Pennsylvania Department of Health
LOCUST GROVE RETIREMENT VILLAGE
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LOCUST GROVE RETIREMENT VILLAGE
Inspection Results For:

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LOCUST GROVE RETIREMENT VILLAGE - 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 a Civil Rights Compliance Survey, completed on July 10, 2026, it was determined that Locust Grove Retirement Village 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:

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

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.

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

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

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

Plan of Correction - To be completed: 08/06/2026

1. Expired, unlabeled, and improperly stored food items were discarded immediately. Refrigeration and freezer storage areas were inspected and temperature monitoring practices were reviewed.
2. An audit was completed of food storage and preparation areas, including review of dating, labeling, storage practices, and temperature logs.
3. Dietary staff were re-educated regarding food safety requirements and documentation of corrective actions.
4. The Dietary Manager or Designee will conduct daily audits for 4 weeks and weekly audits x 2 months. The results of these audits will be reviewed during QAPI.

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

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(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 maintenance services to ensure a clean, comfortable, orderly, and homelike environment on one of four nursing units (100 Hall) and in facility's main activity room. Findings Include: Observations on July 8, 2026, at 11:15 AM of the activity room revealed residents were gathered around the tables. Large brown stains were noted scattered on the ceiling at various areas, the largest area was roughly round and measuring two feet in diameter. A dried brown area was also noted in the fluorescent light fixture. Further observation revealed there was water gathering on the ceiling and dripping into a bucket that was located between two tables with residents gathered around them. There was a round two-inch hole noted in the ceiling near roughly ten inches from where the water was gathering and dripping into a bucket on the ground. A second area, located further into the room revealed water pooling on the ceiling. A bucket/bin was not located below this area, and a small amount of water had started to gather on the floor below. Concurrent interview with Employee 1, Activities Director, revealed that the water was believed to be from condensation from the air condition lines located above the ceiling. Employee 1 indicated that repairs to the ceiling had been completed in the past and that the problem seemed to recur multiple times over the years she had been there. The Nursing Home administrator and the Director of Nursing were made aware of the above concerns during a meeting on July 9, 2026, at 2:30 PM. Observation of the shower room on the 100 Nursing Unit on July 9, 2026, at 9:38 AM revealed a section of the cove base missing (where the floor met the wall) with underlying brick visible. Further observation revealed a significant accumulation of dust on a ceiling vent. The above information for the shower room was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 10, 2026, at 10:56 AM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Plan of Correction - To be completed: 08/06/2026

1. The Activity Room ceiling leak, stained ceiling areas, and the ceiling opening were repaired. The missing cove base in the 100 hall shower room was repaired. The dusty vent in the 100 hall shower room was cleaned.
2. A Facility-wide Environmental audit of Resident rooms, shower rooms, common areas, and ancillary departments was completed to identify damaged ceiling surfaces, missing cove base, or dusty vents.
3. Staff were educated regarding prompt reporting of environmental hazards.
4.The Maintenance Director or Designee will complete weekly environmental audits for four weeks and monthly audits for 2 months. Results will be reviewed through QAPI and corrective action initiated as needed.

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 and resident and staff interview, it was determined that the facility failed to develop a comprehensive person-centered care plan regarding dementia care for two of two residents reviewed (Residents 8 and 10). Findings Include: Clinical record review for Resident 8 revealed they had an active diagnosis of unspecified dementia (decline in cognitive ability) , unspecified severity, with other behavioral disturbance that was initiated on November 29, 2022. Further review of Resident 8's clinical record revealed a care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) focus area initiated for the resident's impaired cognitive function updated May 15, 2026. Interventions for the focus area only included general statements such as asking yes/no questions, present just one thought, idea, or question at a time, and to document/report changes in cognitive function. Resident 8's care plan did not include any individualized information or any individualized interventions specific to resident to manage the resident's cognitive loss to aid staff caring for the resident. The Nursing Home administrator and the Director of Nursing were made aware of the above findings during a meeting on July 10, 2026, at 11:10 AM. The Nursing Home administrator and the Director of Nursing were made aware of the above findings during a meeting on July 10, 2026, at 11:10 AM. Clinical record review for Resident 10 revealed an active diagnosis of dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety dated September 18, 2025. Further review of Residents 10's clinical record revealed a care plan focus initiated July 16, 2024, for the resident's impaired cognitive function. Interventions included only general statements such as asking yes/no questions, cue, reorient and supervise as needed, communicate with the resident and family regarding capabilities and needs, educate on the disease process, and to keep care consistent. There was no evidence to indicate any individualized interventions specific to the resident's history, approaches or care needs were indicated for the resident's cognitive loss to aid in the resident's care. The above information regarding Resident 10 was reviewed with the Nursing Home Administrator and Director of Nursing on July 10, 2026, at 12:35 PM. The facility failed to develop comprehensive person-centered care plans for Resident 8 and 10's dementia diagnosis. 483.21(b)(1)(c)(3) Comprehensive Care Plans 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Plan of Correction - To be completed: 08/06/2026

1. Resident's 8 and 10 had comprehensive dementia-related care plans revised to include individualized, person-centered interventions.
2. A 100% audit of Residents with dementia or cognitive impairment was conducted to ensure individualized interventions are present on their dementia/cognitive loss care plan.
3. Nursing, Social Services, and MDS Staff were educated regarding individualized dementia care planning requirements.
4. The Social Service Director or Designee will audit 5 dementia/cognitive loss care plans weekly x 4 weeks and monthly x 2 months. Results of audits will be reviewed in QAPI meetings.

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, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 38 and 72). Findings include: The facility's medication error rate was 12 percent based on 25 medication opportunities with three medication errors. Observations on July 9, 2026, at 8:54 AM of Resident 38's medication administration revealed Employee 2, licensed practical nurse, administered 12.5 mg (milligrams) Movantik (a medicine used for constipation, also known as Naloxegol Oxalate) oral tablet. Further observation revealed that the blister pack (a pre-formed plastic packaging used to store pharmaceuticals) had a yellow sticker that indicated taking the medicine on an empty stomach. Concurrent interview with Employee 2 revealed that the residents in the hallway had already eaten breakfast. Review of facility documents indicate that meal delivery times for breakfast on Resident 38's unit is 7:25 AM. The medication reference Drugs.com instructions regarding the administration of Movantik noted, "Take this medicine on an empty stomach, at least 1 hour before or 2 hours after your first meal of the day." During an interview with Employee 2 on July 10, 2026, at 10:32 AM, she stated that she never noticed the sticker before. Resident 38 did not receive the medication within the above defined parameters. The Nursing Home administrator and the Director of Nursing were made aware of the above concerns during a meeting on July 10, 2026, at 11:30 AM. Resident 72's current physician orders contained the following medication order: Potassium Chloride (a medication used to treat or prevent low potassium levels in the blood) Crys ER (oral extended release) 20 milliequivalents (MEQ); potassium chloride microencapsulated crystals extended release; give one tablet by mouth one time a day for hypokalemia (low potassium levels). Further review of Resident 72's physician orders revealed an order dated April 4, 2021, that crushable medications may be crushed, mixed, and administered together unless contraindicated. Observation of Resident 72's medication administration pass on July 9, 2026, at 9:18 AM revealed that Employee 3, licensed practical nurse (LPN), prepared the resident's medications prior to administration. Employee 3 proceeded to crush the tablets with a pill crushing device which included the Potassium Chloride ER tablet. Employee 3 then proceeded to place the medications in pudding and administer them to Resident 72. A follow-up interview with Employee 3 on July 9, 2026, at 11:10 AM confirmed that the LPN had crushed the resident's potassium. Review of the potassium administration pill pack for Resident 72 revealed a sticker on the medication card that indicated to not chew or crush before swallowing; may break or disintegrate in water, rinse down, do not chew particles. The above information for Resident 72 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 9, 2026, at 2:30 PM. The facility provided documentation titled, "Drug Information," for Potassium Extended-Release Dispersible Tablet Oral. The documentation noted a "How To Use" section that instructed (in part) to "Do not crush, chew, or suck on the tablets. Doing so can release all of the drug at once, increasing the risk of side effects." A follow-up interview on July 10, 2026, at 11:00 AM with the Nursing Home Administration and Director of Nursing revealed that the Director of Nursing indicated that the potassium should not have been crushed. Further review of Resident 72's physician orders revealed an order for Breo Ellipta Aerosol Powder Breath Activated 100-25 micrograms (mcg) / inhalation (INH) Fluticasone Furoate Vilanterol (a medication used to help reduce inflammation in the lungs and improve airflow); administer one puff inhale orally one time a day related to chronic obstructive pulmonary disease (COPD, a lung disease that causes inflammation and restricted air flow into and out of the lungs). Further observation of the medication pass for Resident 72 on July 9, 2026, at 9:40 AM revealed that Employee 3 administered an oral inhalation puff of the inhaler to the resident. Employee 3 did not instruct the resident to rinse their mouth after the medication use. The resident was then observed taking a drink and swallowing the liquid. A follow-up observation on July 9, 2026, at 11:10 AM revealed that the box for the Breo Ellipta revealed a yellow sticker affixed to the side that indicated to rinse mouth after each use. The manufacturer's instructions on the box also instructed to rinse mouth after each use. The above information for Resident 72 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 9, 2026, at 2:30 PM. The facility provided documentation titled, "Drug Information," for the Breo Ellipta 100-25 mcg inhaler. The documentation noted a "How To Use" section that instructed (in part), "To prevent dry mouth, hoarseness, and oral yeast infections from developing, gargle, rinse your mouth with water and spit out after each use. Do not swallow the rinse water." A follow-up interview on July 10, 2026, at 11:00 AM with the Nursing Home Administration and Director of Nursing revealed that the Director of Nursing indicated that the resident should have rinsed their mouth and spit out the rinse following medication administration of the Breo Ellipta. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 08/06/2026

1. Medication administration practices for Residents 38 and 72 were reviewed. Nurses involved received counseling and education regarding medication specific administration instructions, non-crush medications, inhaler administration, and pharmacy caution labels.
2. An audit was completed for Residents with medications requiring non-crush, medications requiring administration on an empty stomach, and inhalers requiring mouth rinsing after administration.
3. All licensed nurses were reeducated regarding medication administration rights and medication-specific instructions. Competency validation was completed.
4. Five medication pass observations will be completed weekly by the DCS or designee for four weeks and monthly for 2 months. Findings will be reviewed through QAPI.

§ 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 four of five employees reviewed (Employees 5, 6, 7 and 8). Findings include: Review of Employee 5's (resident aide) personnel file revealed that the facility hired him on June 29, 2026. Review of Employee 6's (license practical nurse) personnel file revealed that the facility hired her on May 12, 2026. Review of Employee 7's (registered nurse) personnel file revealed that the facility hired her on May 12, 2026. Review of Employee 8's (nurse aide) personnel file revealed that the facility hired her on March 3, 2026. Personnel files for Employees 5, 6, 7, and 8, did not include any evidence or documentation by a licensed practitioner (e.g., physician) of verification of the employees' health status to attest that the four employees were free of communicable disease to support placement in the position to which they are assigned. Interview with Employee 9, human resources coordinator, on July 9, 2026, at 3:20 PM, confirmed the facility had no evidence that a licensed practitioner verified the health status for the employees indicated above. Interview with Nursing Home Administrator on July 10, 2026, at 10:21 AM, confirmed the facility failed to obtain a license practitioners signature for the above findings for Employees 5, 6, 7, and 8.

Plan of Correction - To be completed: 08/06/2026

1. Required Practitioner verification of health status was obtained for affected employees and placed in their personnel files.
2. An audit of current Staff personnel files was completed to verify required pre-employment health documentation.
3. The HR onboarding checklist was revised to require completion and verification of Practitioner health screenings before employees begin work.
The HR Director was provided education on need to verify pre-employment health documentation.
4. The HR Director will audit all new employee files for 3 months to ensure pre-employment health documentation is present in their personnel file. Audits will be reviewed during QAPI.

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

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

Plan of Correction - To be completed: 08/06/2026

1. The Facility cannot retroactively correct past CNA Ratios.
2. The Facility will continue to take measures to adequately provide CNA staff to ensure the needs of the Residents are met. These measures include regular Recruitment and Retention meetings, increased advertising efforts, utilization of Agency staff, and our CNA class graduates.
3. The Director of Clinical Services/Designee will provide education on minimum CNA staffing ratios to RN Supervisors, HR Director, and Scheduler.
4. The Director of Clinical Services/Designee will audit daily schedules 5 times a week for 6 weeks. the results of the audits will be reviewed during our QAPI meetings.

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

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

Observations: Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, for five of 21 days reviewed. Findings include: Review of nursing staff care hours provided by the facility for February 15, 2026, through February 21, 2026, May 24, 2026, through May 30, 2026, and July 3, 2026, through July 9, 2026, revealed that the facility failed to meet the minimum hours per patient day for the following days: February 21, 2026, with 3.08 hours per resident per day. May 24, 2026, with 3.01 hours per resident per day. May 26, 2026, with 3.17 hours per resident per day. May 29, 2026, with 3.18 hours per resident per day. July 4, 2026, with 3.04 hours per resident per day. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on July 9, 2026, at 2:15 PM.

Plan of Correction - To be completed: 08/06/2026

1. The Facility cannot retroactively correct past PPD levels.
2. The Facility will continue to put measures in place to adequately provide Nursing Staff to ensure the needs of the Residents are met. These measures include our Recruitment and Retention committee, increased advertising efforts, utilization of Agency Staff, and our CNA graduates.
3. The Director of Clinical Services/Designee will provide education on minimum CNA staffing ratios to RN Supervisors, HR Director, and Scheduler.
4. The Director of Clinical Services/Designee will audit the daily schedules 5 times a week for 6 weeks. The results of the audits will be reviewed during our QAPI meetings.

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