous resident still present in the shower when they utilize it.

Observation of the Hallway D shower room on June 15, 2026, at 11:40 AM revealed a presence of black mold along 3 out of 4 bottom edges of the shower walls. The fuzzy black mold was consistent along the bottom where the floor meets the wall, the mold was unable to be wiped clean with a paper towel.

Observations of the A Hall shower room revealed 6 wheelchairs present in the shower room with a small walking path to the shower area. The small walking path was large enough to fit one wheelchair in the area. The shower room also revealed 3 garbage cans present, one filled with soiled linens.

Observations of the B hall bathtub room revealed a bathtub full of equipment, including bed bolsters, two wheelchairs, and multiple garbage cans with lids present. The area revealed no walking path. The bathtub unable to be used.

Interview with the Director of Nursing on June 16, 2026, at 1:00 PM reviewed the above findings of the facility's failure to ensure the facility was homelike, clean, and properly maintained.

28 Pa Code 201.18(e)(2.1) Management.

Plan of Correction - To be completed: 07/16/2026

Preparation, submission and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with state and federal regulatory requirements

All areas are addressed. Floors in dining rooms, resident rooms, and resident room areas were immediately cleaned during survey. Floors under ice machines were cleaned. Chairs have since been removed from dining rooms. Shower rooms have been deep cleaned, and unnecessary equipment was removed.

To identify other affected areas an environmental audit was completed on 6/29/26 and negative findings were addressed

To prevent reoccurrence the NHA/designee will educate the facility staff on providing a clean and homelike environment

To monitor and maintain compliance 5 resident rooms and ancillary spaces will be audited weekly x4 and then monthly x2. Results will be reviewed at QAPI

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:

§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Observations:

Based on a review of scheduled facility mealtimes, facility policy, resident interviews, and staff interview, it was determined that the facility failed to consistently offer nourishing evening snacks when the scheduled time between dinner and breakfast exceeded 14 hours for residents residing on four nursing units. This deficient practice affected six of six residents who participated in a resident council interview (Residents 48, 95, 39, 33, 75, and 69).

Findings include:

A review of the facility policy titled Meal Times and Frequency Policy, last reviewed by the facility on June 5, 2026, revealed it is the facility policy that there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day; except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal (dinner) and breakfast the following day if a resident group agrees to this meal span.

A review of the facility's scheduled meal service times revealed that the time between dinner and breakfast exceeded 14 hours on all nursing units reviewed.

Residents residing in North Nursing Unit Area 1 were scheduled to receive dinner at 4:40 PM and breakfast at 7:10 AM the following day, resulting in a meal interval of 14 hours and 30 minutes.

Residents residing in North Nursing Unit Area 2 were scheduled to receive dinner at 5:00 PM and breakfast at 7:20 AM the following day, resulting in a meal interval of 14 hours and 20 minutes.

Residents residing in South Nursing Unit Area 1 were scheduled to receive dinner at 4:50 PM and breakfast at 7:15 AM the following day, resulting in a meal interval of 14 hours and 25 minutes.

Residents residing in South Nursing Unit Area 2 were scheduled to receive dinner at 5:15 PM and breakfast at 7:30 AM the following day, resulting in a meal interval of 14 hours and 15 minutes.

During a resident council interview on June 15, 2026, at 10:00 AM, six of six residents interviewed (Residents 48, 95, 39, 33, 75, and 69) stated that evening snacks were not consistently offered.

During an interview on June 15, 2026, at 2:00 PM, the Nursing Home Administrator (NHA) stated that it was the facility's practice to offer residents nourishing evening snacks. However, the NHA was unable to provide documentation or other evidence demonstrating that evening snacks were consistently offered to residents.

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

Plan of Correction - To be completed: 07/16/2026

Residents 48,95,39,33,75 and 69's Are aware that their mealtimes were revised to have no more than 14 hours between dinner and breakfast. Above residents will be offered HSs snacks on a daily basis and are aware that they can request alternate snacks upon request

To identify like resident's that could have been affected, all residents have the potential to be affected, so the facility revised current mealtimes to 14 hours between dinner and breakfast for the facility

To prevent reoccurrence the Regional Dietary manger will educate the Dietary Manager on mealtimes and frequency. Nursing staff will be educated regarding offering HS snacks.
To monitor and maintain compliance Dietary Manager/designee will audit 5 residents weekly they are receiving their meals timely and are being offered HS snacks weekly x4 and then monthly x2. Results will be reviewed at QAPI

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Plan of Correction - To be completed: 07/16/2026

The facility is unable to retroactively correct failing to have an accurate of resident 35's controlled substance administration. Controlled substance inventory sheets are being signed according to policy. Physician was made aware of resident 98's medication being administered late.

To identify like resident's that could be have been affected an audit was completed on all controlled substance inventory sheets and medication administration record to ensure physicians were made aware of any late or missed medications

To prevent reoccurrence the DON/designee will educate the Licensed Staff on The controlled substance policy and medication shortage/unavailable policy

To monitor and maintain compliance DON/designee will audit 5 resident records to ensure that medications are given per MD orders and that MD is notified if medications are not available, that controlled substance inventory records are correct to ensure nurses have accurately signed out the administration. Facility will also audit that the shift to shift controlled substance documentation is according to facility policy weekly x4 and then monthly x2. Results will be reviewed at QAPI

483.10(e)(1),483.12(a)(2),483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:

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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

§483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Plan of Correction - To be completed: 07/16/2026

Resident 98 is no longer on the medication

To identify like resident's that could be affected an audit was completed on all PRN Psychoactive Medications to ensure medications have the required 14 day re-evaluation by the MD/NP

To prevent reoccurrence the DON/designee will educate the Licensed Staff on psychoactive medication management

To monitor and maintain compliance DON/designee will audit 5 residents on PRN Psychoactive medication to ensure medications have the required 14 day re-evaluation by the MD/NP weekly x4 and then monthly x2. Results will be reviewed at QAPI

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.

Plan of Correction - To be completed: 07/16/2026

The facility is unable to retroactively correct failing to withhold medication for resident 38

To identify like resident's that could be have been affected an audit was completed on all Physicians orders with parameters for administration to ensure all medications were given according to MD orders

To prevent reoccurrence the DON/designee will educate the Licensed Staff on following physician's orders for parameters

To monitor and maintain compliance DON/designee will audit 5 residents with MD orders that have parameters weekly x4 and then monthly x2. Results will be reviewed at QAPI

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Plan of Correction - To be completed: 07/16/2026

Resident 84 is currently wearing her Left palm guard per physicians order.

To identify like resident's that could have been affected an audit was completed on all residents with palm guards to ensure the palm guards are applied according to MD orders

To prevent reoccurrence the DON/designee will educate the Licensed Staff on the splints and braces policy

To monitor and maintain compliance DON/designee will audit 5 residents with MD orders for palm guards to ensure the palm guards are applied according to MD orders weekly x4 and then monthly x2. Results will be reviewed at QAPI

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on clinical record review, observation, review of facility policy, and staff interview, it was determined that the facility failed to ensure oxygen was administered in accordance with physician orders for one of 20 residents reviewed (Resident 98).

Findings include:

A review of the facility policy titled "Oxygen Administration," last reviewed by the facility on June 5, 2026, revealed it is the facility's policy to administer oxygen by the route and at the rate ordered by the provider.

Clinical record review revealed Resident 98 was admitted to the facility on December 28, 2022, with diagnoses that included asthma (a chronic condition in which the airways become inflamed and narrowed, making breathing difficult) and chronic obstructive pulmonary disease (COPD, a progressive lung disease that limits airflow and makes breathing difficult).

A review of Resident 98's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 20, 2026, revealed that Resident 98 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 07 indicates severe cognitive impairment indicating significant difficulty with basic memory tasks, recognizing the date, or recalling recent information).

Clinical record review revealed a physician order dated April 18, 2024, directing oxygen administration at two liters per minute (L/min) via nasal cannula (a device consisting of small prongs placed in the nostrils to deliver supplemental oxygen).

Observation on June 14, 2026, at 9:43 AM revealed Resident 98 was asleep in bed with oxygen in use through a nasal cannula. The oxygen tubing connected the nasal cannula to an oxygen concentrator (a machine that filters room air and delivers concentrated oxygen). Observation of the concentrator revealed the oxygen flow rate was set at 4.5 L/min.

During an interview on June 14, 2026, at 11:16 a.m., Employee 1, Licensed Practical Nurse (LPN), confirmed Resident 98's physician order directed oxygen administration at 2 L/min. Employee 1 observed the oxygen concentrator setting and adjusted the flow rate from 4.5 L/min to 2 L/min.

The above information was reviewed during an interview on June 15, 2026, at 12:30 PM, with the facility Director of Nursing and Nursing Home Administrator (NHA).

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

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

Plan of Correction - To be completed: 07/16/2026

Resident 98 is currently wearing oxygen via nasal cannula at 2LPM

To identify like resident's that could have been affected an audit was completed on all residents with orders for Oxygen to ensure that oxygen is being delivered per the physician's orders

To prevent reoccurrence the DON/designee will educate the Licensed Staff on Oxygen administration policy

To monitor and maintain compliance DON/designee will audit 5 residents with MD orders for Oxygen to ensure the resident is receiving oxygen according to MD orders weekly x4 and then monthly x2. Results will be reviewed at QAPI

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on a review of clinical records, laboratory reports, facility policy, and staff interviews, it was determined the facility failed to ensure a resident was free from unnecessary medication by administering an antibiotic without documented clinical evidence supporting an active infection for one of 20 residents reviewed (Resident 97).

Findings Include:

A review of Resident 97's clinical record revealed the resident was admitted to the facility on October 9, 2023, with diagnoses that included epilepsy (a chronic neurological disorder characterized by recurring seizures) and Parkinsonism (a group of neurological disorders that cause movement problems such as tremors, stiffness, and slowed movement).

A review of the facility policy titled "Antimicrobial Stewardship Program Policy," last reviewed by the facility on June 6, 2026, revealed antibiotics should be prescribed only when clinical evidence supports the presence of an active infection. The policy further revealed appropriate indications for antibiotic use include meeting established clinical criteria for an active infection. The policy indicated that prescribers should provide complete antibiotic orders, including the medication name, dose, duration of treatment, and indication for use.

The facility utilized McGeer's Criteria Checklist to determine whether residents met evidence-based criteria for the initiation of antibiotic therapy. McGeer's Criteria is a standardized surveillance tool used in long-term care facilities to identify signs and symptoms consistent with infection and to support appropriate antibiotic use.

A review of a physician's order dated April 27, 2026, revealed an order for Macrobid 100 milligrams (an antibiotic medication) to be administered twice daily for five days for a urinary tract infection (UTI, an infection involving the urinary system).

A review of Resident 97's clinical record failed to identify documentation of signs or symptoms supporting a urinary tract infection prior to the initiation of antibiotic therapy. Specifically, the clinical record failed to identify documented fever (an elevated body temperature that may indicate infection), dysuria (pain or burning during urination), urinary urgency (a sudden need to urinate), urinary frequency (urinating more often than usual), suprapubic pain (pain in the lower abdomen over the bladder), flank pain (pain in the side or back near the kidneys), rigors (episodes of shaking chills), acute mental status changes, or other documented clinical findings supporting the presence of an active urinary tract infection.

A review of Resident 97's clinical record failed to identify a completed McGeer's Criteria Checklist or other documentation demonstrating the resident met the facility's established criteria for antibiotic treatment prior to the initiation of therapy.

A review of Resident 97's April 2026 Medication Administration Record revealed the resident received four doses of Macrobid.

A review of a urinalysis with culture report (a report used to check if a resident has an active infection, the culture report is a two-part test used to detect, identify, and determine the treatment for urinary tract infections.) dated April 27, 2026, at 3:40 PM, revealed minimal bacterial growth consisting of mixed normal urogenital skin microbiota, which are bacteria commonly found on the skin and genital area and are generally not indicative of a urinary tract infection.

Further review revealed the provider reviewed the urine culture results on April 30, 2026. The culture findings did not support the presence of a urinary tract infection, and the provider subsequently discontinued the antibiotic.

During an interview on June 15, 2026, at 11:00 AM, the Infection Preventionist stated Resident 97 met McGeer's Criteria for antibiotic use. However, the facility was unable to provide documentation of signs or symptoms supporting an active urinary tract infection or documentation demonstrating the resident met McGeer's Criteria prior to the initiation of antibiotic therapy.

The facility failed to ensure Resident 97 was free from unnecessary antibiotic use by initiating and administering an antibiotic without documented clinical evidence of an active infection and without documentation supporting that the resident met the facility's established criteria for antibiotic treatment prior to initiation of therapy. As a result, Resident 97 received four doses of an antibiotic before the urine culture results were reviewed and the medication was discontinued.

During an interview on June 16, 2026, at 1:00 PM, the above findings were review with the Director of Nursing.

28 Pa. Code 211.2(d)(3)(5) Medical Director.

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

Plan of Correction - To be completed: 07/16/2026

The facility is unable to retroactively correct resident 97 receiving the cited medication, however this resident is no longer ordered on this medication

To identify like resident's that could be have been affected an audit was completed on all residents ordered on antibiotics to that surveillance is completed per policy

To prevent reoccurrence the DON/designee will educate the Licensed Staff on Antibiotic Stewardship

To monitor and maintain compliance DON/designee will audit 5 residents on antibiotics per week to ensure that surveillance is completed, antibiotic is ordered per MD order and care planned per policy weekly x4 and then monthly x2. Results will be reviewed at QAPI

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 observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications for two of two medication carts observed (A Hall and B Hall medication carts).

Findings include:

Review of the facility policy titled "Storage and Expiration Dating of Medications and Biologicals" last reviewed by the facility June 5, 2026, indicated that multi-use medication vials or bottles that have been opened or accessed (e.g. seal broken) are to be labeled with the date they were opened to ensure proper tracking for expiration purposes.

An observation of the medication cart located on A hall unit on June 14, 2026, at 8:56 AM, in the presence of Employee 2 RN (Registered Nurse) of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin glargine (a long acting insulin medication used to lower blood sugar) and one (1) multi-dose pen of Insulin Aspart (a fast short acting insulin medication used to lower blood sugar), and one (1) Insulin Lispro (a fast acting insulin medication used to lower blood sugar) that had been opened and available for resident use, but not dated when initially opened.

Review of manufacturer safety information revealed the multi-dose pens of Insulin are to be discarded 28 days after opening and available for resident use.

An interview with Employee 2 RN on June 14, 2026, at 8:59 AM, confirmed all three (3) multi dose insulin pens, one (1) Insulin Aspart, one (1) Insulin Glargine and one (1) Insulin Lispro were opened, available for use, currently being used for administration, and not dated when initially opened.

An observation of the medication cart located on B hall unit on June 14, 2026, at 9: 53 AM, in the presence of Employee 1 LPN (Licensed Practical Nurse) revealed one (1) multi-dose insulin pen of SoloStar insulin (prefilled insulin pen containing a long-acting insulin that works steadily over 24 hours without big peaks or drops in effect) with an expiration date of May 16, 2026 and one (1) vial of Insulin Lispro that had been opened and available for use, but not dated when initially opened.

An interview with Employee 1 (LPN) on June 14, 2026, at 9:55 AM, confirmed the one multi dose insulin pen of Solostar insulin was expired, and one (1) Insulin vial Lispro was not dated when initially opened. Both medications were being stored in the medication cart, and currently being used for administration.

Interview with Director of Nursing and the Nursing Home Administrator on June 16, 2026, at 01:00 PM, reviewed the above findings of the facility's failure to ensure staff date each insulin when opened, to ensure the medication was not used passed the expiration date.

28 Pa. Code 211.9(a)(1)(k) Pharmacy services.

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

Plan of Correction - To be completed: 07/16/2026

Both multi-dose pens were removed from cart and destroyed

To identify like resident's that could be have been affected an audit was completed on all medication carts and refrigerators to ensure that all medication is labeled and dated according to manufacture guidelines

To prevent reoccurrence the DON/designee will educate the Licensed Staff on Medication labeling and storage policy

To monitor and maintain compliance DON/designee will audit 1 medication cart per week to ensure all medications are labeled and dated according to policy weekly x4 and then monthly x2. Results will be reviewed at QAPI

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 07/16/2026

The facility cannot retroactively correct the past C.N.A Ratios
Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One NA to 10 residents on day shift; one NA to 11 residents on evening shift and one NA to 15 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios.
The facility contracts with agencies to supply aides to meet requirements but call offs and no-show result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for nurse aides. The facility offers bonuses to staff to encourage staff to pick up additional shifts.
To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one NA to 10 residents on days, one NA to 11 residents on evenings and one NA to 15 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies.
To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 07/16/2026

The facility cannot retroactively correct the past LPN Ratio
Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One LPN to 25 residents on day shift; one LPN to 30 residents on evening shift and one LPN to 40 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios.
The facility contracts with agencies to supply LPN's to meet requirements but call offs and no-shows result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for LPN's. The facility offers bonuses to staff to encourage staff to pick up additional shifts.
To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one LPN to 25 residents on days, one LPN to 25 residents on evenings and one LPN to 40 residents on nights.. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies.
To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 07/16/2026

The facility cannot retroactively correct the staffing PPD issues.
The facility utilizes staffing agencies, bonuses for staff and actively recruiting for new staff. Management staff is utilized to achieve mandated staffing requirements.
To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the daily PPD of 3.2 hours. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum PPD. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. The deployment sheets are developed in advance so staffing challenges can be addressed. A good faith effort is made to achieve the mandated staffing requirements. Supervisors are educated on the importance of filling call offs to meet requirements.
To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum PPD. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement