Pennsylvania Department of Health
ONYX WELLNESS CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ONYX WELLNESS CENTER
Inspection Results For:

There are 122 surveys for this facility. Please select a date to view the survey results.

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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 a complaint, completed on May 22, 2025, 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:

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

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

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

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

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

Observations:

Based on observations and staff interview it was determined that the facility failed to maintain essential kitchen equipment in clean and sanitary conditions related to the ice machine.

Findings Include:

A tour of the main kitchen was conducted on May 20, 2025, at 9:20 a.m. with Food Service Director, Employee E16.

Observations inside the ice machine revealed the white, plastic, inner lining had a blackish/brown stain along the bottom half perimeter.

Further observations of the area surrounding the ice machine revealed the plastic baseboard along the wall adjacent (facing) the ice machine was peeling off and has significant build-up of dirt and debris.

The floor underneath and surrounding the area of the ice machine was dirty and had a significant build up of dirt and debris. Three to four fruit flies were hovering the area of the ice machine.

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

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

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

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

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

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

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

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

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

Observations:

Based on observations and interviews with staff, it was determined that the facility failed to provide an environment that promotes the maintenance and enhancement of each resident's dignity for two of two nursing units (First floor and Second floor nursing units).

Findings Include:

Observations during the initial tour on May 20, 2025 at 1:01 p.m. revealed Resident R92's room had a NPO (nothing per mouth) sign posted at the head on the resident's bed on the wall. The sign had nine residents information listed.
Four residents listed as NPO
Four residents listed as Necar Thick
One resident listed as Honey.
Two residents listed as "No straws"
Two residents listed as "Do Not Leave Liquids at Bedside"

Observations on May 20, 2025 at 12:34 p.m. of the first floor nursing units activities/dining room revealed residents were being served their meals on plastic trays. Further observation for dining area revealed a "Thickened liquids" sign posted in the dining area on the left when you walk in on the wall.

Interview with Resident R1 on April 1, 2025, at 11:30 a.m. stated facility always serves the food on the trays for meals.

Observations during a follow up day on May 22, 2025 at 11:53 a.m. on the second floor unit in the activities/dining room during lunch revealed residents were being served their meals on plastic trays. Further observation for dining area revealed a "Thickened liquids" sign posted in the dining area on the left when you walk in on the wall.

Interview with Regional Employee E3 on May 22, 2025 at 11:56 a.m. confirmed the Liquid Diet Posting was posted on the dining room wall area on the left when you walk in.

28 Pa. Code 201.29 (j) Resident Rights

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

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

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 observations, resident interviews, and staff interviews, it was determined that the facility did not ensure clean and homelike environment was maintained in resident care areas and dining experience for two of two nursing units observed (First Floor and Second Floor).

Findings Include:

Observations on May 20, 2025, at 10:20 a.m. on East Wing First Floor in room 18 revealed a red paint colored on the wall next to the A-Bed.

Observations on May 20, 2025, at 10:40 a.m. on East Wing First Floor in room 23 revealed the baseboard along the perimeter of the wall behind the B-bed was peeling off.

Observations on May 20, 2025, at 10:51 a.m. revealed the resident had a bathroom with a leak behind toilet, on the floor was a wet saturated towel between the sink and toilet area along the wall. On the wall in the bathroom there was also a broken piece of plastic from the plastic box that holds gloves. The box was broken so that no gloves could be held inside of it.

Observations on May 20, 2025, at 11:03 a.m. on East Wing First Floor in room 15 revealed the bottom drawer on the right side of the closet was broken and hanging off.

Observations on May 20, 2025, at 11:08 a.m. revealed Resident R38's room revealed the air conditioning vents had heavy caked on dust.

Observations during the initial tour on May 20, 2025 at 12:34 p.m. of the first floor nursing units activities/dining room revealed residents were being served their meals in this room. There was one hand sanitizer located on the wall in the dining room which was not working at the time.

Observations on May 20, 2025 at 1:01 p.m. of Resident R92's room revealed the resident's bathroom had several floor tiles that were peeling. The resident was laying in her bed and at the head of the bed underneath the bed there was residue from dried up tube feeding formula and caked up dirt visible on the floor and on the baseboards. To the left of Resident R92's bed was one fall mat which also had dried up tube feeding formula.

Continued observations on May 22, 2025 at 11:53 a.m. on the second floor (upper floor) unit revealed Resident R80 came out to the nurses station and said that aide is sitting down in there and she said, "I am not passing out trays because I am agency staff and I don't know anybodys names."

After entering the dining/activities room on the second floor nurse aide Employee E14 was seen getting up out of a chair with a cellphone in one hand a bag of chips in the other. Employee E14 was asked her name and stated it. When asked if it was her first time working at the facility Employee E14 stated, "no it's not but I don't know these peoples names and diets" and then walked out of the dining room area.

Nurse aide Employee E15 was also in the room in the same area as Employee E15 and started to attempt to open up to food truck and read to lunch meal tickets. Employee E15 was asked if she was familiar with the residents in the room and she stated, "some of them".

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

Plan of Correction - To be completed: 06/18/2025

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. (A) Maintenance Department Re-Painted wall in room 18 near A- Bed. Replaced Baseboard, Repaired Toilet Leak, and replaced glove dispenser box in room 23.
Repaired Bottom Drawer of resident closet in room 15. Repaired flooring in bathroom of room 127. Replaced Hand Sanitizer Dispenser in 1st floor Dining Room.
(B) Housekeeping Department Cleaned AC vents in room 124. Completed a deep cleaning of room 127.
(C) Director of Nursing/Designee will compile a list of residents who utilize the dining area with physician diet orders and resident information to identify each resident. Facility Educator will in-service staff to ensure they are familiar with the dining area and the dining process. Staff will be aware and familiar with the resident's names and physician ordered diets to maintain dignity, consistency of care and safety.

2. Administrator / Designee will educate Maintenance, Housekeeping, Dietary, and Nursing staff on requirements to Maintaining a Safe/Clean/Comfortable/Homelike Environment.
3. Administrator / Designee will (a) conduct house wide Maintenance and environmental audits (b) audit all tube feeding pumps for tube feeding formula residue, and (c) conduct audits of staff during mealtimes ensuring they are familiar with residents and their required diets, to ensure facility is maintaining a Safe/Clean/Comfortable/Homelike Environment.
4. Administrator / Designee will continue to audit environmental and dining services weekly x 4 and then monthly x2 results of audits will be brought to QAPI for further 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 review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure the POLST form accurately reflected the resident's code status for one of 32 residents reviewed (Resident R15).

Findings Include:

Review of Resident R15's clinical record revealed the resident was admitted to the facility on February 5, 2019, and had diagnoses of Senile Degeneration of Brain ( a decline in an individual's memory, behavior, and cognitive abilities) and Chronic Obstructive Pulmonary Disease (a progressive lung disease characterized by difficulty breathing, often caused by long-term exposure to irritants).

Review of Resident R15's electronic medical record revealed a physician order dated October 19, 2023, that specified the resident's code status was Do Not Resuscitate (DNR - allow natural death if resident found with no pulse and is not breathing), Do Not Hospitalize (DNH), and Do Not Intubate (DNI).

Further review of Resident R15's electronic medical record revealed a form, Physician Orders for Life Sustaining Treatment (POLST), dated and signed by the physician on February 14, 2019, that indicated the resident's code status was a "CPR/Attempt Resuscitation" (Cardiopulmonary Resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest).

Interview with the Director of Nursing , on May 20, 2025, at 12:50 p.m., confirmed the POLST form did not accurately reflect the physician order for code status on Resident R15's electronic medical record.

28 Pa Code 211.10(d) Resident care policies.

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

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 an individualized person-centered care plan to address a resident's dementia care needs for one of 32 residents reviewed (Resident R 67).

Findings Include:

Review of the admission sheet of Resident 67, revealed that Resident R67 was admitted to the facility on December 6, 2024, with diagnoses including Dementia (Dementia is a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

On May 21, 2025, at 1:55 p.m., review of Resident R67's interdisciplinary plan of care revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R67.

During an interview on May 21, 2025, at 2:05 p.m., the Director of Nursing (DON), confirmed the finding, and the DON stated that the facility tried to make the care plans as specific as possible. No additional information was received.

The facility overlooked to develop and implement a person-centered care plan to include and support Resident R67's dementia care needs.

28 Pa Code 211.11(d) Resident care plan

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

483.35(a)(3)(4)(d) REQUIREMENT Competent Nursing Staff:

§483.35 Nursing Services

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(d) Proficiency of nurse aides.

The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on observations, review of facility documentation, review of personnel files and interviews with residents and staff, it was determined that the facility failed to ensure that agency nursing staff demonstrated competencies and skill sets necessary to care for residents' needs for three of three agency personnel files reviewed (Employees E9, E10 and E11).

Findings include:

Interview on May 20, 2025, at 10:35 a.m. Resident R89 stated, "agency staff don't give good care."

Interview on May 20, 2025, at 11:02 a.m. Resident R27 stated, "agency staff don't do anything for us."

Interview on May 20, 2025, at 12:36 p.m. Resident R37 stated, "agency staff just sit around and don't give us care."

Interview on May 21, 2025, at 9:37 a.m. Resident R80 stated, "agency staff don't give us care and never give showers at night."

Interview on May 21, 2025, at 11:14 a.m. Resident R44's family member stated, "agency staff don't know residents' care needs and don't reapproach Resident R44 when she's having a tough day or declines care."

Review of facility staffing schedules revealed that Employee E9, licensed nurse; Employee E10, licensed nurse; and Employee E11, nurse aide; worked at the facility on May 20, 2025, as agency nursing staff.

Observation on May 20, 2025, at 9:28 a.m. revealed Employee E9, agency licensed nurse, prepare and administer medications to Resident R103. Interview, at the time of the observation, Employee E9, agency licensed nurse, stated that it was her first day working at the facility and that she did not receive any trainings or skills competency evaluations by the facility.

Observation on May 20, 2025, at 11:00 a.m. revealed Employee E10, agency licensed nurse, prepare and administer medications to Resident R91. Interview, at the time of the observation, Employee E10, agency licensed nurse, also stated that it was her first day working at the facility and confirmed that she did not receive any trainings or skills competency evaluations by the facility.

Review of personnel files for Employee E9, licensed nurse; Employee E10, licensed nurse; and Employee E11, nurse aide; revealed that there were no trainings or skills competency evaluations that were conducted by the facility available for review at the time of the survey.

Interview on May 22, 2025, at 11:46 a.m. the Director of Nursing confirmed that the facility did not conduct any skills competency evaluations for Employee E9, licensed nurse; Employee E10, licensed nurse; and Employee E11, nurse aide.

28 Pa. Code 201.20(a)(b) Staff development

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

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

483.25(b)(2)(i)(ii) REQUIREMENT Foot Care:

§483.25(b)(2) Foot care.
To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must:
(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and
(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.

Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to timely arrange a podiatry appointment for one of two residents reviewed for foot care (Resident R47).

Findings Include:

Review of Resident R47's comprehensive care plan revised December 3, 2022, revealed the resident had potential for impaired skin integrity related to congestive heart failure (heart is not able to pump enough blood to meet the body's needs causing fluid build up in the body), type 2 diabetes mellitus (body's inability to effectively process sugars (glucose) causing high blood sugar levels), and hypertension (high blood pressure). Intervention dated January 5, 2025, included to consult podiatry as ordered.

Review of Resident R47's clinical record revealed a nursing note dated December 5, 2024, that indicated upon assessment with the wound team, Resident R47's right great toe was noted with ingrown toenail and touching second toe. Per the note, treatment was applied and podiatry aware and will follow-up.

Review of Resident R47's clinical record revealed medication administration note dated December 9, 2024, "consult appointment needed with podiatry ASAP (as soon as possible) d/c (discontinue) when complete". Further review of the note revealed "[Resident R47] needs consult for podiatry per MD for right foot greater and first toe".

Review of Resident R47's clinical record revealed medication administration note dated December 14, 2024, "consult appointment needed with podiatry ASAP (as soon as possible) d/c (discontinued) when complete". Further review of the note revealed "[Resident R47] needs consult for podiatry per MD (physician) for right foot greater and first toe".

Review of Resident R47's clinical record revealed medication administration note dated December 15, 2024, "consult appointment needed with podiatry ASAP d/c when complete". Further review of the note revealed "[Resident R47] needs consult for podiatry per MD for right foot greater and first toe".

Review of Resident R47's clinical record revealed medication administration note dated December 20, 2024, "consult appointment needed with podiatry ASAP d/c when complete".

Review of Resident 47's entire clinical record revealed no documented evidence podiatry was consulted as ordered by the physician.

Further review of Resident R47's clinical record revealed a nursing note dated December 30, 2024, that the resident complained of feet pain and upon assessment by the nurse Resident R47 was noted with ruptured blisters to bilateral feet. Podiatry was in the building and consulted to assess the resident.

Interview on May 22, 2025, at 1:07 p.m. with the Director of Nursing, Employee E2, confirmed the facility did not have documented evidence that a podiatry consult was timely ordered per the physician orders.

28 Pa Code 211.10(d) Resident care policies.

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

483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including:
(i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes -
(A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section;
(B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act.
(C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and
(D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
(ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.)
(iii) Information regarding Medicare and Medicaid eligibility and coverage;
(iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program;
(v) Contact information for the Medicaid Fraud Control Unit; and
(vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.

Observations:

Based on review of facility policy, observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency phone number and contact information, readily accessible on two of two nursing floors. (1st Floor, 2nd Nursing Units)

Findings Include:

Review of facility policy titled, Resident Rights with a revision date of August 31, 2022 states, "Purpose: Ensures residents know that they can lodge complaints without reprecussions."

During an observation of First Floor nursing units on May 20, 2025 at 11:00 a.m. revealed there was no posting for the required Department of Health contact information. A tour of the lobby area revealed there was a standard size page for the contact information for Department of Health but the phone number was outdated in between the exterior door of the lobby and the interior glass door of the lobby.

Resident Council meeting was held on May 22, 2025, at 10:30 a.m. on the first floor with nine awake, alert, and oriented residents. Several residents reported that they were not aware of where the information on how to contact the State Department of Health is in the building. (R50, R74, R78, R93).

A tour was taken with the Director of Social Services, Employee E12 Observation of the First Floor Nursing unit with the Employee E12 on May 22th at 1:05 p.m. to look for required notices and postings.

A tour of the first floor (bottom floor) nursing unit revealed there were no required Department of Health contact information posted. The Director of Social Services, Employee E12 showed the surveyor a clear plastic covering next to the elevator that did not have a paper in it and stated, "it is usually here, but we have one resident and sometimes he takes the paper".

The tour of the second floor (top floor) revealed there was another clear plastic covering next to the elevator that did not have a paper in it. Further review of floor revealed there was one posted size posting for the Department of Health but it was written in Spanish. The Director of Social Services Employee E12 confirmed 2:03 p.m. that there were no postings for the required Department of Health contact information in English on either on the nursing units (first floor or second floor).

Interview with the Nursing Home Administrator Employee E1 on May 22, 2025 at 2:09 p.m. confirmed that there was no posting for the Department of Health contact information in English in the facility due to renovations of the bathrooms over the weekend and the signs had been taken down.

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

28 Pa. Code: 201.18(b)(1) Management

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