Pennsylvania Department of Health
HAVEN PLACE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HAVEN PLACE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 96 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.


HAVEN PLACE REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on September 4, 2026, it was determined that Haven Place Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

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

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

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

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

Plan of Correction - To be completed: 10/12/2026

1. Nutritional assessments have been completed for resident's # 5,56, 1, 17,12, physicians have been notified and care plans have been updated to address nutritional interventions to prevent additional significant weight changes.

2. All residents have the potential to be affected. The facilities registered dietician will audit all current residents to identify any residents with a new significant weight change (5% in 30 days, 10% in 180 days). Nutritional assessments will be completed with physician notification and orders for continued weight monitoring will be initiated. Care plans will be updated for all residents who have a new significant weight change to ensure appropriate nutritional interventions to reduce risk for additional significant weight change.

3. Dietician will be educated by Regional Dietician on the regulation regarding Nutrition/Hydration Status Maintenance and applicable policies.

4. DON or designee will audit weight exception report weekly to identify any new residents with significant weight change to ensure that nutritional assessment has been completed, physician has been notified, additional weight monitoring has been implemented and care plan has been updated to reflect residents nutritional needs.

5. Date of Compliance 10/12/2026

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

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.

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

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

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

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

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

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

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

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

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

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's representative received written notice of the facility bed-hold policy as soon as practicable for four of five residents reviewed for hospitalizations (Residents 4, 87, 5 and 9).

Findings include:
Clinical record review for Resident 4 revealed he was transferred to the emergency department for further evaluation after a fall on July 13, 2026. There was no evidence Resident 4's responsible party received a written notice of the bed hold policy as soon as practicable for Resident 4's transfer.

Clinical record review for Resident 5 revealed they were transferred to the emergency department for further evaluation of a change in mental status on May 29, 2026. There was no evidence Resident 5's responsible party received a written notice of the bed hold policy as soon as practicable for Resident 5's transfer.

Clinical record review for Resident 9 revealed they were transferred to the emergency department for further evaluation of respiratory distress on May 27, 2026, and for further evaluation of increased somnolence (drowsiness) on July 20, 2026. There was no evidence Resident 9's responsible party received a written notice of the bed hold policy as soon as practicable for Resident 9's transfers.

Clinical record review for Resident 87 revealed she was transferred to the emergency department for further evaluation of a change in her mental and physical status on August 3, 2026. There was no evidence Resident 87's responsible party received a written notice of the bed hold policy as soon as practicable for Resident 87's transfer.

Interview with Employee 9 (business office manager) on September 2, 2026, at 10:05 AM, confirmed that the facility did not provide Residents 4, 5, 9 and 87's responsible party written bed-hold notices for the above-mentioned hospitalizations.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on September 2, 2026, at 1:35 PM.

28 Pa. Code 201.14(a) Responsibility of license

Plan of Correction - To be completed: 10/12/2026

1. Unable to retro-correct deficient practice for resident # 4, 5, 9, and 87.

2. BOM or designee will complete an audit of all residents who have been transferred out of the facility in the past 30 days to ensure that facility has evidence that the family has been provided the bed hold policy

3. NHA or designee will provide education to the BOM on the current policy related to Bed-hold/Leave of absence.

4. NHA will complete weekly audits of all residents transfers out of the facility to ensure evidence that family has been provided the bed hold policy. Audits will be completed weekly x 2 months. Results of audits will be reviewed by the QAPI committee.

5. Date of compliance 10/12/2026_

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 and staff interviews, it was determined that the facility failed to ensure an environment free of the potential spread of infection on one of two nursing units (First floor; Resident 17).

Findings include:

Clinical record review for Resident 17 revealed he was admitted to the facility on August 12, 2026. A physician order dated August 12, 2026, revealed resident was in isolation for active methicillin-resistant staphylococcus aureus (MRSA) (a type of staph bacteria that does not respond to many common antibiotics) infection and during treatment all meals and services were to be provided in his room.

Clinical record review for Resident 17 revealed a physician order dated August 14, 2026, for vancomycin (a powerful antibiotic used to treat severe, resistant bacterial infections) 1 gram intravenously daily and treatment to end on September 30, 2026.

Observation of Resident 17 on September 1, 2026, at 9:27 AM and September 2, 2026, at 9:17 AM revealed the resident in a chair in the common dining room on the first floor with other residents.

Interview with Employee 4, licensed practical nurse, on September 2, 2026, at 9:20 AM confirmed that resident was in the common dining room with other residents and she was unaware of the physician order for meals and services to be provided in his room.

Observation of Resident 17's room on August 31, 2026, at 10:48 AM revealed a sign outside the resident's door instructing those who enter to implement contact precautions (infection control measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or resident ' s environment). The sign included instructions to don (put on) a gown and gloves before entering room and doffing (take off) the gown and gloves before exiting the room.

Observation of Resident 17 on August 31, 2026, at 12:26 PM revealed Employee 8, nursing assistant, entered the resident's room with a meal tray. Employee 8 did not don a gown or gloves prior to entering the room and did not perform hand hygiene prior to exiting his room. Concurrent interview with Employee 8 revealed she had asked other staff if she needed to wear a gown and gloves to deliver a meal tray and she was told no.

Observation of the first floor on August 31, 2026, at 10:35 AM revealed Employee 8 walking down the hallway carrying an uncovered soiled brief to the trash receptacle. Interview with Employee 8 revealed she was unaware that practice would potentially contaminate the environment.

Observation of the first floor on September 1, 2026, at 8:28 AM revealed a large clean linen cart located in the hallway near the beauty shop with the front uncovered. The facility failed to reduce the risk of accidental contamination of the clean linen.

The surveyor reviewed the above infection control concerns during an interview with the Director of Nursing on September 2, 2026, at 10:35 AM.

483.80 (a)(1)(2)(4)(e)(f) Infection Prevention and Control
Previously cited 9/5/25

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

Plan of Correction - To be completed: 10/12/2026

1. Facility is unable to retro correct deficient practice due to resident no longer on precautions.

2. All residents have the potential to be affected. Infection Preventionist will complete an visual audit of all current residents on transmission-based precautions to ensure precautions are being followed. Infection Preventionist will complete a visual audit on each unit on all 3 shifts to ensure that soiled linen and garbage is being disposed of appropriately and that all linen carts have been covered.

3. Infection Preventionist or designee will in-service all nursing staff on policy related to Categories of Transmission Based Precautions, Standard Precautions and Laundry and Bedding, Soiled as well as practice of ensuring that linen cart is covered at all times.

4. Infection preventionist will conduct 10 infection control observation audits weekly x 4 weeks, then monthly x 2 months. Results of audits will be reviewed by QAPI committee.

5. Date of Compliance 10/12/2026

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

§483.45(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;

Observations:

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 13, 38, and 40).

Findings include:

The facility' s medication error rate was 15.38% based on 26 medication opportunities with four errors.

Observation of Resident 13's medication administration on September 1, 2026, at 8:27 AM revealed Employee 3, licensed practical nurse, administered tamsulosin (medication that relaxes the muscles in the opening of the bladder) 0.4 milligrams (mg). Further observation revealed that the blister pack (a pre-formed plastic packaging used to store pharmaceuticals) had a yellow sticker that indicated taking the medication a half hour after the same meal every day.

Concurrent interview with Employee 3 revealed that the resident had just received her breakfast tray and had not started eating.

The medication reference Drugs.com instructions regarding the administration of tamsulosin noted, "Tamsulosin is taken once daily, about half an hour after the same meal every day" .

Resident 13 did not receive the medication within the above defined parameters.

Resident 13's current physician orders contained the following medication order: sensipar (a medication used to lower high levels of parathyroid hormone and calcium in the blood) 30mg give one tablet my mouth with meals.

Further observation of Resident 13's same medication administration pass on September 1, 2026, revealed that Employee 3 prepared the resident's medication prior to administration. Employee 3 proceeded to crush most of the tablets with a pill crusher device which included the sensipar tablet. Employee then proceeded to place the medication in pudding and administer them to Resident 72.

Observation of the blister pack for the sensipar medication included a yellow sticker that indicated do not crush the medication.

Concurrent interview with Employee 3 revealed that she had crushed the sensipar tablet prior to administering it in pudding.

The medication reference Drugs.com instructions regarding the administration of sensipar noted, "Do not crush or break a tablet" .

Observation of Resident 38's medication administration on September 2, 2026, at 8:40 AM revealed that Employee 4, licensed practical nurse, administered Colestid Oral Tablet 1 gram (a cholesterol lowering medication) while the resident was actively eating their breakfast. Observation of the blister pack had a yellow sticker indicating that the medication should be administered one hour after meals.

Clinical record review of Resident 38 revealed that the Medication Administration Record (MAR, document that includes all medications ordered for a resident by the physician and used to record administration data) also indicated that the medication should be taken one hour after meals.

Observation of Resident 40's medication administration on September 2, 2026, at 8:55 AM revealed Employee 4, licensed practical nurse, administered trazodone HCl (a type of antidepressant) Oral Tablet 25 milligrams.

Clinical record review for Resident 40 revealed that the physician order for Resident 40's trazadone medication instructed it should be administered at bedtime, indicating the medication was administered at the incorrect time.

The surveyors reviewed the above concerns with Resident 13, 38, and 40 during an interview with the Nursing Home Administrator and the Director of Nursing on September 3, 2026, at 10:25 AM.

483.45(f) Medication Errors
Previously cited 5/1/26

28 Pa Code 211.9 (a)(1) Pharmacy Services

28 Pa Code 211.10 (c) Resident Care Policies

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

Plan of Correction - To be completed: 10/12/2026

1. Medication error reports have been completed for resident #40, 38 and 13.

2. Audit will be completed for all residents ordered Tamsulosin to ensure time of administration if 1 ½ hrs following a meal, residents ordered Sensipar have additional instructions to do not crush, residents ordered Colestid will be administered 1 hour after meals and residents who are ordered Trazadone will be scheduled to be administered at HS.

3. DON or designee will educated all licensed staff on facility policy related to Administering Medications. All licensed staff will receive medication administration observation and competency with additional education provided as indicated.

4. DON or designee will complete 3 medication observations weekly x 2 months to ensure medications are not given in error. Results of audits will be reviewed by QAPI committee.

5 Date of compliance 10/12/2026

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by three of five residents reviewed (Residents 4, 11, and 2).

Findings include:

Clinical record review for Resident 4 revealed the facility admitted him on September 16, 2024, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life).

A review of Resident 4's annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 4, 2026, indicated that the facility assessed Resident 4 as having a diagnosis of dementia, or cognitive loss. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 4's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review revealed the facility admitted Resident 11 on May 5, 2026, with diagnoses including dementia.

A review of Resident 11's admission MDS dated June 11, 2026, indicated that the facility assessed Resident 11 as having a diagnosis of dementia, or cognitive loss. The facility determined that a care plan for dementia and cognitive loss would be developed.

The facility developed a care plan for Resident 11 noting he had verbal and physical agitation related to his dementia on June 5, 2026. The only interventions listed were for staff to administer Resident 11's medications per his physician orders, if Resident 11's behavioral intervention strategies are not working then leave and reapproach Resident 11 later, and a psych consult as needed. There were no individualized behavioral intervention strategies noted for the resident.

A review of Resident 11's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

Clinical record review for Resident 2, admitted May 17, 2023, revealed they an active diagnosis of dementia since December 12, 2023.

A review of Resident 2's annual MDS dated August 7, 2026, indicated that the facility assessed Resident 2 as having a diagnosis of dementia, or cognitive loss. The facility determined that a care plan for dementia and cognitive loss would be developed.

The facility developed a care plan for Resident 2 noting he had impaired cognitive function/dementia, impulse control disorder, anxiety, schizophrenia, and a history of suicidal ideation on May 25, 2023. Interventions listed included for staff to administer Resident 2's medications per his physician orders, maintain environmental and routine consistency, cue, reorient and supervise as needed, and ask yes/no questions. There were no individualized behavioral intervention strategies noted.

A review of Resident 2's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.

The above findings for Residents 4, 11 and 2 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on September 2, 2026, at 2:36 PM. They confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address managing the resident's dementia.

483.40(b)(3) Dementia Treatment and Services
Previously cited 9/5/25

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

Plan of Correction - To be completed: 10/12/2026

1. Care plans for resident # 4, 11 and 2 have been updated to include individualized behavioral intervention strategies to address diagnosis of dementia.

2. All residents with Dementia have the potential to be affected. Social worker will audit all residents with a diagnosis of Dementia to ensure their care plans include individualized behavioral management strategies and person centered interventions to address dementia

3. Social worker will be educated on regulation regarding Dementia care and Person centered care planning.

4. DON or designee will audit all new admissions with a diagnosis of dementia to ensure that care plans included individualized behavioral interventions and person centered care plans. Audits will be completed weekly x 4 weeks, then monthly x 2 months. Results of audits will be reviewed at QAPI committee.

5. Date of compliance 10/12/2026

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on review of clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for one of 11 residents reviewed (Resident 7).

Findings include:
Clinical record review for Resident 7 revealed an admission date of July 7, 2026. Resident 7 had no active physician's order indicating their code status (whether or not the patient wishes to receive all possible life-saving interventions if their heart stops or they stop breathing).

During an interview with Resident 7 on September 1, 2026, at 11:00 AM, they stated nobody had spoken with them regarding advanced directives, and that they did not have a living will and would like assistance in getting one.

Subsequent interview with Employee 6, registered nurse, at 11:15 AM confirmed the resident had no documented advanced directive available at the nursing station, and nothing in the resident' s electronic health records indicated she had an advanced directive.

Information regarding Resident 7's advanced directive was requested from the Nursing Home Administrator and the Director of Nursing on September 1, 2026, at 1:30 PM.

The Nursing Home Administrator confirmed that no information related to Resident 7's advanced directives was available on September 3, 2026, at 9:30 AM.

28 Pa. Code 201.29(a) Resident rights

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

Plan of Correction - To be completed: 10/12/2026

1. Advance directives reviewed with resident #7 and polst form completed and signed by physician. Facility is actively assisting resident in completing a living will.

2. DON or designee will complete an audit of all current residents to ensure advance directive directives have been completed and signed for all residents and orders reflect residents wishes.

3. DON or designee will educate all licensed staff on facility policy related to advance directives.

4. DON or designee will audit all new admissions weekly x 4 weeks, then biweekly x 4 weeks to ensure advance directives have been obtained for each resident. Results of audits will be reviewed by QAPI committee.

Date of Compliance 10/12/2026

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 clinical record review and staff interviews it was determined that the facility failed to ensure essential equipment for obtaining weights is maintained in a safe, operating condition for one of 10 residents reviewed (Resident 12).

Findings include:

Clinical record review for Resident 12 revealed thirteen nursing progress notes between the dates of February 1, 2026, and April 16, 2026, that reported his weight was unable to be obtained due to the Hoyer lift scale (medical transfer device used to safely lift and move patients with limited mobility and obtain weights) not functioning.

Interview with Employee 5, registered dietitian, on September 2, 2026, at 12:10 PM confirmed that the facility had one Hoyer lift scale and Resident 12 was unable to be weighed due to that scale not in operational condition at that time.

Interview with the Nursing Home Administrator and the Director of Nursing on September 2, 2026, at 2:42 PM confirmed that the Hoyer lift scale was not functioning at that time and the facility ordered a new scale which they have received. The Nursing Home Administrator added that the staff could have borrowed a Hoyer lift scale from their sister facility.

Cross refer 692

28 Pa Code 201.14 (a) Responsibility of licensee

Plan of Correction - To be completed: 10/12/2026

1. A new hoyer lift with scale was purchased and Resident 12 is to be weighed on hoyer scale going forward. The facility purchased a bariatric wheelchair scale as a contingency plan in case in the future if the hoyer scale would need repaired so weights can still be obtained. Resident 12 would be hoyered to the wheelchair and then wheeled on to the scale to obtain weights.

2. DON or Designee will complete an audit of current residents to ensure that weights have been obtained as ordered.

3. Dietician and Nursing staff will be educated on weight policy and to notify administration immediately if equipment is not available.

4. Dietician or designee will audit 10 residents weekly to ensure that weights have been completed as ordered. NHA will check hoyer lift weekly to ensure it is in working order. Audits will be completed weekly x 2 months. Results of audits will be reviewed by QAPI committee.

5. Date of Compliance 10/12/2026

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for one of five residents reviewed for unnecessary medications (Resident 11).

Findings include:

The facility policy entitled "Pharmacy Consultant Policy and Procedures," last reviewed without changes July 23, 2026, revealed the pharmacy consultant will conduct a monthly review of the medication administration record to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each individual resident. The pharmacy consultant will review the medication record for new admissions, re-admissions, and as requested by the Director of Nursing or Physician. The pharmacist will report any irregularities to the attending physician and the Director of Nursing, and these reports must be acted upon in a timely manner. The pharmacist will provide the Director of Nursing with pharmacy recommendation reports on an ongoing basis each month. The Director of Nursing will act upon these recommendations by bringing them to the attention of the attending physician and ensuring any changes are implemented in a timely manner.

Clinical record review for Resident for Resident 11 revealed a consultant pharmacist recommendation dated June 9, 2026, noting Advair (a prescription inhaler) contains an inhaled steroid and recommended rinsing mouth after each use to help avoid developing thrush, be added to the physician order, and medication administration record. The pharmacist also noted the Lidocaine Patch (pain relieving patch) order does not appear to have a prompt to remove the patch, noting the patches would be worn 12 hours on, 12 hours off, requesting a prompt be added to remove Lidocaine patch 12 hours after applying. Further review of Resident 11's clinical record revealed there was no evidence that the physician or Director of Nursing acted upon the pharmacist recommendation.

A consultant pharmacy recommendation dated July 21, 2026, revealed the pharmacist repeated the June 9, 2026, recommendations for the Advair and Lidocaine patch. There was no evidence that the physician or Director of Nursing acted upon the pharmacist's July 21, 2026, recommendation.

Interview with the Nursing Home Administrator and Director of Nursing on September 3, 2026, at 9:42 AM confirmed the facility failed to act upon Resident 11's June 9, and July 21, 2026, pharmacy recommendations until after the surveyor's questioning.

The facility failed to ensure that Resident 11's attending physician addressed the pharmacy recommendations in a timely manner.

28 Pa. Code 211.9 (k) Pharmacy services

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

Plan of Correction - To be completed: 10/12/2026

1. Resident 11's clinical record was reviewed by the Director of Nursing and attending physician/designee upon identification of the concern. The consultant pharmacist recommendations dated June 9, 2026, and July 21, 2026, regarding Advair and the Lidocaine Patch were reviewed and revised.

2. DON or designee will audit pharmacy consultant recommendations made in the past 30 days to ensure all recommendations have been addressed by physician or nursing

3. Nursing administration team will be in-serviced on policy related to Pharmacy Consultant policy and procedures.

4. DON or designee will audit all pharmacy recommendations made to either the physician or nursing to ensure that recommendations have been implemented timely. Audits will be completed monthly x 2 months. Results of audits will be reviewed by the QAPI committee.

5. Date of Compliance 10/12/2026

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on clinical record review and staff and resident interviews, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of two residents reviewed for mood and behaviors (Resident 11).

Findings include:

Clinical record review for Resident 11 revealed the facility admitted him on June 5, 2026, with a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event).

Review of Resident 11's history and physical dated May 8, 2026, revealed Resident 11's active problems included PTSD.

Review of a Trauma Screening Tool completed by Employee 11 (social worker) on June 5, 2026, revealed Employee 11 and psych nurse practitioner "resolved Resident 11's PTSD."

Review of a social service social history completed with Resident 11's daughter dated August 31, 2026, revealed Resident 11 was exhibiting symptoms of PTSD, noting loud noises as a trigger, and to keep Resident 11 in a quiet area.

Interview with Resident 11 on September 3, 2026, at 10:58 AM revealed Resident 11 became emotional when discussing his PTSD. Resident 11 stated his PTSD was related to his son passing away.

Interview with Employee 11 (social worker) on September 3, 2026, at 10:41 AM revealed that she was aware of Resident 11's son passing away. Employee 11 confirmed the facility failed to develop a comprehensive, person-centered care plan for Resident 11 related to his PTSD.

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

Plan of Correction - To be completed: 10/12/2026

1. The care plan for resident # 11 has been updated to reflect PTSD with known triggers and interventions to avoid or reduce mental anguish.

2. All residents with a known history of PTSD have the potential to be affected. Social worker or designee will complete an audit of all current residents with a diagnosis of PTSD to ensure that a comprehensive person centered care plan has been implemented to address known triggers and interventions in place to avoid or reduce mental anguish.

3. Social worker will be educated on policy related to Trauma informed care.

4. DON or designee will audit new admissions weekly x 4 weeks, then monthly x 2 months to ensure any new residents with dx of PTSD have comprehensive care plan for person centered care to address PTSD and known triggers. Results of audit will be reviewed by QAPI committee

5. Date of compliance 10/12/2026

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.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident' s range of motion of one of two residents reviewed (Resident 12).

Findings Include:

Clinical record review for Resident 12 revealed he was admitted on June 20, 2023, and he currently has diagnosis including dementia (a group of symptoms affecting memory, thinking, and social abilities) and schizophrenia (a mental illness that affects how people think, feel, and behave).

Review of Resident 12's quarterly Minimum Data Set (MDS, an assessment completed at periodic intervals of time to determine resident care needs) dated May 19, 2026, revealed facility staff assessed the resident as having no functional limitation in upper and lower extremity range of motion, and that the resident was dependent (required staff to perform the activity) for upper body dressing, lower body dressing, roll left and right, chair/bed to chair transfers, as well as not being able to ambulate.

Clinical record review for Resident 12 revealed an occupational therapy discharge summary dated July 28, 2026, which included discharge recommendations for a restorative range of motion program to be performed during activity of daily living (ADL) tasks.

Resident 12's clinical record revealed no evidence of a restorative range of motion program initiated after discharge from occupational therapy.

Interview with the Nursing Home Administrator and the Director of Nursing on September 3, 2026, at 10:09 AM confirmed no restorative range of motion program was initiated for Resident 12.

483.25(c) Mobility
Previously cited 9/5/25

28 PA Code 211.12 (d)(1)(5) Nursing Services

Plan of Correction - To be completed: 10/12/2026

1. ROM program has been initiated for resident #12 based on recommendations by occupational therapy.

2. All current residents have the potential to be affected. DON or designee will review all discharge summaries by occupational therapy for current residents in the past 30 days to ensure that recommendations for ROM have been initiated.

3. Nursing administration will be education on regulation for increasing/preventing decrease in ROM/Mobility

4. DON or designee will audit 5 occupational discharge summaries weekly to ensure any recommendations for ROM have been implemented on residents care plan. Audit will be completed weekly x 4 weeks, then monthly x 2 months. Results of audits will be reviewed by QAPI committee.

5. Date of compliance 10/12/2026

483.25 REQUIREMENT Quality of Care:

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment in accordance with professional standards of practice for a resident with an indwelling urinary catheter one of two residents reviewed (Resident 8).

Findings include:

Clinical record review for Resident 8 revealed the resident returned from the hospital on July 1, 2026, with an order for a foley catheter (a flexible tube placed through the urethra into the bladder to drain urine continuously). The diagnosis provided by the physician for his foley catheter was urinary retention (inability to completely empty the bladder) due to obstructive uropathy (blockage in the urinary tract).

There was no evidence of any orders related the care of Resident 8's catheter.

Review of Resident 8's treatment administration record (electronic document completed by licensed nurses to document administration of treatments) for July and August 2026, revealed no documentation for catheter care provided.

Review of Resident 8's nurse aide documentation for July and August 2026, revealed no documentation for catheter care provided.

Interview with the Director of Nursing on September 3, 2026, at 11:38AM confirmed the facility was unable to provide documentation that catheter care was provided to Resident 8.

483.25 Quality of Care
Previously cited 9/5/25

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

Plan of Correction - To be completed: 10/12/2026

1. Orders for foley care have been received for resident # 8.

2. All residents with foley catheters have the potential to be affected. Infection Preventionist or designee will audit all current residents with foley catheters to ensure that orders for care of foley have been implemented.

3. Licensed staff will be educated on policy related to care of foley catheters.

4. Infection Preventionist or designee will audit any new residents with foley catheters to ensure orders for care of foley have been implemented and will audit all current residents documentation record to ensure that care has been completed. Audits will be completed weekly x 2 months. Results of audits will be reviewed by QAPI committee.

5. Date of compliance 10/12/2026

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 clinical record review, observation, and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for identified care needs for four of 19 residents reviewed (Resident 2, 5, 51 and 60).

Findings Include:

Clinical record review for Resident 5 revealed they were admitted on February 26, 2026. An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) completed on the same date indicated "nutritional status" triggered on the Care Area Assessment (CAA- section of the MDS that identifies what risks or complications exist, and whether a care plan intervention is needed and if it is going to proceed to a care plan) for the resident and that it was to proceed to the resident's care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes, represented as the Focus, Goal, and Interventions/Tasks) .

Further review revealed that Resident 5 had active physician orders for nutritional supplements including 4oz of Boost VHC (a very high calorie nutritional drink) two times a day and ice cream one time a day.

Review of Resident 5's care plan revealed the resident's care plan listed a focus on the resident's nutrition with goals including maintaining nutritional status, and no significant change in weight, although, no interventions at all were listed for the resident's nutrition focus area.

During an interview on September 2, 2026, at 11:45 AM with Employee 5, registered dietitian, they confirmed that there were no interventions present for Resident 5 because they had not been aware it was their responsibility to ensure these were updated.

The Nursing Home Administrator and the Director of Nursing made aware of the above findings for Resident 5 on September 2, 2026, at 2:30 PM.

Clinical record review for Resident 2 revealed a nursing progress note dated August 30, 2026, that indicated the resident was exit seeking that afternoon and attempting to get on the elevators. Further review revealed additional progress notes dated August 9, 2026, indicating the resident was exit seeking, and again on May 8, 2026, stating that the resident was intercepted exiting before elevator doors closed.

Additionally, a progress note inputted by social services on August 21, 2026, for Resident 2 indicated the resident was positive for wandering behavior. Practitioner notes dated August 21, 2026, also discussed recent nocturnal wandering, and episodic exit-seeking behavior.

There was no evidence that the facility developed a care plan that described the resident's needs and preferences, and how the facility will assist in meeting these needs and preferences related to wandering and exit seeking behavior.

Documentation available related to Resident 2's wandering behavior was requested on September 2, 2026, at 2:30 PM from the Nursing Home Administrator and the Director of Nursing.

A progress note written by the Director of Nursing on September 2, 2026, at 5:21 PM after the above request, described the exit seeking behavior that occurred with Resident 2 on August 30, 2026, as an isolated event, and that the resident was not an elopement risk. Interview with the Director of Nursing on September 3, 2026, at 9:30 AM, revealed that she was unaware of the additional documented exit seeking episodes, and she confirmed that Resident 2 had not had a care plan in place related to their wandering behaviors.

Clinical record review for Resident 51 revealed resident had been admitted on August 3, 2026. Review of the resident's admission MDS dated August 9, 2026, revealed "dental care" triggered as an area on the resident's CAA summary as an area that was to proceed to the resident's plan of care.

Review of Resident 51's care plan revealed no evidence the resident's dental care was addressed.

Clinical record review for Resident 60 revealed resident was admitted on June 26, 2026. Review of an admission MDS completed on June 30, 2026, revealed "dental care" triggered as an area on the CAA summary as an area that was to proceed to the resident's plan of care.

Review of Resident 60's care plan revealed no evidence the resident's dental care was addressed.

Additional record review of Resident 60's admission MDS dated June 30, 2026, revealed that "nutritional status" triggered on the CAA summary and was to be added to resident's plan of care.

Review of Resident 60's care plan revealed a nutrition focus area and goal were added to the resident's care plan although, no interventions at all were listed for the nutrition focus area.

During an interview on September 2, 2026, at 11:45 AM with Employee 5, registered dietitian, they confirmed that there were no interventions present for Resident 60 because they had not been aware it was their responsibility to ensure these were updated.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing, on September 3, 2026, at 9:30 AM.

483.21(b)(1)(3) Develop/Implement Comprehensive Care Plan
Previously cited 06/05/2026

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

Plan of Correction - To be completed: 10/12/2026

1. Registered dietician has updated the nutritional care plan for resident # 5 to include nutritional risks and all current interventions. Care plan updated for resident # 2 to address wandering behavior. Care plan updated for resident #51 to address dental needs. Resident #60 care plan was updated to include interventions for nutritional focus along with dental care needs.

2. All residents with nutritional risks have the potential to be affected. Dieticians will complete an audit of all current residents most recent MDS to identify any residents that trigger on CAA for nutritional status and will ensure that the care plan addresses nutritional risks with current interventions. Nursing notes for the past 7 days will be reviewed to identify any residents with wandering behavior and care plan interventions will be implemented. Audit of all current residents triggering for dental care and care plans will be updated.

3. Registered dietician will be educated by Regional Dietician on identifying residents who triggers for nutritional risks and care planning process. Licensed staff will be in-serviced on requirement for putting interventions in place for residents with wandering behavior and residents requiring dental services.

4. RNAC will audit 5 MDS's weekly that have been completed to ensure that resident who trigger for nutritional risks, wandering behavior and need for dental care have a care plan with interventions to address risks. Audits will be completed weekly x 4 weeks, then monthly x 2 months. Results of audits will be reviewed by QAPI committee.
5. Date of compliance 10/12/2026

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

§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 observation and staff interview, it was determined that the facility failed to maintain adequate housekeeping and maintenance services to ensure a clean, comfortable, orderly, and homelike environment on two of two nursing units, (first floor and second floor) and for four of 24 residents reviewed (Residents 9, 24, 90, and 91).

Findings:

Observation of Resident 24's room on August 31, 2026, at 12:00 PM revealed four areas on the wall beside the bathroom door, each measuring four inches and roughly round, that appeared to have been treated with drywall mud. Concurrent interview with the resident revealed that the areas had always been like that and that her whole room was "a mess," as Resident 24 alerted to chairs that were in their room that were piled with personal items including clothing, blankets, washcloths, and assorted boxes and containers.

Observation on September 1, 2026, at 10:00 on the first floor in Hallway C revealed a clean linen cart with assorted items piled on top, including washcloths, a pillow, unopened boxes of gloves, wipes, tissues, an umbrella, a personal fan, and a reusable ice pack holder. Concurrent interview with Employee 7, licensed practical nurse, revealed she was unsure why those items were being stored up there.

Continued observation of the C Hallway revealed that the white tile floor at the threshold to the hallway near the first-floor nursing unit appeared to be gray and dirty. A metal dividing strip in the C Hallway across the floor was filled with crumbs and black debris.

Observation of Resident 9's room revealed a plastic chair rail running along the wall behind the resident ' s bed was broken and cracked. An eight-inch piece of plastic had separated and was noted to have jagged edges and pointed, sharp looking corners.

Observation of the second-floor environment on August 31, 2026, at 11:03 AM revealed the wall behind Residents 90 and 91's bed was marred. The floor in Resident 90's room was dirty with black sticky spots throughout the room. Observation of the dining room at this time revealed the floor was still dirty with food from breakfast and there were large sticky spots all over the floor. When walking across the dining room the surveyor's shoe stuck to the floor.

Observation of Resident 90's floor on September 1, 2026, at 10:52 AM revealed the floor remained dirty with sticky spots throughout.

Concurrent observation of Resident 48's floor revealed there was smashed food on the floor in front of her bed. The food appeared to be from the day prior. Further observation of Resident 48's floor on September 1, 2026, at 1:28 PM revealed the smashed food remained on the floor.

The above environmental concerns were reviewed with the Nursing Home Administrator and the Director of Nursing on September 1, 2026, at 1:30 PM.

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

Plan of Correction - To be completed: 10/12/2026

1. All areas of concern identified during survey have been remedied and corrected.

2. All resident areas have the potential to be affected. The administrator or designee will conduct a comprehensive environmental inspection of resident rooms, resident common areas, and linen carts on each unit. Any additional environmental concerns will be corrected.

3. The NHA or designee will educate all nursing, housekeeping and maintenance staff on regulation regarding maintaining a clean, comfortable, orderly and homelike environment.

4. NHA or designee will complete an environmental inspection of resident rooms, resident common areas and linen carts weekly x 4 weeks, then monthly x 3 months. Results of audits will be reviewed by QAPI committee.

5.Date of compliance 10/12/2026

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

§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.

Observations:

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' medication regime was free from potentially unnecessary medications for two of five residents reviewed for medication regimen review (Residents 4 and 11).

Findings include:

The facility policy titled " Behavior Assessment, Intervention and Monitoring " last reviewed without changes on July 23, 2026, indicates that the facility will identify residents with impaired cognition, altered behavior, or mental illness, and will then identify, document and inform the physician regarding any changes in a resident ' s mental status, behavior, and cognition. The facility will then monitor residents who are being treated for altered mood or behavior for any improvements or worsening in the resident ' s behavior, mood, and function, and document this in the clinical record. The facility nursing staff and physician will monitor for side effects and complications related to psychoactive medication (such as lethargy, anorexia, involuntary movements, recurrent falling).

Clinical record review revealed the facility admitted Resident 11 on June 5, 2026. Review of Resident 11 ' s medication regime included the use of the following psychotropic medications:

Seroquel (antipsychotic medication) 50 milligrams (mg), one tablet three times a day, related to a brief psychotic disorder.
Seroquel 25 mg, one table three times a day.
Olanzapine (antipsychotic medication) 2.5 mg, one tablet in the morning, related to his brief psychotic disorder.
Trazodone (antidepressant medication)100 mg, one tablet at bedtime, related to his major depressive disorder.

The facility initiated a care plan on June 5, 2026, noting Resident 11 was at risk for adverse effects related to his psychotropic medication use, with a goal to show no side effects of his medication use.

Review of Resident 11 ' s Medication Administration Record and Treatment Administration Records dated June, July, and August 2026, revealed no ongoing monitoring of Resident 11 ' s potential adverse side effects from the use of his antipsychotic and antidepressant medications.

Clinical record review revealed the facility admitted Resident 4 on September 16, 2024. Review of Resident 4's medication regime included the use of the following psychotropic medications:

Rexulti (Antipsychotic medication) 1 mg, one tablet every day, related to his brief psychotic disorder
Trazodone 50 mg, one tablet at bedtime related to his major depressive disorder
Trazodone 100 mg, one tablet at bedtime related to his major depressive disorder

Review of Resident 4's clinical record did not include evidence that the facility monitored Resident 4's individualized targeted behavior symptoms related to his use of psychotropic medications.

Interview with the Nursing Home Administrator and Director of Nursing on September 3, 2026, confirmed the above findings for Residents 11 and 4.

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

Plan of Correction - To be completed: 10/12/2026

1. Facility initiated side effect monitoring and behavior monitoring for resident # 11 and #4.

2. DON or designee will complete an audit of all residents receiving psychotropic medications and ensure that side effect monitoring and behavior monitoring are in place.

3. DON or designee will educate all licensed staff on facility policy related to Behavior assessment, intervention and monitoring.

4. DON or designee will complete order reviews to identify any residents with new orders for psychotropic meds to ensure behavior monitoring and side effect monitoring has been implemented. Audits will be completed 5 x week x 4 weeks, then weekly x 4 weeks. Results of audits will be reviewed by QAPI committee.

5. Date of compliance. 10/12/2026

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

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

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

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

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 19 residents reviewed (Resident 1).

Findings include:

Clinical record review for Resident 1 revealed a MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 1, 2026, that the facility assessed Resident 1 as having an active diagnosis of pneumonia.

Interview with the Director of Nursing and Nursing Home Administrator on September 2, 2026, at 2:36 PM confirmed Resident 1's MDS was coded in error regarding his pneumonia diagnosis. The Director of Nursing confirmed Resident 1 was never diagnosed with pneumonia.

The facility failed to accurately assess Residents 1's MDS assessments as noted above.

28 Pa. Code 211.5(f)(ix) Medical records

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

Plan of Correction - To be completed: 10/12/2026

1. MDS for resident # 1 has been modified to remove diagnosis of pneumonia.

2. All residents have the potential to be affected. RNAC or designee will audit all MDS's submitted in the past 30 days to verify accurate coding for infections based on applicable MDS coding requirements.

3. NHA or designee will provide education to RNAC regarding coding of infections based on RAI guidelines.

4. NHA or designee will audit 5 MDS's weekly x 4 weeks, then biweekly x 1 month to ensure accuracy of coding related to infections. Results of audits will be reviewed by QAPI committee.

5. Date of compliance 10/12/2026

§ 201.14(a) LICENSURE Responsibility of licensee.:

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

Observations:

Based on staff interview and review of facility documents, it was determined that the facility did not comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan.

Findings include:

Act 52, Infection Control Plan, states that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable, to the specific health care facility:

(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee, or contractor of the health care facility.

Interview with Employee 10, infection preventionist, on September 1, 2026, at 10:10 AM revealed that the facility conducted infection control committee meetings during their scheduled QAPI (Quality Assurance Performance Improvement) meetings on a monthly basis but had separate sign-in sheets for their infection control portion of the meetings.

Review of the facility's monthly Infection Control meeting sign-in sheets from January 2026 through August 2026 (time of the survey), revealed that a laboratory representative, pharmacist, physical plant/safety officer, or a community member were noted as present for any of the following dates:

January 27, 2026
February 24, 2026
March 24, 2026
April 28, 2026
May 26, 2026
June 23, 2026
July 28, 2026
August 25, 2026

Interview with the Nursing Home Administrator and the Director of Nursing on September 2, 2026, at 2:25 PM confirmed the above required attendees were not present at any of the meetings.

Plan of Correction - To be completed: 10/12/2026

1.The facility acknowledges that the multidisciplinary Infection Control Committee did not include representation from all applicable disciplines as required by the facility's Act 52 Infection Control Plan. Immediately upon identification of the deficiency, the Nursing Home Administrator (NHA) and Infection Preventionist (IP) reviewed the facility's Infection Control Committee structure and meeting process. The facility will establish and maintain a multidisciplinary Infection Control Committee that includes representation from the applicable disciplines identified in the Act 52 Infection Control Plan.

2. All residents and staff may potentially be affected by failure to maintain a properly constituted multidisciplinary Infection Control Committee. The Nursing Home Administrator and Infection Preventionist will review the Infection Control Committee membership and meeting attendance requirements to ensure that all applicable disciplines are identified and represented.

3. The Nursing Home Administrator, Director of Nursing, Infection Preventionist, Medical Director, and applicable department heads/committee representatives will receive education regarding the requirements of the Act 52 Infection Control Plan and the facility's revised Infection Control Committee process.

4. The Infection Preventionist or designee will audit the Infection Control Committee roster and meeting attendance monthly for three (3) consecutive months to verify that the required applicable disciplines are represented and attendance is appropriately documented.

5. Date of Compliance 10/12/2026

§ 201.18(b)(2) LICENSURE Management.:

(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.

Observations:

Based on closed clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure accurate documentation regarding the disposition of a resident ' s personal belongings for two of three closed record reviews (Resident 87 and 89).

Findings include:

Closed clinical record review for Resident 89 revealed the resident was admitted to the facility on July 1, 2026, and was discharged on July 5, 2026. Further review of Resident 89's clinical record review revealed a document titled, "Inventory of Personal Effects" signed by the resident on admission but lacked a signature for receipt of personal property upon discharge.

Closed clinical record review for Resident 87 revealed the resident was admitted to the facility on July 21, 2026, and was discharged to the hospital on August 3, 2026. There was no documentation in Resident 87's closed clinical record regarding the disposition of her personal belongings.

Interview with the Nursing Home Administration on September 3, 2026, at 8:38 AM confirmed she had no evidence of the disposition of Resident 87 and 89's personal belongings upon discharge.

Plan of Correction - To be completed: 10/12/2026

1.  Facility is unable to retro correct deficient practice.

2. All residents who discharge, transfer to another facility, transfer to a hospital, or otherwise leave the facility may potentially be affected by this deficient practice. The Director of Nursing (DON), Nursing Home Administrator (NHA), and Medical Records/Health Information staff will conduct a facility-wide review of residents discharged within the previous 30 days to determine whether documentation of personal belongings disposition is present in the closed or discharge record.

3. The facility will implement a standardized Resident Discharge – Personal Belongings and Property Disposition Checklist that will be completed for every resident upon discharge, transfer, or other departure from the facility. All staff will receive education regarding the revised personal belongings disposition process.

4. The Director of Nursing or designee will audit 10 discharged/transferred resident records weekly for four (4) weeks to verify that personal belongings disposition is accurately documented. Following the initial four-week period, the DON/designee will audit 5 discharged/transferred resident records weekly for two (2) additional months. Results will be reviewed monthly at QAPI.

5. Date of Compliance 10/12/2026

§ 201.19(4) LICENSURE Personnel policies and procedures.:

(4) A determination by a health care practitioner that the employee, as of the employee's start date, is free from the communicable diseases or conditions listed in § 27.155 (relating to restrictions on health care practitioners).

Observations:

Based on review of employee personnel records and staff interview, it was determined that the facility failed to ensure personnel records included verification of employees' health status for one of five employees reviewed (Employee 2).

Findings include:

Review of Employee 2's (licensed practical nurse) personnel file revealed that the facility hired her on June 14, 2026.

Personnel file for Employees 2 did not include any evidence or documentation by a licensed practitioner (e.g., physician) of verification of the employees' health status to attest that Employee 2 was free of communicable disease to support placement in the position to which she was assigned.

Interview with the Nursing Home Administrator on September 2, 2026, at 10:04 AM confirmed the above findings for Employee 2.

Plan of Correction - To be completed: 10/12/2026

1. The facility acknowledges that Employee 2's personnel record did not contain documentation from a licensed practitioner verifying the employee's health status and attesting that the employee was free of communicable disease to support placement in the position to which she was assigned. Upon identification of the deficiency, the Nursing Home Administrator (NHA) and Director of Nursing (DON) reviewed Employee 2's personnel record. The facility will obtain the required health-status verification from a licensed practitioner, consistent with applicable Pennsylvania requirements and facility policy. The completed documentation will be placed in Employee 2's personnel record.

2. The NHA/designee will conduct an audit of active employee personnel files to determine whether required health-status verification documentation is present. Any missing documentation will be identified and addressed promptly in accordance with applicable requirements and facility policy.

3. The facility will revise its employee onboarding and personnel-file checklist to include a specific verification step for employee health status. The Nursing Home Administrator/designee, and department managers involved in hiring or onboarding employees will be educated regarding the requirements for documenting employee health status.

4. The Nursing Home Administrator/designee will audit the facility's new hires weekly for four (4) weeks to verify compliance with new hire health status and then monthly for 2 months. Results will be reviewed in monthly QAPI.

5. Date of Compliance 10/12/2026

§ 201.22(b) LICENSURE Prevention, control and surveillance of tuber:

(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:

Based on a review of select personnel records and staff interview it was determined that the facility failed to adhere to recommendations of the Centers for Disease Control and Prevention (CDC) related to screening newly hired employees for TB (tuberculosis) for one of five newly hired employees reviewed (Employee 1).

Findings include:

The Centers for Disease Control and Prevention (CDC) recommendations (https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm) stipulates that all U.S. health care personnel should be screened for TB upon hire (i.e., preplacement) by either a TB blood test or a two-step TB skin test. Information from the baseline individual TB risk assessment should be used to interpret the results of a TB blood test or TB skin test given upon hire (i.e., preplacement). Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease.

Review of Employee 1's (nurse aide) personnel record revealed that the facility hired her on June 1, 2026. Information available in Employee 1's personnel record revealed evidence of a two-step tuberculin skin test given on October 7 and October 15, 2025. The first tuberculin skin test was read on October 9, 2025, and the results were documented as negative. There was no evidence the second tuberculin skin test was not read.

Employee 1's personnel record also had no evidence of additional preplacement tuberculin skin test upon her hire date at the facility.

Interview with the Nursing Home Administrator on September 2, 2026, at 10:04 AM confirmed the above findings for Employee 1.

Plan of Correction - To be completed: 10/12/2026

1. Employee 1 will be referred for appropriate TB screening consistent with current CDC recommendations and facility policy. The facility will ensure that required testing, risk assessment, symptom evaluation, and any follow-up indicated by the results are completed and appropriately documented.

2. All newly hired health care personnel may potentially be affected by this deficient practice. The NHA, DON, and Human Resources/Personnel designee will conduct an audit of personnel records for all employees hired within the previous 12 months to verify that baseline/preplacement TB screening is appropriately documented.

3. The facility will revise its employee onboarding and Employee Health/TB Screening process to specifically require verification of baseline TB screening before completion of the employee's preplacement health clearance. The Nursing Home Administrator, Director of Nursing, Human Resources/Personnel staff, Employee Health staff, and managers responsible for employee onboarding will receive education regarding TB screening requirements for newly hired health care personnel. Staff responsible for performing or documenting TB skin testing will receive additional education regarding the importance of documenting the date and result of each test reading.

4. The Nursing Home Administrator or designee will audit newly hired health care personnel records weekly for four (4) weeks to verify that required preplacement TB screening is complete and properly documented. Following the initial four-week period, the NHA/designee will audit 10 newly hired employee records monthly for three (3) months, or all newly hired employee records if fewer than 10 employees were hired during the audit period. Results will be reviewed monthly at QAPI.

5. Date of Compliance 10/12/2026

§ 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 closed record review and staff interview, it was determined that the facility failed to ensure completion of a discharge summary for three of three discharged residents reviewed (Residents 87, 88, and 89).

Findings include:

Closed clinical record review for Resident 87 revealed the facility admitted the resident on July 21, 2026, and discharged the resident on August 3, 2026. Review of Resident 87's closed clinical record on September 3, 2026, revealed Resident 87's record did not contain a discharge summary including final diagnosis.

Interview with the Nursing Home Administrator on September 3, 2026, at 9:49 AM confirmed the above findings for Resident 87.

Closed clinical record review for Resident 89 revealed the resident admitted to the facility on July 1, 2026, and discharged on July 5, 2026. Review of Resident 89's closed clinical record on September 1, 2026, revealed Resident 89's record did not contain a discharge summary including final diagnosis.

Interview with the Nursing Home Administrator on September 3, 2026, at 8:38AM confirmed the above findings for Resident 89.

Closed clinical record review for Resident 88 revealed the facility admitted them on June 17, 2026, and they were discharged from the facility on July 7, 2026. Review of Resident 88's record revealed it did not contain a discharge summary including final diagnosis.

Interview with the Nursing Home Administrator on September 2, 2026, they confirmed that a discharge summary could not be located for Resident 88.

Plan of Correction - To be completed: 10/12/2026

1. Because these residents have already discharged, the facility is unable to retro correct the deficient practice.

2. All residents who are discharged or transferred from the facility may potentially be affected by this deficient practitioner. The Medical Records/Health Information designee, DON, and NHA will conduct an audit of all resident records for residents discharged within the previous 30 days to determine whether a completed discharge summary is present and includes the resident's final diagnoses.

3. The facility will revise its discharge process and discharge-summary policy to establish a standardized process for completion, review, and filing of discharge summaries. Director of Nursing, licensed nursing staff, Medical Records, and other staff involved in the discharge process will receive education regarding discharge-summary requirements.

4. The Director of Nursing or designee, in collaboration with Medical Records, will audit 10 discharged resident records weekly for four (4) weeks to verify that discharge summaries are present and complete. Following the initial four-week period, 5 discharged resident records will be audited weekly for two (2) additional months.

5. Date of Compliance 10/12/2026

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:

(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on closed clinical record review and staff interviews, it was determined that the facility failed to document the accounting and disposition of medications in the clinical record upon discharge for two of the three residents reviewed (Residents 87 and 89).

Findings include:

Closed record review for Resident 87 revealed that the facility discharged Resident 87 to the hospital on August 3, 2026.

Review of Resident 87's closed clinical record revealed there was no documentation for the accounting and disposition of the following medications:

Furosemide (for edema) 20 milligrams (mg) tablet
Glipizide (for diabetes) 10 mg tablet
Novolog (for diabetes) 100 unit/milliliter

Interview with Nursing Home Administrator on September 3, 2026, at 9:49 AM confirmed that the facility was unable to provide documented evidence of appropriate disposition of Resident 87's medications upon discharge.

Closed record review for Resident 89 revealed that the facility discharged the resident on July 5, 2026.

Review of Resident 89's closed clinical record revealed there was no documentation for the accounting and disposition of the following medications:

Famotidine (for heartburn) 20 milligrams (mg) tablet
Fluoxetine HCL (for depression) 20 mg
Levothyroxine (for underactive thyroid) 88 micrograms (mcg)
Losartan Potassium (for high blood pressure) 25 mg
Omeprazole (for reflux) 20 mg
Rosuvastatin calcium (for high cholesterol) 40 mg
Cefadroxil (for bacterial infection) 500 mg
Oxycodone (for pain) 5 mg
Tizanidine (to relax muscles) 4 mg

Interview with the Nursing Home Administrator on September 3, 2026, confirmed the facility was unable to provide documented evidence of appropriate disposition of Resident 89's medication upon discharge.

Plan of Correction - To be completed: 10/12/2026

1. The facility is unable to retro-correct the deficient practice.

2. All residents who discharge, transfer to another facility, or are transferred to a hospital may potentially be affected by this deficient practice. The DON/designee and Medical Records/Health Information designee will conduct an audit of residents discharged or transferred within the previous 30 days to verify that documentation of medication accounting and disposition is present in the clinical record. Any missing documentation will be addressed using available, verifiable information and appropriate documentation procedures.

3. All licensed nurses, medication nurses, nursing supervisors, Medical Records staff, and other personnel involved in resident discharge or transfer will receive education regarding the revised medication accounting and disposition process.

4. The Director of Nursing or designee will audit 10 discharged/transferred resident records weekly for four (4) weeks to verify that medication accounting and disposition are appropriately documented. Following the initial four-week period, the DON/designee will audit 5 discharged/transferred resident records weekly for two (2) additional months. If fewer than the required number of residents are discharged/transferred during an audit period, all applicable records will be reviewed. Results will be reviewed monthly at QAPI

5. Date of Compliance 10/12/2026

§ 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.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents on the day shift for one of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility for August 27, 2026, through September 2, 2026, revealed the following LPNs scheduled for the resident census:

Day Shift (requires one LPN per 25 residents):

August 29, 2026, 3.20 LPNs for a census of 84; requires 3.36 LPNs

The above information was reviewed with the Nursing Home Administrator on September 2, 2026, at 2:30 PM.

Plan of Correction - To be completed: 10/12/2026

1. The facility cannot retro the deficiency and acknowledges that the nursing staff care hours for the day shift on August 29, 2026, did not meet the required LPN staffing level based upon the resident census.

2. The DON or designee will review the resident census and staffing schedule for each shift prior to the beginning of the shift to verify that required nursing staffing levels are met. The DON and NHA will review the staffing schedule at least 24 hours in advance whenever possible to identify anticipated staffing shortages.

3. The NHA, DON, Assistant Director of Nursing, staffing coordinator, nursing supervisors, and other staff responsible for creating or reviewing nursing schedules will receive education regarding applicable staffing requirements and the facility's revised staffing-monitoring process.

4. The Director of Nursing or designee will audit the facility's nursing staffing levels daily for four (4) weeks to verify compliance with applicable LPN staffing requirements. Results will be reviewed monthly at QAPI.

5. Date of Compliance 10/12/2026

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