Pennsylvania Department of Health
YARDLEY REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

YARDLEY REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

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YARDLEY REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and an Abbreviated survey in response to a complaint, completed February 27, 2026, it was determined that Yardley Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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.

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

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 35 sampled residents. (Residents 23, 158)

Findings include:

Clinical record review revealed that Resident 23 had diagnoses that included hypertension (high blood pressure) and type 2 diabetes. A physician's order dated May 26, 2023, directed staff to administer a blood pressure medication (amlodipine) daily. The physician ordered that staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was lower than 120 millimeters of mercury (mm/Hg). Review of Resident 23's Medication Administration Records (MAR) for October, November and December 2025, and January and February 2026, revealed that the staff administered amlodipine once in October, once in December, six times in January, and once in February when Resident 23's SBP was lower than 120 mm/Hg.

Clinical record review revealed that Resident 158 had diagnoses that included hypertension (high blood pressure) and multiple sclerosis. A physician's order dated May 15, 2025, directed staff to administer a blood pressure medication (diltiazem) three times a day. The physician ordered that staff were not to administer the medication if the resident's SBP was lower than 110 mm/Hg or if their heart rate was less than 60 beats per minute. Review of Resident 158's clinical record revealed that Resident 158's heart rate was measured only two times in September 2025, and once each in January and February 2026. Review of Resident 158's MAR for October, November, and December 2025, revealed that staff administered diltiazem to Resident 158 three times daily without measuring the resident's heart rate.

In an interview on February 27, 2026, at 10:53 a.m., the Director of Nursing confirmed that physicians' orders for residents 23 and 158 were not followed and medications were administered outside the ordered parameters as identified.

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

Plan of Correction - To be completed: 03/24/2026

1. Resident 23 and Resident 158 are receiving amlodipine and diltiazem as ordered.

2. An audit was completed to validate residents have blood pressure and heart rate parameters in orders and nurse is following order.

3. Nurses will be re-educated by designee on following parameter within physician order.

4. Designee will complete random weekly audits for 4 weeks and monthly audits for 2 months to validate administration of heart rate and blood pressure medication per physician order. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 35 sampled residents. (Resident 13)

Findings include:

Review of the facility policy entitled, "Pain Management," last reviewed January 25, 2026, revealed that the physician would order non-pharmacological and medication interventions to address a resident's pain. Staff were to provide a comfortable environment and complementary interventions that included local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain.

Clinical record review revealed that Resident 13 had diagnoses that included dementia, diabetes, and abnormalities of gait and mobility (unusual patterns of walking that affect balance). On November 26, 2025, the physician ordered for the resident to receive tramadol every 12 hours as needed for pain. Review of Resident 13's care plan revealed that the resident had pain and the interventions included that staff provide pain relief measures with positioning, relaxation therapy, heat, cold application, bathing, and/or muscle stimulation. Review of Medication Administration Records revealed that the resident received the as needed tramadol with no documented evidence that non-pharmacological interventions were attempted prior to administration 15 times in December 2025, 13 times in January 2026, and 18 times in February 2026.

In an interview on February 27, 2025, at 10:36 a.m., the Assistant Director of Nursing confirmed that there was no evidence to support that non-pharmacological interventions for pain had been provided prior to the administration of as needed pain medication as identified.

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

Plan of Correction - To be completed: 03/24/2026

1. Resident 13 is being provided non-pharmacological and medication interventions to address resident's pain.

2. The NHA/ Designee will complete an initial audit to validate resident 13 and other residents' tramadol and other pain PRN medications have nonpharmacological interventions offered prior to administration.

3. Nursing will be re-educated by the NHA/Designee that nonpharmacological interventions are offered before PRN tramadol and other pain medication administration.

4. NHA/designee will complete random weekly audits for 4 weeks and monthly audits for 2 months to validate residents' are offered nonpharmacological intervention prior to tramadol and other PRN pain medication administration. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

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.

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:
Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions (EBP) and the use of personal protective equipment (PPE) to prevent the spread of infection for one of 35 sampled residents. (Resident 1)

Findings include:

Review of the facility policy entitled, "Enhanced Barrier Precautions," last reviewed January 25, 2026, revealed that EBP were to be used with any "high-risk resident" with a wound or indwelling device during "high contact care activities" including during wound care, the care of feeding and tracheostomy tubes, providing hygiene, and changing briefs and linens. EBP included the use of PPE such as protective gowns and gloves during high-risk activities.

Clinical record review revealed that Resident 1 had diagnoses that included Steele-Richardson-Olszewski syndrome (a neurodegenerative disorder that affects movement, balance, eye control, speech, swallowing, and cognition), dementia, the presence of an enteral feeding tube, and pressure ulcers. The Minimum Data Set assessment dated November 24, 2025, revealed that Resident 1 had stage four pressure ulcers on the sacrum (lower back), right hip, and buttocks, and was dependent on staff for toileting and personal hygiene. On February 25, 2026, at 12:00 p.m., a nurse aide (NA 1) was observed entering Resident 1's room to change her briefs without wearing a protective gown. In an interview at that time, NA 1 stated that she provided incontinence care without a gown.

On February 27, 2026, at 1:00 p.m., the Director of Nursing confirmed that staff did not use appropriate PPE during Resident 1's care.

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

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

Plan of Correction - To be completed: 03/24/2026

1. Employee 1 was re-educated on appropriate use of PPE for Enhanced Barrier Precautions.

2. The NHA/ Designee will complete an initial audit to validate residents on Enhanced Barrier Precautions have appropriate signage to alert staff of precautions.

3. Nursing department and therapy dept will be re-educated by the NHA/Designee that residents on Enhanced Barrier precautions have appropriate ppe worn when providing care.

4. NHA/designee will complete random weekly audits for 4 weeks and monthly audits for 2 months to validate staff wearing and doffing appropriate ppe with residents' on Enhanced Barrier Precautions. Audit results will be submitted to Quality Assurance Performance Improvement Committee for additional review and recommendations as needed. Further audit frequency will be determined based on prior audit findings.

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