Pennsylvania Department of Health
 ONYX WELLNESS CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ONYX WELLNESS CENTER
Inspection Results For:

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ONYX WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated Survey in response to three complaints, completed on February 05, 2026, it was determined that Onyx Wellness Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process. 


 Plan of Correction:


483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations: Based on review of facility policies, drug manufacture's information, interview with resident, and staff interviews, it was determined the facility failed to ensure a newly admitted resident diagnosed with End-Stage Renal Disease (ESRD) and a kidney transplant recipient received life sustaining medication. This failure resulted in the resident missing a total of eight doses of the medication Tacrolimus 0.5 milligrams, which led to critical laboratory values and placed the resident in an Immediate Jeopardy situation of organ rejection for Resident 119. Findings include: Review of the facility's admission policy titled "Admission Assessment and Follow Up: Role of the Nurse" (last revised September 2012), outlines the nurse's role in gathering information about a resident's physical, emotional, cognitive, and psychosocial status at admission. The information is used to begin care planning and complete required assessments, including the Minimum Data Set (MDS- federal mandated assessment tool for all residents). The nurse must greet and assist the resident, ensure comfort, and complete an admission assessment that includes recent medical history, prior hospitalizations, current diagnoses, medications, and treatments. A physical and supplemental assessment must also be conducted. Further review revealed the nurse must reconcile medications using the medication history, admission orders, previous medication administration record (MAR), and discharge summary. Findings are communicated to the attending physician, other departments, and outside services (laboratory or diagnostic services) are notified as needed. Review of the facility's medication reconciliation policy titled, "Reconciliation of Medications on Admission" (last revised July 2017) revealed it is designed to ensure medication safety when a resident is admitted or readmitted. The process requires staff to create an accurate and complete list of all medications a resident is taking in order to prevent medication errors, omissions, or unintended changes during transitions of care. Preparation includes gathering necessary information such as the approved medication reconciliation form, discharge summary from the referring facility, admission order sheet, prescription and supplement information obtained from the resident, and the most recent medication administration record (MAR) for readmissions. Medication reconciliation involves comparing the resident's medications before discharge with those ordered after admission. The list must include prescription and over-the-counter medications with the drug name, dosage, frequency, route, and indication for use. Continued review of the facility's medication reconciliation policy revealed the purpose of this process is to: Reduce medication errors and improve resident safetyEnsure medications continue without interruption at the correct dose and routeVerify medications are appropriate for the resident's condition and do not cause harmful interactionsEnsure accurate communication of all medications, routes, and dosages to the attending physician and care team The medication reconciliation procedure requires staff to first obtain a complete medication history from the resident, including prescription drugs, over-the-counter medications, herbal supplements, vitamins, patches, eye drops, creams, inhalers, injections, and other treatments. Information collected should include dose, route, frequency, last dose taken, and the reason for use. Residents should also identify all physicians and pharmacies used. Staff must then document all medications on the approved reconciliation form using information from the medication history, discharge summary, previous MAR (if applicable), and admission orders. Finally, the medication list must be reviewed carefully to identify and resolve any discrepancies or conflicts. Review of manufacturer's official prescribing information for the medication Tacrolimus revealed the medication is an immunosuppressant medication used to prevent organ rejection in patients who have received a kidney, liver, or heart transplant. It works by suppressing the immune system, reducing the risk of the body attacking the transplanted organ. In the product monograph it indicates, if a dose is missed, patients should contact their physician or pharmacist for advice and should not try to make up a missed dose on their own. The insert also emphasizes taking Tacrolimus exactly as prescribed and maintaining a consistent dosing schedule to reduce the risk of transplant rejection. Review of the National Kidney Foundation (NKF) article"(Immunosuppressant anti-rejection medicines July 24, 2025) revealed, transplant patients must take immunosuppressant medications including Tacrolimus exactly as prescribed every day to reduce the risk of organ rejection. Missing even one dose can increase the risk of the immune system beginning to attack the transplanted organ. Continued review of the NKF revealed, missing any Tacrolimus medication doses may result in lower than needed blood levels of the drug, which is strongly associated with an increased risk of organ rejection or graft loss. Even a single missed dose can reduce drug exposure in the blood, although the exact clinical risk varies; consistent non-adherence significantly raises the likelihood of rejection. Review of the Resident R119's Admission Minimum Data Set (MDS- federally mandated assessment tool used to evaluate resident's clinical status and care needs), dated March 6, 2026, revealed the resident was admitted to the facility on February 27, 2026, from an acute care hospital. The MDS documented diagnoses including Coronary Artery Disease (condition involving narrowing of the heart's arteries that reduces blood flow to the heart); heart failure (chronic condition in which the heart is unable to pump blood effectively); Hypertension (persistently elevated blood pressure that increases the risk of cardiovascular and kidney disease); Peripheral Vascular Disease (circulatory disorder causing reduced blood flow to the extremities); Renal Failure (condition in which the kidneys are unable to adequately filter waste and maintain fluid balance); Diabetes Mellitus (metabolic disorder characterized by elevated blood glucose levels), Acquired Immunodeficiency (indicating a weakened immune system that increases susceptibility to infections); acquired absence of the right leg below the knee and acquired absence of the left leg below the knee (indicating bilateral below-knee amputations); and status post kidney transplant, (resident previously received a donor kidney due to kidney failure and requires ongoing medical management and immunosuppressive therapy). Continued review of Resident R119's MDS assessment revealed the resident was assessed with a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively intact. Review of Resident R119's hospital records dated February 27, 2026, revealed Resident R119 was a 66-year-old with significant past medical history, including End-Stage Renal Disease (ESRD-condition in which the kidneys permanently lose the ability to function adequately and require dialysis or transplantation). Resident R119 is status post renal transplant, meaning he/she received a donor kidney to replace the failed kidney(s). Prior to the transplant he/she required intermittent hemodialysis (treatment that filters waste and excess fluid from the blood using a machine when the kidneys cannot do so); this therapy has since been discontinued following the transplant. Continued review of the hospital records revealed that Resident R119 was a kidney transplant recipient, a condition that requires lifelong management with immunosuppressive therapy and close monitoring of transplant function and medication levels. The resident was prescribed immunosuppressive medications, including Tacrolimus and Mycophenolate, as documented in the medication administration record. These medications are used to suppress the immune response and reduce the risk of rejection of the transplanted kidney. Ongoing administration of these medications is necessary to support continued function of the transplanted organ. Further review of the hospital medication list for Resident R119 revealed the following order: "Tacrolimus capsule 0.5 mg take three capsules (1.5 mg total) by mouth every 12 hours." The discharge documentation indicated the medication was prescribed to prevent organ rejection. Review of Resident R119's hospital records revealed a laboratory study dated February 23, 2026, at 8:10 AM, which reported a Tacrolimus level of 10.9 ng/mL (nanograms per milliliter). The typical maintenance therapeutic range for Tacrolimus is 510 ng/mL. Review of Resident R119's Medication Administration Record (MAR) for February 2026 following Resident R119's admission to the facility failed to reveal an order for the medication Tacrolimus. Interview conducted with Resident R119 on March 2, 2026 at 10:00 am, revealed he/she has not received the (anti-rejection) medication since his/her admission of Friday February 27, 2026 (4 days prior). The resident stated that he/she is a kidney transplant recipient and emphasized that (his/her) immunosuppressant medication, Tacrolimus, is crucial for preventing transplant rejection. Resident R119 revealed, (he/she) has been requesting this medication since Friday, but staff "did not seem to know anything about it." Continued interview with Resident R119 revealed (he/she) informed the Assistant Director of Nursing earlier that morning, who reportedly stated she would look into the issue; however, Resident R119 was given the same statement to medication request throughout the weekend. Resident R119 appeared anxious and unsettled, stating, although he/she has "a lot on (his/her) mind," the priority is receiving his/her much-needed medications. Further interview with Resident R119 confirmed (he/she)has received all other prescribed medications except Tacrolimus and remains unclear why the medication has not been administered, whether due to availability issues or miscommunication. Resident R119 expressed significant concern about the risk associated with missing this critical component of his/her life sustaining medication regime. Interview conducted on March 2, 2026, at 2:15 p.m. with the Assistant Director of Nursing (ADON), Employee E17, revealed when a resident is admitted to the facility, it is the responsibility of the nursing supervisor or the admitting nurse to complete the admission process, which includes verifying the resident's medications against the hospital discharge record. The ADON, Employee E17 revealed she received notification prior to the resident's arrival and began processing the medication orders; however, the nurse on duty completed the admission and was responsible for finalizing the medication orders. The ADON, Employee E17 confirmed a miscommunication regarding the paperwork: revealing the facility did not receive specific discharge instructions from the hospital. Instead, the hospital sent a comprehensive packet containing all information from the hospital stay, including the resident's medications, medical history, and past diagnoses, without clearly indicating critical medications. Interview with Licensed nurse, Employee E11 on March 2, 2026, confirmed she was working on Friday, February 27, 2026, and was the admitting nurse for Resident R119. Licensed nurse, Employee E11 confirmed that she entered Resident R119 medication orders. Continued interview with Licensed Nurse, Employee E11 revealed she did not receive the official hospital discharge summary containing a verified medication list. Instead, she relied on a comprehensive packet of hospital records that included the resident's medications and medical history. During interview, Licensed nurse, Employee E11 reported the medication list provided to the physician was based on information from the hospital records and was not independently verified. As a result, Tacrolimus was not included in the admission medication orders. Further interview with Licensed nurse, Employee E11 confirmed the packet she reviewed did list the resident's medications, including Tacrolimus, stating, "I must have missed that one." She also reported that she did not contact the hospital to confirm the medication list. Although she attempted to call, the hospital nurse was either leaving or had already left, and she did not receive a return call or a faxed confirmation. Phone interview conducted with Resident R119's physician, Employee E13 on March 3, 2026, at 09:30 am, revealed, he was notified the previous afternoon on March 2, 2026, that Resident R119 had missed doses of Tacrolimus. The physician revealed that he evaluated the resident on the morning of March 3, 2026, and ordered laboratory work to determine the resident's Tacrolimus level. He further instructed staff to hold the medication until the laboratory results were reported. Review of laboratory results dated March 3, 2026, for Resident R119 revealed multiple abnormal findings indicating significant renal dysfunction and critically low immunosuppressant medication levels. Laboratory testing showed potassium 5.4 mmol/L (reference range 3.45.3), indicating mild hyperkalemia; chloride 110 mmol/L (reference range 98107); and CO2 20 mmol/L (reference range 2232), suggesting metabolic imbalance. Kidney function studies revealed urea nitrogen (BUN) 70 mg/dL (reference range 823) and creatinine 3.24 mg/dL (reference range 0.601.50), both significantly elevated, indicating impaired renal function. The BUN/creatinine ratio was 21.6 (reference range 1220). The estimated glomerular filtration rate (eGFR) was 20 (reference range >59), indicating severely decreased kidney function. Further review of laboratory results revealed Resident R119's Tacrolimus level was reported as <2.0, which is critically below the therapeutic range of 5.020.0. These findings are clinically significant because critically low levels of Tacrolimus, combined with abnormal kidney function laboratory values, can place a kidney transplant recipient at significant risk for acute transplant rejection and further deterioration of kidney function. Based on the above findings, Immediate Jeopardy to the health and safety of Resident R119 was identified and revealed to the Nursing Home Administrator and Director of Nursing on March 4, 2026, at 2:00 p.m. Immediate Jeopardy was identified due to the facility's failure to administer the necessary immunosuppressive medication Tacrolimus, which resulted in Resident R119 missing a total of eight doses and experiencing critically low blood medication levels; placing ResidentR119 at immediate risk for acute transplant rejection and further deterioration of kidney function. The Nursing Home Administrator was provided with the immediate jeopardy template, and an immediate action plan was requested. On March 4,2026, the facility developed and submitted the following corrective action plan Resident was admitted on 2/27/2026 with no med reconciliation within 24hour which created a medication omission (Tacrolimus)On 3/2/2026 MD was notified of omission of medication; Per MD resident will start on Tacrolimus 1.5mg q 12 hours on 3/3/2026 after Tacrolimus lab has been obtained.Call placed to resident's nephrologist on 3/2/2026 at 1624 to update on admission to facility and lack of after visit discharge summary received from hospital until today. Residents' medications orders were reviewed with facility physician and order for Tacrolimus was initiated along with labs orderedLab was done on 3/3/2026, and per MD (physician) administer Tacrolimus with same dosage and frequency and continue as prescribed.Results of labs were reviewed by MD on March 4, 2026, ordered to continue the same dose, re-do lab on 3/6/2026 and continue the scheduled follow up with Nephrology on 3/12/2026.The resident was monitored for adverse effects and remained clinically stable.All new admissions and re-admissions will have medication reconciliation reviewed by: Admitting nurse, and, a second licensed nurse within 24 hours of admission.Nurses will be re-educated by UM/designee on: medication reconciliation on new/readmissions and 24-hour audits are to be completedRandom medication administration audits will be conducted to ensure documentation matches administration by DNS/Designee.100% of new admissions and re-admissions will be audited within 24 hours.Random nurses and medication passes will be audited.Any errors identified will result in re-education and corrective counseling.Random Medication administration Audits will be conducted weekly for four weeks, then monthly for 4 months or until substantial compliance is met.Results will be reviewed by the DON and QA Committee.Trends will be tracked and additional education provided as needed.Staff education on admission policy and procedure ongoing will have 90% educated by 3/5/2026 and 100% by 3/6/2026 Review of employee list, facility policy, observations of medication administration pass, and interviews with licensed nurses on medication reconciliation were conducted. Interviews with Licensed nurses' Employee E18, E19, E20, E21, E22, and E22, confirmed they received education on the facility's medication reconciliation process. Interviews with staff demonstrated a thorough understanding of medication reconciliation procedures, including the requirement to reconcile medications upon admission, compare them with new physician orders, and ensure medications are verified and triple-checked for accuracy to prevent omissions. Verification of the implementation of the immediate action plan was completed through review of staff education records and staff interviews. The Immediate Jeopardy was lifted on March 5, 2026, at 4:06 p.m. The Immediate Jeopardy identified for Resident R119 occurred February 27, 2026, to March 4, 2026. 28 Pa. Code 201.14 (a)Responsibility of Licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.20 (a)(1)(6) Staff development 28 Pa. Code 211.2 (d)(3) Medical Director 28 Pa Code 211.9(2) Pharmacy 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services
 Plan of Correction - To be completed: 03/19/2026

Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations.

1. Director of Nursing/Designee immediately notified MD that medication Tacrolimus was omitted from R119's medication profile upon admission to the facility and that 8 doses of Tacrolimus were missed. R119's medication reconciliation was immediately corrected after orders received by physician. Labs were ordered by physician. Resident RR119 notified. Resident plan of care was updated for Immunosuppression with individualized interventions for R119.
2. The Director of Nursing/Designee completed an audit of all residents to identify those who are prescribed immunosuppressant medication used to prevent organ rejection have been identified and are receiving the medication as ordered. No further issues identified.
3. Director of Nursing/Designee did nursing staff in-service for 100% of nursing staff on medication reconciliation on new/readmissions and 24 hour audit are to be completed and provided to Director of Nursing/Designee for final review.
6. Director of Nursing/Designee will audit 100% of new admission/readmissions within 24 hours. Results will be reviewed at QAPI for evaluation and recommendations.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations: Based on review of clinical records, facility documentation, and interview with staff, it was determined the facility failed to ensure a resident's snack bin was not in a location easily accessible to resident, which resulted in actual harm to Resident R87, while trying to obtain snacks, fell out of bed sustaining a laceration to the head, requiring two sutures and multiple steri-strips for one of two residents reviewed for falls (Resident R87). Findings include: Review of facility policy "Fall prevention," dated 2022, revealed the facility will implement fall prevention protocol as determined by resident's needs. Interview the resident and his/her family members to determine any factors that may predispose the resident for fall and/or activities that have helped prevent falls in the home environment. Review of Resident R87's clinical record revealed Resident R87 was admitted to the facility on July 31, 2025 with diagnoses of Chronic Obstructive Pulmonary Disease (airway disease that restricts breathing), Hemiplegia affecting right dominant side (paralysis on one side of the body), and Cerebral Infarction (blood supply to part of the brain is blocked or reduced). Review of Resident R87's Minimum Data Set assessment (MDS- mandated assessment of a resident's abilities and care needs), dated December 31, 2025, revealed Resident R87 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of Resident R87's nursing note, dated July 01, 2025, revealed "Approx. 4:15pm this nurse was in hallway when CNA (nurse aide) called me in resident room. Observed resident lying on (his/her) right side inside (his/her) snack box. Resident was reaching for (his/her) snacks." Review of Resident R87's care plan, (revised August 01, 2020) revealed Resident R87 is at risk for falls or fall related injury. Further review of Resident R87's care plan revealed an intervention, (initiated July 02, 2025) instructing staff to remove snack bin out of resident's sight and reach. Review of Resident R87's nursing note, dated February 07, 2026, revealed Resident R87 was found lying on floor on top of leg rests and snack bucket next to (his/her) bed by staff. Three lacerations to right side of head were noted. Review of facility investigation, dated February 07, 2026, revealed staff observed Resident R87 lying on the floor with (his/her) head on the floor and (his/her) legs in snack bin. Resident R87 was found to have three lacerations to (his/her) head. Lacerations measuring 4" long x wide; 2 1/2" long x wide; 1" long x 1/4" wide. At approx. 5:00 a.m. the nurse assistant provided Resident R87 with something to eat and drink at the resident's request from the snack bin. At 6:30 a.m. the resident attempted to lean over in bed and get himself another snack from the snack bin which was located next to Resident R87's bed triggering resident to roll off the bed onto the floor. Resident R87 was sent to emergency department of evaluation. The resident returned to the facility with two sutures and multiple steri- strips (thin bandages often used by surgeons as backup to dissolvable stiches). Review of witness statement, by nursing assistant, Employee E27, revealed Employee E27, observed Resident R87 "on the floor inside (his/her) snack bin." Nurse aide, Employee E27, then moved the bed and nightstand to get to the resident, as well as lowered the bed. There was blood observed to the right side of Resident R87's head." Review of nurse aide witness statement, Employee E28, revealed she refilled the resident's snack bin then placed the bin back where she found it, under the bed on right side by the headboard. Interview on February 04, 2026, at 1:45 p.m. with Director of Nursing, Employee E2, confirmed Resident R87 fell out of bed while attempting to reach for snack bin under his/her bed. The facility failed to ensure Resident R87's snack bin was not in a location easily accessible to Resident R87, which resulted in actual harm to Resident R87, who reached for more snacks, fell out of bed and sustained a laceration to the head, requiring two sutures and multiple steri- strips. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services
 Plan of Correction - To be completed: 03/19/2026

Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations.

1. Resident 87's snack bin was removed from their room.
2. The Director of Nursing/Designee completed an audit of all residents to identify those who have an intervention to keep snacks out of reach to ensure that their snacks are removed from their room. No further issues identified.
3. Facility Educator/Designee will provide nursing staff with an in-service on the need for snacks to be removed from the rooms of the residents who are required to keep their snacks out of reach and have those snacks secured in an alternative location.
5. Director of Nursing/Designee will do care plan audit to ensure that residents' who can not have snacks within reach must those snacks removed and secured in alternative location so that staff can provide to residents when requested with interventions updated to reflect plan. Audit 10 residents times 4 weeks; and then monthly times 3 months. Results will be reviewed at QAPI for evaluation and recommendations.

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 record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents' advance directives and physician orders for Life-Sustaining Treatment (POLST) were followed according to the residents' expressed wishes for 2 of 2 residents reviewed with advance directives. Resident R116 and R121) Findings include: Review of the facility's Advance Directives Policydated December 19, 2022, indicated the facility is responsible for respecting residents' rights to participate in medical decision-making and to exercise self-determination regarding their care. The policy states that residents will be informed of their right to accept or refuse medical or surgical treatment and to create an advance directive in accordance with the Patient Self-Determination Act (PSDA) and state law. The facility will provide written information about advance directives upon admission, or to the resident's representative if the resident is incapacitated. The policy further states that care will not be conditioned or withheld based on whether a resident has an advance directive. Any advance directive must be maintained in the resident's medical record, and admission staff must document whether the resident has an advance directive and that information regarding advance directives was provided during the admission process. If a resident expresses a desire to revise a prior advance directive, the change must be documented and a revised directive submitted in accordance with applicable regulations. Review of thePennsylvania POLST (Physician Orders for Life-Sustaining Treatment)is a medical order designed to ensure that a patient's treatment preferences, including life-sustaining interventions and comfort measures, are clearly documented and followed across healthcare settings. At the time the POLST is completed, any existing advance directives must be reviewed. The form must be signed by a physician and the patient or authorized surrogate, though verbal physician orders are acceptable if followed by a physician signature per facility policy. If the patient's condition changes, the patient or surrogate must be contacted to update the POLST. Oral fluids and nutrition should be offered when medically feasible, and comfort measures must be provided in an appropriate setting. Patients or authorized surrogates may revoke or modify any part of the POLST at any time, including withholding or withdrawing life-sustaining treatment. The POLST should be reviewed periodically, and if it becomes invalid or is replaced, the previous form must be voided by marking through sections AE and writing "VOID" across the form. If any section is incomplete, providers should follow other appropriate methods to determine treatment preferences. Review of Resident R 116's POLST (Physician Orders for Life-Sustaining Treatment) revealed that the resident elected DNR (Do Not Resuscitate), Do Not Attempt Resuscitation and DNH (Do Not Hospitalize) when not in cardiopulmonary arrest, with a focus on comfort measures only. Orders include the use of medications by any route, positioning, wound care, and other interventions to relieve pain and suffering. Oxygen, oral suction, and manual treatment of airway obstruction may be used as needed for comfort. Resident R 116 is not to be transferred for life-sustaining treatment but may be transferred if comfort needs cannot be met in the current location. Review of Part C (Antibiotics) indicates that antibiotics may be used only if life can be prolonged. Review of Part D (Artificially Administered Hydration/Nutrition) indicates that oral fluids and nutrition should be offered if feasible, but Resident R116 has elected no artificial hydration or nutrition by tube. The form was signed by the physician, the resident, and a registered nurse on August 9, 2021, acknowledging that the orders reflect the resident's known desires and best interests. Review of Resident R 116's Minimum Data Set (MDS- federal mandated assessment tool) dated June 30, 2025, revealed the resident had been residing in the facility since 2021. The resident scored 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Documented diagnoses includedcerebrovascular accident (stroke- a condition caused by interrupted blood flow to the brain resulting in neurological impairment); diabetes mellitus (failure of the body to produce insulin); and hyperlipidemia (a condition characterized by elevated levels of fats or cholesterol in the blood, which increases the risk of cardiovascular disease). Review of the Resident R116's care plan revealed a focus area addressing advance directives. The care plan indicated the resident's code status as Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH) with comfort measures only. The care plan directed staff to refer to the resident's POLST form for specific medical orders. Review of the POLST indicated it was initiated on February 16, 2022, and revised on July 22, 2025. Interventions included that the resident's physician would periodically review the POLST form and the resident's code status during routine visits with the resident. Review of Resident R 116's nursing notes dated January 3, 2026, at 2:46 PM, the resident was febrile and monitored for cold-like symptoms. On January 5, 2026, at 6:59 PM, nursing observed increased respiratory effort, diminished breath sounds, wheezing, elevated blood pressure (183/96 mmHg), temperature 103.7and heart rate 114 bpm (beats per minute). The physician was notified. Continued review of nursing notes dated January 6, 2026, at 11:19 AM, the physician evaluated the resident in-house, new orders were received for immediate blood work and the resident's representative was notified and updated regarding the plan of care. Laboratory results later showed sodium 157 mmol/L, and the physician on call was contacted; the resident representative was again notified. On January 7, 2026, at 10:27 AM, laboratory results and chest X-ray results were reviewed. The chest X-ray showed early changes suggestive of pneumonia, slightly worse than prior imaging. New orders for IV (intravenous) fluids and repeat BMP were implemented. Theresident representative was informed of the findings and interventions, including the plan to normalize sodium levels. OnJanuary 8, 2026, at 11:44 AM, the Social Services Department notified the Director of Nursing that the resident's guardian had changed the code status to full code. The resident had a previously signed POLST indicating DNR (do not resuscitate/DNI (do no intubate)/DNH (do not hospitalize) with comfort measures only, signed prior to guardianship. The physician assistant was notified, and resident was sent to the hospital. Interview with Social Worker, Employee E6, on March 5, 2026, at 1:00 PM, she reported that she called the resident's guardian, who instructed her via phone to change the resident's code status to full code. She immediately notified the nursing department of the guardian's request. The social worker Employee E6 acknowledged that she acted on the guardian's verbal instruction without obtaining proper documentation, verifying authority, or ensuring a physician-signed POLST update. She also stated she believed there weretwo POLST forms in the resident's chart but was unable to provide or locate the second form. The resident's guardian stated he has another POLST but was unable to provide it. He acknowledged that the POLST in the resident's clinical record was signed by the resident prior to guardianship and that after becoming guardian, he instructed the facility to change the POLST to full code, but no signed or documented POLST exists in the chart. The guardian claimed he had authority to change the resident's code status based on verbal conversations with the resident. Review of the clinical record revealed that the resident's representative was notified throughout the resident's decline, but no code status change was documented until the physician assistant sent the resident to the ER, and there is no written record of the POLST change. Review of Resident R121's clinical record revealed Resident R121 was admitted to the facility on August 18, 2025 with a diagnosis of heart failure (condition where the heart muscle can't pump blood as well as it should), protein calorie malnutrition (happens when you are not consuming enough protein and calories), and cerebral infarct (also known as an ischemic stroke, isthe death of brain tissue due to lack of blood flow). Review of Resident R121's Minimum Data Set (MDS- mandated assessment of a resident's abilities and care needs), dated August 25, 2025 revealed Resident R121 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of Resident R121's POLST (Portable Orders for Life Sustaining Treatment), signed August 25, 2025, revealed Resident R121 and RR (resident representative) discussed/elected DNR (Do Not Resuscitate), Do Not Attempt Resuscitation, and DNH (Do Not Hospitalize). When not in cardiopulmonary arrest, resident elected for comfort measures only, which include the use of medications by any route, positioning, wound care, and other interventions to relieve pain and suffering. Oxygen, oral suction, and manual treatment of airway obstruction may be used as needed for comfort. The resident is not to be transferred for life-sustaining treatment but may be transferred if comfort needs cannot be met in the current location. Review of facility investigation, dated August 31, 2025, revealed on August 31, 2025 Resident R121 was found in his/her room on the floor. Resident R121 was laying on right side with head at foot of bed. Resident R121 was noted to have hematoma on right side of head and nose area. The nurse then called 911 to have Resident R121 evaluated at the emergency room (ER). Further review of facility investigation revealed "agency nurse did not follow resident's POLST for DNR/DNI/DNH and did not obtain an order to have resident sent to ER for further evaluation. Agency nurse called 911 and left voicemail to office ... Resident was at the facility on comfort measures only and was made DNR/DNI/DNH signing a POLST form on 8/25/2025". Interview on March 05, 2026 at 11:35 p.m. with Director of Nursing, Employee E2, confirmed Resident R121's POLST was not followed on August 31, 2025. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa Code 211.2 (d)(7) Medical Director 28 Pa. Code 211.12 (d)(5) Nursing Services
 Plan of Correction - To be completed: 03/19/2026

Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations.

1. Resident 116 has been discharged. Resident 121 has been discharged.
2. The Social Services Director/Designee completed an audit on all residents' plan of care to reflect resident representative wishes and match wishes expressed on POLST form and physician's orders.
3. Facility Educator/Designee will provide nursing staff with in-service to ensure that residents' POLST forms reflect residents' code status contained with the electronic medical record.
4. The Social Services Director/Designee will do facility audit to ensure that all residents code status; POLST and care plan are correct.
5. The Social Services Director/Designee will audit 10 residents weekly for 4 weeks; and then monthly for 3 months and quarterly at care conference. Results of audits will be presented at QAPI for further evaluation and recommendations.




483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan: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.
§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations: Based on review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure a baseline care plan was developed within 48 hours of admission related to dementia care for one of 22 residents reviewed. (Resident R9) Findings Include: Review of Resident 9's clinical records revealed Resident R9 was admitted to the facility on January 14, 2026 with diagnoses that included but were not limited to Dementia (progressive disease characterized by impaired memory, thinking and behavior that affects ability to perform daily tasks), bipolar disorder (mood disorder marked by extremes in feelings of elation or depression), cerebral ischemia (lack of blood flow to brain causing damage or death to brain tissue), chronic obstructive pulmonary disease ("COPD," a progressive lung disease causing breathing difficulties), and difficulty in walking. Review of Resident R9's clinical record revealed Resident R9 had a care plan dated January 15, 2026, that included interventions related to focus areas of potential for discomfort/side effects related to use of psychotropic medications, alterations of respiratory status, COPD (chronic obstructive pulmonary disease), and interventions pertaining to risk for falls. Further review of Resident R9's care plan revealed no interventions in place to provide the necessary care to properly care for Resident R9's dementia care needs. Interview with Employee E2, Director of Nursing, on March 5, 2026, at approximately 1:00 PM confirmed no care plan was in place related to Resident R9's dementia care needs. 28 Pa. Code 211.10(d) Resident care policies
 Plan of Correction - To be completed: 03/19/2026

Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations
1. The Director of Nursing/Designee updated R9 plan of care to add Dementia care plan along with individualized intervention.
2. The Director of Nursing/Designee completed an audit of all residents with a Dementia diagnosis to ensure that a Dementia Care Plan is part of their care plans with individualized interventions. No further issues identified.
3. Facility Educator/Designee will provide nursing staff with in-service to ensure that residents' with a Dementia diagnosis have a Dementia care plan with individualized interventions.
4. The Director of Nursing/Designee will do facility audit to ensure that all residents' with a Dementia diagnosis have a care plan with individualized interventions.
5. The Director of Nursing/Designee will audit 10 residents weekly for 4 weeks; and then monthly for 3 months. Results of audits will be presented at QAPI for further evaluation and recommendations.

483.25 REQUIREMENT Quality of Care: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.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations: Based on review of facility policy, observations and interviews with staff, it was determined that the facility failed to ensure that residents were provided appropriate supervision while dining for 6 of 6 residents observed. (Resident R60, R92, R58, R94, R101, and R39) Findings include: Review of facility policy titled "Dining Service"(dated 12/19/2022) requires that all residents receive a nourishing, balanced diet served in accordance with their preferences. Staff are responsible for validating meal accuracy, assisting with meal service, monitoring residents during meals, and responding to resident needs. Trays must not be left unattended, and residents must have adequate time and support to safely complete their meals. Observations on March 5, 2026, at 08:35, revealed Residents R60, R92, R58, R94, R101, and R39 were observed in the first-floor dining area without assigned supervision. One resident made choking/grunting noises. Licensed nurse Employee E25 intervened after noticing the resident, stating that residents should not be left alone. Interview with Nursing Assistant Employee E26 who immediately came into the room,when asked about assignment, stated she was unaware she was scheduled to monitor the dining area. Interview with the DON Employee E2 confirmed on March 5, 2026 at 10:40 a.m. that it is facility protocol for nursing staff to monitor residents during all meals and that residents should never be left unattended while eating. 28 Pa. Code 211.12 (d)(7) Nursing Services
 Plan of Correction - To be completed: 03/19/2026

Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations

1. The Director of Nursing/designee updated dining area for sign in and out sheet for facility staff to be available at meal times to ensure appropriate supervision for residents R60, R92, R58, R94, R101, and R39.
2. The Director of Nursing/Designee completed an audit of all residents to ensure that receive appropriate supervision during mealtimes. No further issues identified.
3. Facility Educator/Designee will provide nursing staff with in-service on dining room assignment/monitoring process to ensure that a staff member is present in the dining rooms during all meals. In-service to include signing in and out for the meals.
4. The Director of Nursing/Designee will do facility audit to ensure that the facility nursing staff is assigned to the dining rooms during meals and that the sign in sheet is up to date to ensure monitoring in the dining rooms daily times 4 weeks; weekly times 4 weeks; and then monthly times 3 months. Results will be reviewed at QAPI for evaluation and recommendations.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(i) Food safety requirements.
The facility must -

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

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations: Based on observation and staff interviews, it was determined that the facility failed to ensure safe and sanitary food storage practices on four of the facility's four nursing units." Findings include: Review of facility nutrition services practice manual food policies titled Storage dry Storage revealed store perishable foods in the refrigerator and or foods kept refrigerated by the manufacturer maintain refrigerator temperatures at thirty-four thirty-eight degrees storable meat away from vegetables and cooked foods label products with delivery date including month and year the product was received store leftover foods and container which are shallow to facilitate cooling impervious and dishwasher safe label all leftovers with recipe name and date of storage discard refrigerator leftovers after seventy-two hours cover all pre-dish items with plastic wrapper foil to prevent all flavors drying and or cross-contamination A review of the facility's Nutrition Services Practice Manual, under Food Storage and Dry Storage Policies, revealed the following requirements: Perishable foods must be stored in the refrigerator or units and kept at manufacturer-recommended temperatures, with refrigerators maintained between 3438meats must be stored separately from vegetables and cooked foods to prevent cross-contamination. All products must be labeled with the delivery date, including month and year of receipt. Leftover foods must be stored in shallow containers to facilitate cooling, and containers must be impervious, dishwasher safe, and labeled with the recipe name and date of storage. Refrigerator leftovers must be discarded after 72 hours. All pre-dish items must be covered with plastic wrap or foil to prevent flavor transfer, drying, and cross-contamination. During the initial tour of the facility kitchen on March 2, 2026, at 9:30 AM, several food storage concerns were observed. Sour cream and salsa containers did not have a date indicating when they were opened or received. Coleslaw dressing and relish were also observed without date labeling. A container of PAM cooking spray, received on February 25, 2026, was not labeled with an open or use date. In addition, a pan of diced chicken prepared for chicken salad intended for use that evening did not have a preparation or use date. Three trays of Jell-O were observed uncovered and without date labeling. Containers of applesauce and sliced apples were also not dated. A container of jelly was dated February 21, which exceeded the seven-day storage guideline per facility policy and should have been discarded. Observation of the dry storage area revealed that rice and flour bins contained scoops left inside the bins, which may pose a risk for contamination. An interview was conducted with the Food Service Director (Employee E9) at the time of the above observations. The Food Service Director confirmed the observations, acknowledging that several food items were not properly dated or covered in accordance with facility policy. 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 211.6(f) Dietary Services
 Plan of Correction - To be completed: 03/19/2026

Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations.

1. Food Service Director immediately covered, labeled and dated the food items that were missing labeling and dating, discarded items whose storage timeline exceeded storage guidelines and removed scoops that were left inside the rice and flower bins.
2. NHA conducted complete dietary audit to ensure no further items were left open, unlabeled, or exceeding storage timelines and no food items or equipment were at risk of contamination.
3. NHA/ Designee educated FSD and Dietary staff members on requirements to ensure to cover, label, and date all prepared foods and date all factory labeled food items for dates they were opened or use by dates.
4. NHA / designee to conduct audits weekly x 4 and then monthly x 2 or until substantial compliance is achieved of kitchen to ensure items are labeled, dated and stored correctly. Results will be brought to facility QAPI meeting by Administrator for further evaluation and recommendations.


483.70 REQUIREMENT Administration: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.
§483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations: Based on review of clinical records, facility policies, job descriptions, medication documentation, and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure that a newly admitted resident diagnosed with End-Stage Renal Disease (ESRD) and a kidney transplant recipientreceived life sustaining medication.This failure resulted in a resident missing a critical immunosuppressive medication and placing the resident an Immediate Jeopardy situation. (Resident 119) Findings include: Review of The Director of Nursing (DON)'s job description revealed that the DONis responsible for the overall planning, coordination, and supervision of nursing services, including ensuring that nursing staff perform accurate admission assessments, medication reconciliation, and timely administration of physician-ordered medications. The DON is expected to oversee staff performance, implement clinical policies, monitor compliance with federal, state, and local regulations, and facilitate interdisciplinary communication among physicians, therapists, and support personnel. This role requires the DON to make independent clinical decisions, respond to emergencies, and maintain systems that protect resident safety and quality of care. Review of theNursing Home Administrator (NHA)'s job description revealed that the NHAis responsible for the overall operation of the facility, including ensuring compliance with all regulatory requirements, implementing operational policies, managing staffing, and overseeing coordination among departments. The NHA must ensure that systems are in place to provide safe and effective care, supervise leadership staff including the DON, address deficiencies in clinical practice, and maintain accountability for facility-wide adherence to policies and procedures. The NHA also serves as the primary liaison with regulatory agencies, residents, families, and the public, ensuring that resident safety and quality of care remain the facility's top priority. Review of the facility's policies, including "Admission Assessment and Follow Up: Role of the Nurse" and "Reconciliation of Medications on Admission," requires that nursing staff obtain a complete medication history, reconcile medications with hospital discharge summaries, previous MARs, and physician orders, and ensure critical medications are administered promptly. These policies are essential to prevent medication omissions, ensure continuity of care, and protect residents from harm. Review of Resident R119's clinical record revealed that the resident was a kidney transplant recipient. The resident was admitted to the facility on February 27, 2026 with orders to continue Tacrolimus 1.5 milligrams (mg) by mouth every 12 hours, a critical immunosuppressant medication necessary to prevent organ rejection. Review of the Medication Administration Record (MAR) and interviews revealed that there was no order for the medication Tacrolimus entered upon admission, and the resident did not receive the medication from February 27 through March 3, 2026, missing a total of eight doses. Review of laboratory results obtained on March 3, 2026, revealed criticallylow Tacrolimus level of <2.0 ng/mL, significantly below the therapeutic range, placing the resident at immediate risk for transplant rejection and kidney failure. Based on the deficiencies cited in this report, the NHA andDON failed to ensure the essential functions and duties of their position, contributing to an Immediate Jeopardy situation. Refer to F760 28 Pa. Code 210.14(a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.20 (a)(1)(6) Staff development 28 Pa Code 211.12 ((c)(d)(1)(3)(5) Nursing Services
 Plan of Correction - To be completed: 03/19/2026

Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations.

1. NHA updated Facility policy on medication reconciliation.
2. Action plan completed, to prevent medication omissions, ensure continuity of care and protect residents from harm.
3. COO educated NHA and DON on essential functions and duties of their positions.
4. NHA/ Designee will conduct random audits weekly x 4 then monthly x 2 or until substantial compliance is achieved of DON functions to ensure essential duties are completed. Results will be brought to facility QAPI meeting by Administrator for further evaluation and recommendations.

§ 201.19(1) LICENSURE Personnel policies and procedures.:State only Deficiency.
(1) The employee's job description, educational background and employment history.

Observations: Based on a review of personnel files and interviews with facility staff in was determined that the facility failed to conduct background checks as required for one personnel file reviewed (Employee E15) Findings Include: Review of the facility policy titled, "Compliance and Ethics-Screening Employees, Contractors and Volunteers" revised December 2020 states, "Policy Statement- Employees, contracted individuals and volunteers are screened for violations of fraud, abuse and/or ethics violations prior to employment or engagement. The facility does not hire employees or engage contractors or volunteers who do not meet the screening criteria established by the compliance and ethics committee." Further review of the policy revealed, "Policy Interpretation and Implementation- 1. Background screening and investigations are conducted prior to employment or engagement to ensure that employees, contractors and/or volunteers meet at least the following criteriaThe individual has not been found to a criminal record". Review of Employee E15 employee file revealed the employee was hired on February 10, 2026. The facility failed to conduct a criminal background check prior to the employee's first date of employment. The date of the criminal background check was March 3, 2026. An interview was held on March 5, 2026 at 1:30 p.m. with Human Resources Director Employee E16 confirmed that the criminal background check for Employee E16 had not been completed prior to employment. Interview with Employee E16 revealed the facility was locked out of their Pennsylvania State Criminal Record check account due to non-payment of the credit card on file. The facilities credit card was alerted for fraud which left the facility locked out of the Pennsylvania State Criminal Record check account. When Employee E16 was asked why hiring was no paused until the account for the Pennsylvania State Criminal Record checks could be completed, Employee E16 stated that "we really needed to fill the position, so they had me complete a state background check and a sex offender check instead." Employee E16 confirmed that the criminal background check for Employee E15 was not completed until March 3, 2026. 28 Pa. Code 201.19Personnel policies and procedures.
 Plan of Correction - To be completed: 03/19/2026

Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations.

1. Additional employee background check using EPATCH (Pennsylvania State Police criminal records database) completed for employee E15.
2. NHA/ Designee conducted an audit of recently hired employees to ensure that all employees have background checks completed through EPATCH prior to start of employment no further discrepancies identified
3. NHA educated HR Director on requirements to ensure all employees have background checks completed prior to start of employment conducted through EPATCH (Pennsylvania state police criminal records database).
4. NHA/ Designee will audit new employee files weekly x 4 then monthly x 2 or until substantial compliance is achieved to ensure that background checks were completed prior to start of employment. Results will be brought to facility QAPI meeting by the Administrator for further evaluation and recommendations.


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