Pennsylvania Department of Health
 HIGHLANDS REHABILITATION AND HEALTHCARE
Patient Care Inspection Results

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HIGHLANDS REHABILITATION AND HEALTHCARE
Inspection Results For:

There are  140 surveys for this facility. Please select a date to view the survey results.

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HIGHLANDS REHABILITATION AND HEALTHCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on February 5, 2026, it was determined that Highlands Rehabilitation and Healthcare 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:


483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations: Based on clinical record review and staff interview it was determined that the facility failed to provide the correct required notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 109 and 114). Findings include: A review of the form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. A review of the "Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055" revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows "Beginning on ...," the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay. The SNFABN provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A). SNFs will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. Closed clinical record review of census information for Resident 114 revealed that the facility provided services primarily paid for by Medicare starting November 19, 2025. Resident 114's Medicare payment for services ended December 31, 2025, when she discharged to the community. Review of a CMS-10123 notice provided by the facility for Resident 114 revealed that Medicare coverage for skilled nursing services would end on December 30, 2025. Additional information on the form indicated that staff delivered the notice verbally via a telephone conversation with Resident 114's son on December 29, 2025. The notation indicated that Resident 114's last covered day would be December 31, 2025 (not December 30, 2025, as indicated on the first page of the form). Neither Resident 114 nor a responsible party signed the notice. Nursing documentation dated December 31, 2025, at 1:01 PM revealed that staff reviewed discharge paperwork with Resident 114's son (who staff documented the telephone conversation with on December 29, 2025) and Resident 114 left the facility. The documentation did not indicate that the facility staff attempted to obtain Resident 114's son's dated signature on the CMS-10123 notice when he was in the facility to transport Resident 114 home. Resident 114's clinical record did not contain evidence that facility staff attempted to contact Resident 114 or her responsible party/son to obtain a dated signature on the form after her discharge from the facility. Interview with the Nursing Home Administrator on February 4, 2026, at 2:00 PM confirmed that the facility did not have a signed CMS-10123 form for Resident 114. Clinical record review of census information for Resident 109 revealed that the facility provided services primarily paid for by Medicare starting July 1, 2025. Resident 109's Medicare payment for services ended July 31, 2025. Resident 109 remained in the facility. The facility did not provide a CMS-10055 notice for Resident 109. The facility provided a CMS-R-131 form that the facility used in place of the CMS-10055 form. Resident 109 signed the CMS-R-131 form on July 29, 2025. The form did not include the date on which Resident 109 would be responsible for paying for care that Medicare was not expected to cover. The graph on the CMS website (Beneficiary Notices Initiative) stipulates that the provider types for the CMS-R-131 form use include independent laboratories, home health agencies, hospices, physicians, practitioners, and providers paid under Medicare Part B. The same graph instructs that skilled nursing facilities are to use the CMS-10055 form. The surveyor reviewed the above concerns regarding Resident 109's Medicare notice during an interview with the Nursing Home Administrator and the Director of Nursing on February 4, 2026, at 2:00 PM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights
 Plan of Correction - To be completed: 03/18/2026

Facility cannot retroactively correct residents 114 and 109 notices.

NHA conducted audit of last week of notices provided to ensure accuracy.

Social Service Director will be reeducated on accurately completing MA/MC/Liability notices.

NHA/Designee will conduct audits of MA/MC/Liability notices weekly x4 and monthly x2 to ensure completion. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(i) Food safety requirements.
The facility must -

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

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations: Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain the environment in a safe and sanitary condition in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on February 2, 2026, at 9:18 AM revealed the following: There were four boxes of thickened coffee packets, three boxes of thickened tea packets, and a sleeve of lids stored in the cabinet under the sink. Two bins with carafes (beverage holder) and lids were stored beside the sink and all the carafes and lids had a white residue on them. There was a silver four tier open shelf. On the bottom shelf there was a large open basin of water/juice pitchers and a large open basin of lids. Observation of the oven revealed the knobs were dirty and there was burnt residue all over the stovetop. Observation of the dry storage room revealed there was a loaf of bread with no use by date, a half loaf of bread not secured, a bag of egg noodles, powdered sugar, vanilla tapioca quick pudding, and pie filling mix opened, with no use by dates. Further observation of the kitchen on February 2, 2026. at 11:28 AM, revealed there were three areas on the floor in front of the dishwasher with tiles missing. There was a piece of board and rubber mat on top of these areas. Interviews with Employee 8 (dietary aide) and Employee 9 (cook), revealed the boards and plastic mats are a tripping hazard when they are utilizing the dishwasher. Interview with Employee 4 (maintenance director) on February 5, 2026, at 8:52 AM revealed that the repairs were completed on the kitchen floor on December 23, 2025. He stated he ordered the floor tiles on December 29, 2025, and picked them up from the supplier on January 21, 2026. He confirmed the three areas had approximately 19 tiles missing and were not placed until after the surveyor's questioning. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 4, 2026, at 2:30 PM. 28 Pa. Code 201.14(a) Responsibility of licensee
 Plan of Correction - To be completed: 03/18/2026

The thickened coffee/tea and lids were moved, the carafes were discarded, a lid was placed on the pitcher and lid bins, oven knobs and stovetop were cleaned, loaves of bread were discarded, egg noodles, powdered sugar, vanilla pudding, and pie filling were discarded, and tiles were replaced.

NHA conducted an audit of kitchen storage, dry pantry dates, and tiles to ensure proper storage, items are dated, and no missing tiles. Areas identified were immediately taken care of.

Dietary will be reeducated on storing food items in a safe and sanitary manner and maintenance will be reeducated on maintaining a safe environment in the kitchen.

NHA/Designee will audit storage of food items weekly x4 and monthly x2. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations: Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for three of six residents reviewed for nutritional concerns (Residents 1, 2, and 44). Findings include: The facility policy entitled, "Weight Assessment and Intervention," last reviewed August 27, 2025, revealed that resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of five percent or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Unless notified of significant weight changes, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month: five percent weight loss is significant, greater than five percent is severe Three months: 7.5 percent weight loss is significant, greater than 7.5 percent is severe Six months: 10 percent weight loss is significant, greater than 10 percent is severe Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address to the extent possible: the identified causes of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. Interventions for undesirable weight loss are based on careful considerations of resident choice and preferences, nutrition and hydration needs of the resident, functional factors that inhibit independent eating, medications, environmental factors, and end-of-life decisions and advance directives. Clinical record review for Resident 2 revealed the following weight assessments: August 26, 2025, 206.2 pounds August 27, 2025, 204.2 pounds September 2, 2025, 202.2 pounds September 16, 2025, 194.4 pounds (an 11.8-pound, 5.7 percent, severe weight loss in less than one month) September 30, 2025, 194.6 pounds October 6, 2025, 190.2 pounds (a 16-pound, 7.75 percent, severe weight loss in less than three months; and 12-pound, 5.93 percent severe weight loss in one month) October 7, 2025, 190.2 pounds Nutritional documentation by Employee 1 on October 17, 2025, (a month after the severe weight loss assessed for Resident 2), at 1:40 PM noted Resident 2's weights on October 6 and 7, 2025, which substantiated a 5.9 percent weight loss. Employee 1 documented that Resident 2 was at risk for malnutrition with variable oral intakes of meals. Employee 1 noted that she updated Resident 2's food preferences, encouraged Resident 2 to consume her meals, and recommended weekly weights for four weeks. Employee 1 indicated that she would continue to monitor Resident 2 and follow-up as needed. Staff documented a weight assessment of 172.4 pounds for Resident 2 on November 3, 2025 (which would have reflected an additional 17.8-pound, 9.35 percent severe weight loss in one month, however, a notation by Employee 7 (nurse aide) on November 21, 2025, at 11:50 PM crossed out the entry as incorrect documentation. There were no additional weights documented for Resident 2 until November 18, 2025 (six weeks since her previous weight assessment). The weight assessment documented on November 18, 2025, at 12:18 PM was 168 pounds (a 22.2-pound, 11.67 percent severe weight loss in six weeks). The surveyor reviewed the above concerns regarding Resident 2's weight loss and lack of interdisciplinary response during an interview with the Nursing Home Administrator and the Director of Nursing on February 3, 2026, at 2:00 PM. The surveyor again reviewed the above weight loss concerns for Resident 2 during an interview with the Nursing Home Administrator and the Director of Nursing on February 4, 2026, at 2:00 PM. Interview with the Director of Nursing on February 5, 2026, at 9:56 AM indicated that the nurse aide obtains weight assessments and provides the licensed practical nurse the results who is responsible for entering the information in the resident's electronic medical record; however, this did not occur for Resident 2. There was no evidence that the registered dietitian or physician had the information in the resident's medical record to review. There is no evidence that the registered dietitian assessed Resident 2 during the two months between October 17, 2025, and December 18, 2025. The facility provided no additional information regarding the implementation of new interventions to address Resident 2's severe weight loss. Interview with Employee 1 on February 5, 2026, at 10:39 AM confirmed the following: Staff assessed a 5.72 percent severe weight loss for Resident 2 on September 16, 2025; however, there is no evidence of an interdisciplinary response (to include the registered dietitian or the physician) until October 17, 2025. The plan of care on October 17, 2025, was to include weekly weight assessments; however, Resident 2's electronic medical record had no evidence that these were implemented; or that Employee 1 assessed Resident 2 timely (e.g., within a month) to review the findings of the planned weight assessments. There were no weight assessments for six weeks (when Resident 2 was to have weekly weight assessments) during which a weight assessment that indicated another severe weight loss was inexplicably crossed out as incorrect documentation without a replacement weight assessment. The next documented assessment by Employee 1 for Resident 2 was not until December 18, 2025 (two months following the acknowledgement of a severe weight loss). On August 26, 2025, Resident 2 weighed 206.2 pounds. On December 4, 2025, Resident 2 weighed 177.6 pounds (a 13.87 percent weight loss in less than six months). A quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated December 10, 2025, assessed Resident 2 as not having a 10 percent or more weight loss in the last six months. Review of a plan of care initiated by Employee 1 on September 3, 2025, to address Resident 2's risk for altered nutritional status revealed no evidence of any revisions to her plan of care despite her severe weight loss since admitted to the facility. Clinical record review for Resident 44 revealed the following weight assessments: June 17, 2025, 166.7 pounds July 1, 2025, 169.9 pounds July 8, 2025, 170.3 pounds July 15, 2025, 162. 0 pounds July 22,2025, 171.8 pounds July 29, 2025, 175.8 pounds (a 9.1-pound, 5.17 percent significant weight gain) August 5, 2025, 174.0 pounds September 3, 2025, 179.4 pounds September 8, 2025, 183.7 pounds September 23, 2025, 187.2 pounds (a 20.5-pound, 10.95 percent significant weight gain) A full nutritional assessment was completed by Employee 1 on June 19, 2025, noted Resident 44 BMI (body mass index, a tool that estimates the amount of body fat by using height and weight measurements), was 28.5 in the overweight category. The next assessment of Resident 44 weights was not until September 19, 2025, noting a 9.7-pound, 5.6 percent significant weight gain in one month, and a 17-pound, 10.2 percent weight gain in three months. Employee 1 recommended weekly weights times four to better track Resident 44's weight gain. Further review of Resident 44's clinical record revealed the facility initiated a care plan on June 19, 2025, indicating Resident 44 is at risk for altered nutritional status related to her diagnosis of dementia. Resident 44's care plan was not updated to reflect any interventions addressing her significant weight gains. Interview with Employee 1 on February 4, 2026, at 11:12 AM revealed that she could provide no further documentation indicating she addressed Resident 44's weight gain until September 19, 2025 (nearly two months after significant weight gain). Employee 1 confirmed Resident 44's care plan was not updated to reflect any interventions addressing her weight gains. The findings for Resident 44 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on February 4, 2026, at 2:38 PM Clinical record review for Resident 1 revealed the following weight assessments: July 21, 2025, 224 pounds July 29, 2025, 216.4 pounds August 5, 2025, 216.3 pounds August 19, 2025, 217.8 pounds August 26, 2025, 223.0 pounds September 9, 2025, 222.0 pounds September 16, 2025, 222.5 pounds September 28, 2025, 218.8 pounds November 3, 2025, 208.8 pounds December 3, 2025, 201.1 pounds December 11, 2025, 200.5 pounds December 11, 2025, 203.4 pounds A full nutritional assessment was completed by Employee 1 on October 2, 2025, and noted Resident 1's BMI was 34.3, in the obese category. A nutrition note dated December 18, 2025, at 8:53 AM revealed that Resident 1 was noted to be down 21.6 pounds, (9.7% significant weight loss in 3 months). The note indicated that weekly weights for four weeks would be put in place, and she added a fortified food. A nutrition note dated January 8, 2026, at 6:43 PM revealed that Resident 1 refused to be weighed monthly for January weight. Interview with the Employee 1 on February 5, 2026, at 1:15 PM revealed that she did not do her risk assessment in January 2026, because Resident 1 refused to be weighed. When surveyor ask about the weekly weights, Employee 1 indicated that Resident 1 refused them too but there was no evidence in the clinical record related to this. Surveyor asked Employee 1 if she followed up with Resident 1 related to her significant weight loss and she said she did not because there was no new weight for Resident 1. The Director of Nursing was made aware of the concerns with Resident 1's weight loss on February 5, 2026, at 1:30 PM. The facility failed to provide the highest practicable care related to Resident 1's weight loss. 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/18/2026

Facility cannot retroactively implement interventions to promote acceptable parameters of nutrition.

DON / RD / designee audited current residents for the past 30 days for undesirable or unintended weight changes of 5 % or more since the last weight assessment to ensure weight change verified. Interventions placed and care plan updated as appropriate.

RD and nursing staff will be reeducated on the Weight Assessment and Intervention policy.

DON / RD / designee will audit verified weight changes for interventions and care planning weekly X 4 and monthly X 2. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
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 clinical record review and staff interview, it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care for one of three residents reviewed for advance directives concerns (Resident 2). Findings include: Clinical record review for Resident 2 revealed an active physician order dated December 5, 2025, that instructed staff to not resuscitate Resident 2 (DNR, do not attempt to resuscitate, do not perform CPR, allow natural death) in the event of no pulse or breathing. Review of a POLST (Pennsylvania Orders for Life Sustaining Treatment, a binding medical order that instructs healthcare providers the specific types of medical treatment a resident wishes to receive at the end of life) form signed by Resident 2's physician on January 28, 2026, and signed by Resident 2 indicated that Resident 2 desired CPR/attempt resuscitation (cardiopulmonary resuscitation, chest compressions and artificial breathing assistance) if there is no pulse or breathing. The surveyor reviewed the above concern that Resident 2's active physician orders did not reflect Resident 2's emergency care wishes during an interview with the Director of Nursing and the Nursing Home Administrator on February 4, 2026, at 2:00 PM. Interview with the Director of Nursing on February 5, 2026, at 10:05 AM confirmed that staff obtained a verbal physician's order following the surveyor's questioning to update Resident 2's active physician orders to reflect Resident 2's wishes for CPR as per the January 28, 2026, POLST. .28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/18/2026

Resident 2's code order was changed to reflect POLST.

ADON conducted audit to ensure resident code status orders match their POLST.

Licensed nurses will be reeducated on ensuring active physician orders incorporate resident wishes related to end of life care.

Social Worker/Designee will conduct random audits of code status orders weekly x4 and monthly x2. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations: Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on two of two nursing units (Second and Third Floor Nursing Units, Residents 1, 5, 10, and 11), and provide a safe and clean environment in the facility's main laundry area. Findings include: Observation of the facility's main laundry area on February 4, 2026, at 11:53 AM with Employee 6, Director of Environmental Services, revealed a folded blanket on the floor behind the washing machines and under the wall mounted chemical dispensers. There was an extensive build-up of a dried and flaky substance on the blanket and surrounding floor. The Nursing Home Administrator was informed of the main laundry area findings on February 4, 2026, at 12:02 PM. Observation of Resident 5's room on February 3, 2026, at 9:25 AM revealed that door to the room was all marred and the floor was dirty around the bed and under the dresser near the cove base. Observation of Resident 1's room on February 3, 2026, at 10:30 AM revealed the floor to be dirty with crumbs under the over bed table and by her bed. The door to the room was all marred. Observation of Resident 10's room on February 2, 2026, at 12:44 PM revealed that the door to her room and the bathroom door was all marred. The nursing home administrator and the director of nursing were made aware of the concerns with Resident 1, 5, and 10's environment on February 5, 2026, at 11:00 AM. Observation of Resident 11 on February 2, 2026, at 9:34 AM, and February 3, 2026, at 10:12 AM revealed Resident 11 was seated in the recliner chair in his room. The wall behind Resident 11's recliner was marred. Resident 11 stated "it has been like that for a long time." Reviewed the above findings for Resident 11 during a meeting with the Nursing Home Administrator and Director of Nursing on February 4, 2026, at 2:25 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management
 Plan of Correction - To be completed: 03/18/2026

The towel in laundry was removed and area cleaned immediately. Resident 5 and 1's room was cleaned by housekeeping, and their door was repaired. Resident 10's door was repaired. Resident 11's wall was repaired.

NHA/Designees conducted audits of the laundry area to ensure cleanliness, residents with recliners to ensure the wall behind is free of damage and repaired as needed, resident entrance and bathroom doors, and resident room floors to ensure cleanliness.

Housekeeping and maintenance will be reeducated on maintaining a clean, safe, homelike environment.

NHA/Designee will conduct audits of resident doors, laundry area, and resident floors weekly x4 and monthly x2. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process: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.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

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

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

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

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

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

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

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

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

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

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
Observations: Based on clinical record review and resident and staff interview it was determined that the facility failed to provide written notice of transfer and written notice of the facility bed-hold policy to residents' responsible parties at the time of transfer for two of six residents reviewed for hospitalization concerns (Residents 2 and 6). Findings include: Clinical record review for Resident 2 revealed profile information that indicated that she had resident representatives that included her mother, a male emergency contact, and an adult protective services county representative. Nursing documentation dated October 1, 2025, at 1:45 PM revealed that Resident 2 was admitted to the hospital following an above-the-knee amputation. The facility provided a Notice of Transfer or Discharge dated October 1, 2025, addressed to Resident 2, that noted the transfer to the hospital on October 1, 2025, was necessary for the surgical procedure of a right above-the-knee amputation. Staff documented a verbal review of the notice with Resident 2 on October 1, 2025. There was no indication that Resident 2 and one of her resident representatives received a written copy of the notice. The facility did not provide evidence that Resident 2 and one of her representatives received written notice which specified the duration of the facility's bed-hold policy within 24 hours of Resident 2's transfer. Nursing documentation dated November 21, 2025, at 10:34 AM revealed that Resident 2 was lethargic, difficult to arouse, and had a low blood pressure. Staff contacted the physician who instructed staff to send Resident 2 to the emergency room. Nursing documentation dated November 21, 2025, at 11:52 PM revealed that the hospital informed facility staff that Resident 2 was admitted for an infection related to kidney stones and revision of ureteral stents (tubes placed in the vessels from the kidney to the bladder to correct and/or prevent obstruction). The facility provided a Notice of Transfer or Discharge dated November 21, 2025, addressed to Resident 2, that noted the transfer to the hospital on November 21, 2025, was necessary due to abnormal laboratory results. Staff documented, "resident unable to sign at present," on November 21, 2025. There was no indication that Resident 2 and one of her resident representatives received a written copy of the notice. A Bed Hold Notice form noted, "unable to sign at present time," that Resident 2 was contacted by facility staff on November 21, 2025, at 10:00 AM, and that the Bed Hold Election form was mailed to Resident 2 for signature on November 24, 2025 (three days after the transfer to the hospital). The facility did not provide evidence that Resident 2 and one of her representatives received written notice which specified the duration of the facility's bed-hold policy within 24 hours of Resident 2's transfer. The surveyor reviewed the above concerns regarding Resident 2's and her resident representative's receipt of the required notices upon her transfers to the hospital during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2026, at 12:25 PM. Interview with Resident 6 on February 2, 2026, at 2:13 PM revealed that she was recently hospitalized after she fell and broke her femur (long leg bone in the thigh area). Census information for Resident 6 confirmed that she was on hospital leave starting December 26, 2025. Review of Resident 6's profile information revealed that her resident representatives included her son. The facility provided a Notice of Transfer or Discharge dated December 26, 2025, addressed to Resident 6, that noted the transfer to the hospital on December 26, 2025, was necessary due to a fall with possible fracture. Resident 6 signed the notice on December 26, 2025. There was no evidence that Resident 6's representative received a written copy of the notice. A Bed Hold Notice form noted, "verbal (son's name)," on December 26, 2025. The section of the Bed Hold Notice that is used to document the mailing or emailing of the notice was left blank. The surveyor reviewed the above concerns regarding Resident 6's representative's receipt of the required notices upon her transfer to the hospital during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2026, at 12:25 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights
 Plan of Correction - To be completed: 03/18/2026

Facility cannot retroactively provide written notice of transfer to Resident 6 and 2's representatives.

Social Services/Designee audited the last 30 days of transfers to ensure completion.

Nursing staff will be reeducated on providing written transfer and bed hold notices to resident representatives at the time of transfer.

NHA/Designee will audit transfer notices weekly x4 and monthly x2. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

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

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

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.
Observations: Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of 22 residents reviewed (Residents 3, and 4). Findings include: Clinical record review for Resident 4 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated October 2, 2025, in which facility staff assessed Resident 4 as having no impairments to her upper extremities. The next quarterly assessment completed on January 20, 2026, revealed staff now assessed Resident 4 as having bilateral upper extremity impairments. Review of Resident 4's occupational therapy treatment notes from September 30, 2025, to October 27, 2025, noted Resident 4's range of motion was impaired to her bilateral upper extremities. Interview with Employee 2 (registered nurse assessment coordinator) on February 5, 2026, at 9:21 AM, confirmed the above findings for Resident 4. Employee 2 verified the therapy documentation from the lookback period for October 2, 2025, MDS noted impairments to Resident 4's left and right shoulders with active range of motion limitations. Observation of Resident 3 on February 2, 2026, at 11:30 AM revealed her in bed with bilateral enabler bars on her bed. She indicated that she used the enabler bars to help her turn and move in bed. She also indicated that she can't get out of bed on her own. Review of Resident 3's MDS quarterly assessment date January 8, 2026, revealed that the facility coded her as using bedrails daily as a restraint. Interview with the nursing home administrator and director of nursing on February 3, 2026, at 2:20 PM revealed that this was an MDS coding error and that Resident 3 has enabler bars on her bed, not bedrails that are used as a restraint. 483.20(g) Accuracy of Assessments Previously cited 1/16/25 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services
 Plan of Correction - To be completed: 03/18/2026

Resident 3 and 4's MDS were corrected.

MDS Coordinator conducted an audit to identify other MDS assessments with coding discrepancies for item P0100A and GG0115A and all findings addressed.

RNAC was re-educated on RAI Manual guidelines related to P0100A and GG0115A coding.

The Regional Director of Clinical Reimbursement/Designee will complete random audit on P0100A and GG0115A coding weekly x4 weeks, then monthly x2 months. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.20(e)(1)(2) REQUIREMENT Coordination of PASARR and Assessments: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.
§483.20(e) Coordination.
A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes:

§483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

§483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.
Observations: Based on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-Admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one of three residents reviewed (Resident 7). Findings include: Clinical record review revealed the facility admitted Resident 7 on September 26, 2024, with diagnosis including a family history of alcohol abuse and dependence. Review of Resident 7's clinical record revealed a PASARR Level II determination letter dated May 22, 2024, from the Department of Human Services noted based on a review of the information submitted, the Office of Mental Health and Substance Abuse Services had determined that Resident 7 does not meet the mental health criteria for further review by the office. The letter further stated that although Resident 7 did not meet the criteria for serious mental illness, the documentation submitted indicates that Resident 7 could benefit from drug and alcohol services. Further review of Resident 7's clinical record revealed there was no documentation that the facility recommended and/or provided any drug and alcohol services to Resident 7 as the result of the PASARR II recommendation. Interview with Employee 3 (social worker) on February 4, 2026, at 12:08 PM, confirmed the facility had no documentation that they incorporated the recommendations from Resident 7's PASARR Level II into her care at any time while residing at the facility. The above findings for Resident 7 reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on February 4, 2026, at 2:35 PM There was no evidence at the time of the survey the facility had timely identified and coordinated the provision of specialized services for Resident 7. 28 Pa. Code 211.5(f)(iv)(vi) Medical records.
 Plan of Correction - To be completed: 03/18/2026

Social services met with Resident 7 to offer drug and alcohol services and Resident declined.

NHA conducted audit of PASARR Level II determination letters to ensure specialized services were offered when recommended.

Social services will be reeducated on incorporating recommendations from the PASARR Level II determination and evaluation report.

NHA/Designee will audit new PASARR Level II determination letters weekly x4 and monthly x2 to ensure specialized services are offered. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations: Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to include a resident's representative in participation with care planning for one of 22 residents reviewed (Resident 6), revise a care plan after a resident's change in condition for one of 22 residents reviewed (Resident 2), and revise a care plan related to a pacemaker intervention for one of 22 residents reviewed (Resident 86). Findings include: Clinical record review for Resident 86 revealed the resident had a physician order dated December 26, 2025, that noted a pacemaker (an implanted electronic device to help regulate the beating of the heart). Hospital documentation for Resident 86 dated December 24, 2025, at 1:30 PM revealed that the resident had a permanent pacemaker insertion on February 15, 2023. Observation on February 3, 2026, at 12:14 PM revealed that there was an electronic pacemaker transmittal device on the dresser next to Resident 86's bed. Review of Resident 86's current care plan revealed the resident has an impaired cardiovascular status related to the resident's medical history and presence of a cardiac pacemaker. The care plan did not address the electronic transmittal device (proper placement, troubleshooting any issues, contact information, etc.). The above information for Resident 86's pacemaker was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 3, 2026, at 2:00 PM. Clinical record review for Resident 2 revealed that on August 26, 2025, Resident 2 weighed 206.2 pounds. On December 4, 2025, Resident 2 weighed 177.6 pounds (a 13.87 percent weight loss in less than six months). Review of a plan of care initiated by Employee 1 (registered dietitian) on September 3, 2025, to address Resident 2's risk for altered nutritional status revealed no evidence of any revisions to her plan of care despite her severe weight loss since admitted to the facility. The surveyor reviewed concerns regarding Resident 2's weight loss and interdisciplinary response during interviews with the Nursing Home Administrator and the Director of Nursing on February 3, 2026, at 2:00 PM and February 4, 2026, at 2:00 PM. The surveyor reviewed concerns regarding Resident 2's weight loss with Employee 1 (registered dietitian) on February 5, 2026, at 10:39 AM. Interview with Resident 6 on February 2, 2026, at 1:57 PM revealed that she denied knowledge of care plan meetings and denied that her son or daughter-in-law participated in care plan meetings. Clinical record review for Resident 6 revealed profile information that listed her son as her "Care Conference Person." Care Plan Note documentation on December 1, 2025, at 1:34 PM; September 4, 2025, at 11:32 AM; June 4, 2025, at 8:45 AM; and March 6, 2025, at 1:56 PM revealed no evidence that the facility attempted to include Resident 6's son to participate with care planning. Interview with the Director of Nursing and the Nursing Home Administrator on February 3, 2026, at 2:00 PM confirmed that the facility could not provide evidence of Resident 6's representative participation in her care planning for the past year. Interview with Employee 3 (social services) on February 4, 2026, at 12:07 PM confirmed that she had no evidence that she attempted to involve Resident 6's son (designated as her care conference contact) when conducting care plan meetings. Social services documentation by Employee 3 dated February 4, 2026, at 4:10 PM (following the surveyor's questioning) revealed that she contacted Resident 6's son regarding care plan scheduling and he would be interested in attending meetings again following Resident 6's recent change in health status due to her surgery on her hip. 483.21 Comprehensive Care Plans Previously cited deficiency 1/16/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/18/2026

Resident 86's care plan was revised to include the electronic transmittal device. Social services reached out to Resident 6's son and will be included in her next care plan meeting. Resident 2's care plan was updated by dietician.

DON audited residents with pacemakers to ensure care plan is updated, NHA audited resident contacts listed as Care Conference Person to ensure they and reviewed with social services to ensure they are invited to care plan meetings, and Dietician audited significant weight changes in the last 30 days to ensure care plan has been updated.

IDT will be reeducated on completing care plans and care plan meeting participation.

NHA/Designee will audit pacemaker care plans, weight change care plans and care plan meeting participation weekly x4 and monthly x2. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.25(k) REQUIREMENT Pain Management: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(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 clinical record review and staff and resident interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for one of one resident reviewed for pain (Resident 1). Findings include: Interview with Resident 1 on February 2, 2026, at 10:51 AM revealed that she has constant pain. She said sometimes it is from her stomach, and sometimes it is her legs or back. Clinical record review for Resident 1 revealed that she has a diagnosis of chronic pain (pain that last for longer than three months or occurring with an ongoing condition, that affects daily life and well-being). Review of Resident 1's current physician's order revealed that she had the following medications ordered for pain: Gabapentin 100 milligrams (mg) one every morning and at bedtime Tramadol 50 mg one every four hours as needed for pain. Tylenol 325 mg two tablets every six hours for mild pain 1-3, (on a 1-10 pain scale). Review of Resident 1's medication administration record for the month of December 2025, revealed that she utilized the as needed Tramadol 50 milligrams 45 times. Review of Resident 1's medication administration record for the month of January 2026, revealed that she utilized the as needed Tramadol 50 milligrams 26 times and she utilized the as needed Tylenol 325 mg two tablets three times. Review of Resident 1's medication administration record for the dates of February 1-3, 2026, revealed that she utilized the as needed Tramadol 50 milligrams five times. There was no evidence in the clinical record indicating Resident 1's physician was made aware of the amount of as needed pain medications she used, or that the physician addressed Resident 1's uncontrolled chronic pain. The Director of Nursing was made aware of the concerns noted above related to Resident 1's pain on February 6, 2026, at 10:45 AM. The facility failed to ensure Resident 1's pain was managed consistent with professional standards of practice. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/18/2026

Resident 1 was seen by provider to evaluate pain management.

DON conducted audit of residents receiving prn tramadol to ensure pain management was adequately provided.

Nursing will be reeducated on pain management.

DON/Designee will audit residents receiving prn tramadol weekly x4 and monthly x2 to ensure pain management was provided. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.40 REQUIREMENT Behavioral Health Services: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.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations: Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to provide the highest practicable care for one of one resident reviewed for behavioral health related to suicidal ideation. (Resident 82). Findings include: The facility policy entitled, "Suicide Prevention and Intervention Guideline", last reviewed without changes on August 27, 2025, revealed it is the policy of the facility that individuals voicing and/or displaying feelings and/or actions which indicated suicidal ideation (thoughts, or preoccupations with ending one's own life, ranging from fleeting, passing thoughts to detailed, active planning), receive services and interventions to help them manage these feeling and maintain their psychosocial well-being. Employees are responsible for monitoring acute mood and behavior changes which may indicate potential suicidal ideation and for reporting these changes to their supervisor for appropriate assessment and interventions. With any verbalization of suicide/self-harm ideation, or suicide attempt, the resident should immediately be placed on one-to-one observation until they are transferred to the hospital or are evaluated by a physician/clinician. An immediate written care plan should be developed and implemented specific to the resident's situation and needs. The plan should outline the interventions and monitoring for the resident to remain safe. The plan should also include visual checks, which should be completed and documented at an interval that is determined by the individualized assessment. A nursing progress note dated January 7, 2026, at 2:21 PM revealed that Resident 82 was making statements that she wanted to be discharged so she could go home and commit suicide. The note indicated that Resident 82 was put on frequent checks and that she was immediately seen by the provider in the facility who felt there was no immediate danger and that there was no medical cause of her comments but the provider felt the resident was more depressed related to her current situation and he wanted her seen by psychiatry. The note also indicated that Resident 82's family was present in the facility and stated that she made comments like this in the hospital and was seen and cleared by psychiatry. Resident 82 was to be seen by psychiatry on "Friday" (January 9, 2026). A late entry physician progress noted created January 11, 2026, but noted to be effective January 7, 2026, indicated that the physician was seeing Resident 82 for an initial evaluation because she was a new admission on January 6, 2026. The physician made no mention of Resident 82 having suicidal ideations in his note but did indicate that Resident 82 was seen and evaluated at bedside and there were no additional concerns. The note also indicated that she had a diagnosis of depression. A psychiatry progress noted dated January 9, 2026, revealed that Resident 82 reported that her mood had been good, and she denied depression, anxiety or mood issues, but that staff reported she had made comments about wanting to go home to commit suicide. The note indicated Resident 82 stated she made comments a while ago about that, but she had no recollection of that and denies suicidal ideation at that time. The note also indicated she has very poor insight into her psych issues as she had some delusions such as reporting that she was married three times which the family indicated was not the case. The psychiatrist also indicated that the family does feel Resident 82 is depressed. He also notes that resident did have a daughter that committed suicide. Clinical record review for Resident 82 revealed a nursing progress note dated January 27, 2026, at 8:26 PM that indicated Resident 82 stated to a nurse aide that she was tired, and she was thinking of committing suicide. The note indicated that the writer then approached resident who was in bed and the resident stated she was tired and they would talk in the morning. The nurse then made her aware to use her call light if she needed anything. The note indicated the charge nurse was updated to closely monitor Resident 82, and for social work to follow up tomorrow. There was no social service follow-up noted in the clinical record. A nursing progress note dated January 27, 2026, at 9:11 PM revealed that Resident 82 stated she was fine but really tired and just wanted to sleep. A nursing progress note dated January 28, 2026, at 3:26 am indicated that Resident 82 had no suicidal statements voiced or reported and was resting in bed. Review of Resident 82's care plan revealed that there was no care plan addressing her suicidal ideation until after the surveyor brought it to the facility's attention during a meeting on February 3, 2026, at 2:20 PM, during a meeting with the nursing home administrator and director of nursing. Interview with Employee 3, social service director, on February 4, 2026, at 12:14 PM confirmed the above noted findings that she did not initiate a care plan with individualized interventions related to Resident 82's suicidal ideation until February 3, 2026. There was no evidence in the clinical record to show that the facility initiated one-to-one, more frequent checks, or that individualized interventions were initiated for Resident 82, related to her suicidal ideation on January 7, 2026, or January 27, 2026. The nursing home administrator and director of nursing were made aware of the above noted findings related to Resident 82's suicidal ideation during a meeting on February 4, 2026, at 2:15 PM. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services
 Plan of Correction - To be completed: 03/18/2026

Resident 82's care plan was revised to include suicidal ideation.

Social Service conducted audit of residents with past suicidal ideation to ensure care plan addresses suicidal ideation.

Social Service Director will be reeducated on suicide prevention and intervention guideline.

Social services/Designee will audit progress notes weekly x4 and monthly x2 to ensure suicide prevention policy is followed. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations: Based on a review of select facility policies and procedures, observation, clinical record review, and family and staff interview, it was determined that the facility failed to provide routine dental care for one of one resident reviewed for dental concerns (Resident 58). Findings include: The facility policy entitled, "Dental Consultant," last reviewed August 27, 2025, revealed that dental care shall be provided through the services of a consultant dentist. A consultant dentist is retained by the facility and is responsible for providing a dental assessment of each resident within ninety (90) days of admission and, "...performing or supervising an annual dental revaluation for each resident." The policy did not confirm that the facility would provide dental services provided by the State Medicaid plan (e.g., prophylactic dental cleanings every six months). Interview with Resident 58's daughter on February 2, 2026, at 10:12 AM revealed that she believed Resident 58 needed to "have her teeth fixed," and that Resident 58 had natural teeth that likely needed to be extracted. Resident 58's daughter stated that she was aware a mobile dentist provided services at the facility and claimed that she received a bill for an initial exam for $90.00 (ninety dollars). Observation of Resident 58 on February 2, 2026, at 12:29 PM revealed her to have missing teeth. Clinical record review of Resident 58's census information revealed that the facility admitted her on November 7, 2025, and that the State Medicaid plan was her primary payer source. Review of a Consent for Dental Services dated November 9, 2025, indicated that Resident 58's responsible party agreed to the facility's contracted dental provider to perform, "an annual dental exam, necessary x-rays, and cleanings." The authorization signed by Resident 58's responsible party noted that, "Medicaid recipients are covered for these routine services." The surveyor requested evidence of professional dental services for Resident 58 during an interview with the Nursing Home Administrator and Director of Nursing on February 3, 2026, at 2:00 PM. A letter provided by the facility from the contracted dental provider dated February 4, 2026, indicated that, "(Resident 58) is in compliance with annual routine exams." The letter indicated Resident 58's responsible party wanted dental services when her Medicaid plan was active. The letter further noted, "Per the facility, her Medicaid became active on January 15, 2026, and (the contracted dental provider) was notified of this change on February 3, 2026." Interview with the Nursing Home Administrator and the Director of Nursing on February 4, 2026, at 2:00 PM confirmed that the contracted dental provider was at the facility on February 4, 2026, however, did not provide services to Resident 58. The interview confirmed that Resident 58 had not received any professional dental services in the 90 days since her admission to the facility. The interview indicated that the contracted dental provider sent Resident 58's responsible party notice that an initial exam would be $90.00 if not paid by Medicaid, however, Resident 58 was a Medicaid recipient and would not be liable for the $90.00. Interview with Employee 5 (business office manager) on February 5, 2026, at 1:00 PM revealed that the facility had knowledge that Resident 58's Medicaid application was approved on December 5, 2025 (less than one month after her admission to the facility). Interview with the Director of Nursing on February 5, 2026, at 9:56 AM provided no answer as to how often the contracted dental provider provides services in the facility. Interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2026, at 12:25 PM revealed that the contracted dental provider has no expected frequency of services (e.g., monthly, quarter, etc.); however, Resident 58 would be on the list for services during the next onsite visit. Interview with the Nursing Home Administrator on February 5, 2026, at 1:10 PM confirmed that the facility policy and the consultant dental provider letter did not stipulate that residents would receive routine dental services as provided by the State Medicaid plan. The Nursing Home Administrator indicated that she was not certain of the frequency of routine dental services provided by the State Medicaid plan. Interview with the Director of Nursing on February 5, 2026, at 1:35 PM confirmed that the facility was now aware of the frequency of routine dental services covered under the State plan (e.g., every six months) and would begin educating staff regarding the expectation. 483.55(b)(1)-(5) Dental Services Previously cited deficiency 1/16/25 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/18/2026

Resident 58 is scheduled to be seen by dental on their next visit to facility.

NHA conducted an audit of new admissions in the last 90 days to ensure they have been seen by dental.

Social Services will be educated on scheduling dental services timely.

NHA/Designee will audit new admission dental schedules weekly x4 and monthly x2. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
§ 211.5(d) LICENSURE Medical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Medical information pertaining to a resident ' s stay shall be centralized in the resident ' s record.

Observations: Based on closed clinical record review and staff interview it was determined that the facility failed to ensure the record of a discharged resident was completed within 30 days of discharge for one of three closed records reviewed (Resident 112). Findings include: Closed clinical record review for Resident 112 revealed nursing documentation dated November 14, 2025, at 1:57 PM that Resident 112 was absent of respirations and pulse and death was noted at 1:30 PM. Nursing documentation dated November 14, 2025, at 6:45 PM revealed that Resident 112's belongings were secured by her family and the "inventory sheet signed." Review of Resident 112's Inventory of Personal Effects form dated July 23, 2025, was not signed by any staff or resident responsible person on discharge. Interview with the Nursing Home Administrator and the Director of Nursing on February 3, 2026, at 2:00 PM indicated that the facility had no physical closed record for Resident 112; that all documentation was scanned and maintained in the electronic medical record system. Interview with the Director of Nursing on February 5, 2026, at 9:56 AM confirmed that the Inventory of Personal Effects form included in Resident 112's closed electronic medical record did not include signatures of staff or family. Interview with the Nursing Home Administrator on February 5, 2026, at 1:10 PM indicated that Resident 112's completed (with signatures) Inventory of Personal Effects form was in a nursing office on the nursing unit and not included in the resident's closed electronic medical record. The facility failed to ensure that information pertaining to Resident 112's personal property was centralized in her closed record within 30 days of her discharge.
 Plan of Correction - To be completed: 03/18/2026

Resident 112's inventory sheet was scanned into her chart.

Medical records director completed and audit of the last month of discharges to ensure inventory sheets are included in the chart.

Medical records will be reeducated on closing medical records within 30 days of discharge.

NHA/Designee will audit discharged resident inventory sheets weekly x4 and monthly x2 to ensure they are uploaded into the chart. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:State only Deficiency.
(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations: Based on a review of select facility policies and procedures, closed clinical record review, and staff interview, it was determined that the facility failed to ensure documentation of the method of disposition of medications for an expired resident for one of three closed records reviewed (Resident 112). Findings include: The facility policy entitled, "Discarding and Destroying Medications," last reviewed August 27, 2025, revealed that the medication disposition record contains, as a minimum, the following information: The resident's name The name and strength of the medication The prescription number (if any) The name of the dispensing pharmacy Date medication destroyed The quantity destroyed Method of destruction Reason for destruction Signature of witnesses Closed clinical record review for Resident 112 revealed nursing documentation dated November 14, 2025, at 1:57 PM that Resident 112 was absent of respirations and pulse and death was noted at 1:30 PM. Review of a Medication Disposition Record dated November 18, 2025, indicated that 11 medications required disposition as Resident 112 was deceased. Medications listed included: Haldol (antipsychotic medication) 1 milligram (mg) Olanzapine (antipsychotic medication) 7.5 mg Amlodipine (medication used to lower blood pressure) 10 mg Divalproex (anticonvulsant medication used to treat seizures, bipolar disorder, andmigraines) 125 mg Losartan (medication used to lower blood pressure) 100 mg Memantine (medication used to improve memory and attention associated with dementia declines) 10 mg Metoprolol (medication used to lower blood pressure) 50 mg Mirtazapine (antidepressant medication) 30 mg Sumatriptan (medication used to treat migraines) 50 mg The Disposition Reason Key at the bottom of the form indicated that staff were to code the method of disposition (e.g., released to resident or destroyed). Staff did not note the method of disposition for the above medications. A Medication Disposition Record dated November 13, 2025, indicated that staff documented 109 doses of Depakote Sprinkles (Divalproex) as overstock for Resident 112. The staff did not enter a, "Destruction Date," or method of disposition for the medication. A Controlled Substance Record for Resident 112's Clonazepam (antianxiety medication) 0.5 mg medication indicated that 56 doses remained in stock as of November 12, 2025. Two staff signed for the disposition of the 56 remaining doses on November 13, 2025; however, the form did not indicate the method of disposition. Interview with the Director of Nursing on February 5, 2026, at 9:56 AM confirmed the above findings regarding Resident 112's medication disposition.
 Plan of Correction - To be completed: 03/18/2026

Facility cannot retroactively correct Resident 112's Medication Disposition Record.

DON conducted audit of last two weeks of discharges to ensure medication disposition record was completed.

Nursing will be reeducated on documentation of discarding and destroying medications.

DON/Designee will audit medication disposition records weekly x4 and monthly x2. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations: Based on review of nursing staffing hours and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents during the days shift for six of 21 days reviewed, one NA per 11 residents during the evening shift for eight of 21 days reviewed, one nurse aide per 15 residents during the overnight shift for six of the 21 days reviewed. Findings include: A review of nursing care hours provided by the facility from January 15 through February 4, 2026, revealed the following: Day shift (requires one NA per 10 residents): January 17, 2026, census of 108 with 8.97 NAs, required 10.8. January 24, 2026, census of 108 with 9.20 NAs, required 10.8 January 25, 2026, census of 106 with 6.73 NAs, required 10.6 January 26, 2026, census of 106 with 9.22 NAs, required 10.6 January 31, 2026, census of 109 with 8.33 NAs, required 10.9 February 1, 2026, census of 108 with 9.13 NAs, required 10.8 Evening shift (requires one NA per 11 residents): January 17, 2026, census of 109 with 9.37 NAs, required 9.91 January 23, 2026, census of 108 with 8.10 NAs, required 9.82 January 24, 2026, census of 106 with 9.03 NAs, required 9.64 January 26, 2026, census of 106 with 9.17 NAs, required 9.64 January 27, 2026, census of 106 with 8.37 NAs, required 9.64 January 31, 2026, census of 109 with 9.83 NAs, required 9.91 February 1, 2026, census of 108 with 8.80 NAs, required 9.82 February 2, 2026, census of 108 with 8.07 NAs, required 9.82 Night shift (requires one NA per 15 residents): January 17, 2026, census of 109 with 6.83 NAs, required 7.27 January 29, 2026, census of 109 with 6.40 NAs, required 7.27 January 24, 2026, census of 106 with 6.07 NAs required 7.07 January 26, 2026, census of 106 with 6.27 NAs, required 7.07 January 31, 2026, census of 108 with 5.17 NAs, required 7.20 February 1, 2026, census of 108 with 5.43 NAs, required 7.20 Interview with the Nursing Home Administrator and Director of Nursing on February 4, 2026, at 2:25 PM confirmed that the facility did not meet regulatory NA-to-resident ratios as evidenced above.
 Plan of Correction - To be completed: 03/18/2026

Facility cannot retroactively correct nurse aide staffing ratio.

Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance.

Director of Nursing/Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. Recruitment and retention plan is in place. Facility has a Culture Committee to promote retention.

Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations: Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for three of the 21 days reviewed, and one LPN per 40 residents during the night shift for one of 21 days reviewed . Findings include: Review of nursing staff care hours provided by the facility for January 15-February 4, 2026, revealed the following LPNs scheduled for the resident census: Day Shift (requires one LPN per 25 residents): January 17, 2026, 4.00 LPNs for a census of 108, required 4.32. January 18, 2026, 4.16 LPNs for a census of 109, required 4.36. January 24, 2026, 4.31 LPNs for a census of 108, required 4.32. Night shift (requires one LPN per 40 residents): February 2, 2026, 2.00 LPNs for a census of 108, required 2.70. Interview with the Nursing Home Administrator and Director of Nursing on February 4, 2026, at 2:25 PM confirmed that the facility did not meet regulatory LPN-to-resident ratios as evidenced above
 Plan of Correction - To be completed: 03/18/2026

Facility cannot retroactively correct LPN staffing ratio.

Director of Nursing/Designee will conduct an initial audit of the past two weeks schedule to determine if LPN ratio is in compliance.

Director of Nursing/Designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. Recruitment and retention plan is in place. Facility has a Culture Committee to promote retention.

Director of Nursing/Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations: Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure that the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient per day (PPD), effective July 1, 2024, for 13 of 21 days reviewed. Findings include: A review of nursing care hours provided by the facility from January 15 through February 4, 2026, revealed that the facility failed to meet the minimum hours PPD for the following days: January 16, 2026, hours PPD 3.06 January 17, 2026, hours PPD 2.75 January 18, 2026, hours PPD 2.97 January 21, 2026, hours PPD 3.14 January 23, 2026, hours PPD 2.92 January 24, 2026, hours PPD 2.75 January 25, 2026, hours PPD 2.90 January 26, 2026, hours PPD 2.84 January 27, 2026, hours PPD 3.05 January 30, 2026, hours PPD 3.03 January 31, 2026, hours PPD 2.70 February 1, 2026, hours PPD 2.73 February 2, 2026, hours PPD 2.82 Interview with the Nursing Home Administrator and Director of Nursing on February 4, 2026, at 2:25 PM confirmed that the facility did not meet regulatory daily hours PPD as evidenced above.
 Plan of Correction - To be completed: 03/18/2026

Facility cannot retroactively correct staffing PPD.

Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if PPD is in compliance.

Director of Nursing/Designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. Recruitment and retention plan is in place. Facility has a Culture Committee to promote retention.

Director of Nursing/Designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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