Pennsylvania Department of Health
PARKHOUSE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PARKHOUSE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 166 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


PARKHOUSE REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State licensure,Rights Compliance Survey and an abbreviated survey for three complaints completed on Jaune 12, 2026, it was determined that Parkhouse Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure the resident environment remained as free of accident hazards as possible by failing to ensure that the door leading to the trash chute on the memory care unit remained locked at all times.

Findings include:

Observations conducted on the memory care unit located on the 8th floor on June 9, 2026, at approximately 7:47 a.m. revealed a sign affixed to a door stating, "TRASH CHUTE This door must be kept locked at all times. THANK YOU." Further observation revealed the door was unlocked and located out of view of the nurses' station. A laundry cart had been placed in front of the trash chute, requiring the cart to be moved in order to gain access to the chute.

Subsequent observations conducted on June 10 and June 11, 2026, revealed the door leading to the trash chute remained unlocked. The laundry cart remained positioned in front of the trash chute; however, the chute remained accessible once the cart was moved.

An interview conducted with the Nursing Home Administrator (NHA) and Assistant Nursing Home Administrator (ANHA) on June 11, 2026, at approximately 11:38 a.m. confirmed that the door leading to the trash chute is required to remain locked at all times.

28 PA. Code 201.14(a) Responsibility of licensee

28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services

28 PA, Code 201.18(b)(1)(3)(e)(1) Management

Plan of Correction - To be completed: 07/21/2026

Trash Chute on N8 Locked Immediately. All trash chutes on open units in North Tower checked to confirm door to trash chute is locked at all times. Housekeeping Staff educated Environment remains as free of accident hazards as possible including ensuring trash chute kept locked at all times. Random weekly audit of trash chute doors in North Tower for 4 weeks and monthly for 3 months. Results to be reviewed at QAPI.

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

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

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

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

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

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

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

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

Plan of Correction - To be completed: 07/21/2026

Staff involved immediately educated on Isolation Policy including EBP. Residents who required EBP, including resident 9 and other identified residents, were immediately reviewed to ensure the proper signage was posted, and PPE was available for staff use. Missing signs were placed, PPE supplies were stocked, and care plans were reviewed for accuracy. Housewide audit was completed to identify all residents who require EBP due to wounds, devices, or other qualifying conditions. Each resident was checked to ensure signage was posted, PPE was available, and care plans reflected the appropriate precautions. Nursing staff educated on Isolation Steps: Categories of Transmission Based Precautions Policy. IP/Designee will complete weekly audits for 4 weeks then monthly for 3 months to confirm residents requiring EBP have appropriate signage posted and PPE available. Results to be reviewed at QAPI

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

This is a less serious (but not lowest level) deficiency and 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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

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

Observations:

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to protect the residents' rights for one of thirty-five residents reviewed (Resident 99)

Findings include:

Resident 99 was admitted to the facility on November 17, 2018, with medical diagnoses that include Parkinsons's Disease (movement disorder of the nervous system), difficulty walking, need for assistance with personal care, unsteadiness on feet, and abnormality of gait (deviation from normal walking pattern.)

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 99, dated May 14, 2026, revealed that the resident utilizes a wheelchair, requires partial to moderate assistance with toileting hygiene, and substantial to maximum assistance with sit to stand and toilet transfers.

Review of Resident 99's care plan revealed a focus dated November 11, 2025, noting the resident exhibits toileting deficits, putting them at risk for reduced independence with activities of daily living (adls).

Further review of Resident 99's care plan revealed a focus dated November 24, 2025, noting the resident has an ADL self-care performance deficit related to depression, Parkinson's Disease, and asthma. Interventions included Resident 99 requires the assistance of one staff for personal hygiene, transfers and toilet use.

Observations made on June 9, 2026, at 6:30 a.m. revealed Nurse Aide Employee E9, and Unit Manager Licensed Practical Nurse Employee E10 sitting behind the nurses station with Resident 93.

Observations made on June 9, 2026, at 6:50 a.m., revealed Resident 99 sitting in his/her room, in their wheelchair, a clear liquid was observed pooling on the floor. Closer observation revealed the resident's clothes and wheelchair were wet. Resident 99 stated he/she needed assistance with continence care, and no staff came to assist him/her during the entire night shift. Observation was made of Resident 99 activating his/her call bell at 6:52a.m.
At 6:54 a.m., Employee E9 was observed leaving the nurses' station and walking towards Resident 99's room. Employee E9 immediately returned to the nurses' station.

At 6:55 a.m. Resident 99's call bell was observed to be turned off. During interview Resident 99 stated Employee E9 came in the room, turned the call bell off, and told Resident 99 he/she had to wait for assistance with continence care.

During interview at 6:58 a.m. Employee E9 confirmed he/she went into Resident 99's room, observed the resident required continence care, turned the call bell off, and told the resident he/she had to wait for assistance. Employee E9 stated he/she could not leave Resident 93 because he/she was a fall risk. Employee E10 was observed sitting behind the nurses' station with Employee E9 since this Surveyor's 6:30 a.m. arrival on the unit.

During interview conducted at 10:15 a.m. Resident 99 confirmed that Employee E9 never returned to assistant the resident. Resident 99 stated he/she did not receive continence care until the dayshift started.

During interview with Resident 99 on June 10, 2026, at 12:10 p.m. the resident stated he/she did not receive continence care during the entire night shift again.

Review of resident 99's 30-day toileting task form revealed no documentation of the resident receiving overnight toileting care for June 9, 2026, and June 10, 2026.

Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 5, 2026, at 2:05 p.m., when the above information was presented, the NHA and DON stated they would investigate the matter.

Employee E9 turning off Resident 99's call bell, telling him/her they had to wait for care, and not providing continence care when required violated Resident 99's right to dignified treatment.

28 Pa. Code 201.29(j) Resident Rights.

Plan of Correction - To be completed: 07/21/2026

E9 agency employee no longer scheduled to work at facility. Resident 99 was immediately assessed for unmet toileting and continence care needs. Audit of all residents requiring toileting assistance, continence care, and call bell response was conducted to identify any unmet care needs or concerns regarding dignity. Random interviews were conducted with alert and oriented residents, regarding timeliness of staff response and satisfaction with care. Nursing staff educated on Resident Rights Policy. Random audit of 5 residents weekly for 4 weeks then monthly for 3 months to confirm response to callbell and incontinence care received as needed. Audits to be reviewed during QAPI

483.10(g)(13) REQUIREMENT Posting/Notice of Medicare/Medicaid on Admit:

§483.10(g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

Observations:

Based on record review and staff interview, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) within the required timeframe for one out of one residents reviewed (Resident #335).

Findings include:

Review of Resident 335's medical record revealed a Notice of Medicare Non-Coverage (NOMNC) indicating Medicare-covered skilled services were ending on May 14, 2026. The notice was signed and dated by the resident on May 13, 2026, at 9:00 a.m., which was 1 day prior to the end of Medicare-covered services.

AnInterviewconducted on June 12, 2025, at 12:05 p.m., with the Nursing Home Administrator (NHA) confirmed the NOMNC was not provided within the required 2-day (48-hour) timeframe.

The facility failed to provide the NOMNC within the required 2-day advance timeframe from which it should have been provided.

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

28 Pa. Code 201.29(a) Resident Rights

Plan of Correction - To be completed: 07/21/2026

Resident 335 discharged from facility. Audit of NOMNCs from 5/1/26-6/22/26 to ensure required 2 day notice was provided. Rehab, Social Services and RN/LPN Assessment Coordinators educated on CMS guidelines for Instructions for the Notice of Medicare/Medicaid Coverage. Random weekly audit of 5 NOMNC forms completed for required 2 day notice for 4 weeks then monthly for 3 months. Results of audit to be reviewed during QAPI.

483.10(e)(1),483.12(a)(2),483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

§483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to monitor the resident's behaviors, and medication side effects, for residents receiving a psychotropic medication for three of the five residents reviewed (Resident 15, 17, and 327).

Findings:

A review of the facility's policy titled "Antipsychotic/Anxiolytic Utilization", last review in April 2025, revealed that documentation is necessary to assist in assessing whether the resident's behavioral symptom needs some form of intervention, determining whether the behavioral symptom is transitory or permanent.

A review of Resident 15's physician order dated June 2, 2026, revealed an order "Quetiapine Fumarate (Atypical anti-psychotic) Oral Tablet 25 mg 1 tablet by mouth at bedtime for anxiety".

A review of Resident 15's Medication Administration Records and progress notes medication revealed side effects were not monitored since the Quetiapine Fumarate medication started on March 12, 2026.

A review of Resident 17's physician order dated August 28, 2025, revealed an order "Risperdal (atypical antipsychotic) Oral Tablet 1 MG Give 1 tablet by mouth at bedtime related to psychotic disorder with delusions due to known physiological condition"
A review of Resident 17's Medication Administration Records and progress notes medication revealed side effects were not monitored since the Quetiapine Fumarate medication started on August 28, 2025.

An interview with the Director of Nursing on June 12, 2025, at 10:10am confirmed the above findings.

A review of Resident 327's physician order dated March 12, 2026, revealed an order "Seroquel (Anti-psychotic medication) oral tablet 25 mg Give 25mgby mouth two times a day for psychotic disorder with delusion (A mental health condition where a person experiences persistent, fixed false beliefs that are unshakeable even when presented with factual evidence), please monitor for sedation and increase in falls".

A review of Resident 327's Medication Administration Records and progress notes revealed the resident's behaviors and medication side effects were not monitored since the Seroquel medication started on March 12, 2026.

An interview with the Director of Nursing on June 12, 2026, at 10:00 a.m., confirmed that Resident 327's behavior and medication side effects were not monitored.

The facility failed to ensure Residents 15, 17, and 327's behaviors and medication side effects were monitored.

28 Pa Code 211.10(c) Patient care policies

28 Pa. Code 211.12(c)(1)(3)(5) Nursing services

28 Pa Code 211.5 (f) Clinical records

Plan of Correction - To be completed: 07/21/2026

Resident 15, 17, and 327 orders immediately reviewed and entered for psychotropic monitoring. All residents on psychotropics audited for proper orders for monitoring. Licensed Nurses educated on Antipsychotic Utilization Policy and Psychotropic Monitoring. Randon audits of 5 residents on psychotropics to ensure orders are in place weekly for 4 weeks then monthly. Audits to be reviewed during QAPI

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

§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 records review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for three of the 35 residents reviewed (Residents 2,3, and 283).

Findings Include:

Review of Resident 2 progress note on 4/15/2026 at 12:47 nursing note stated Resident 2 "sustained a witnessed fall after breakfast at 9:2am. Janice did strike her head, and she landed on her L hip after the fall."

Further review of Resident 2 progress note on 4/18/2026 at 11:38 nurses note stated: "Resident Xray results received after rereading DX:Acute left sub capital femur fracture with impaction (broken left side of your thighbone). Md notified and recommended for resident to be sent to hospital. Resident sent to Phoenixville Hospital. Daughter contacted but no answer. Brother contacted and aware of situation."

A review of Resident 2's Quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) MDS is dated 5/18/2026 revealed that under section J1900-"Number of Falls Since Admission/Entry or Reentry or Prior Assessment" did not indicate that residents had a fall with major injury.

Interview with Employee E6 on June 11, 2026, at 12:07pm confirmed the above findings.

A review of Resident 3's nursing progress notes dated December 6, 2025, at 7:43 a.m., revealed the resident was observed on the floor next to the bed. The resident denied pain. The family and the physician were notified.

A review of Resident 3's nursing progress notes dated December 8, 2026, at 1:46 p.m., revealed "new order for Xray three views left foot regarding s/p (status post) fall.

A review of the Xray report dated December 8, 2026, revealed "Acute fracture at base of 1st metatarsal (A break on the shortest, thickest, and strongest bone in the human foot) noted".

A review of Resident 3's Quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated December 26, 2025, did not indicate that resident had a fall with major injury.

A review of Resident 283's nursing progress notes dated May 3, 2026, at 12:35 p.m., revealed an x ray was done post unwitnessed fall on May 1, 2026. The Xray result was "nondisplaced fracture of the nasal bone (A break in the nasal bone but stays aligned without moving)". The physician and the guardian were notified.

A review of Resident 283's Quarterly MDS dated May 19, 2026, did not indicate that residents had a fall with major injury.

An interview with licensed nurse Employee E6 was conducted on June 11, 2026, at 12:23 p.m. Employee E6 confirmed that Resident 3 and 283's falls with major injury were not accurately reflected on their MDS'.

The facility failed to ensure Resident 3 and 283's falls with major injury were not accurately reflected on their MDS assessments.

28 Pa Code 211.5 (f) Clinical records

28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/21/2026

MDS Assessments for R2, R3 and R283 immediately corrected. Audit of MDS Assessments submitted from 11/1/25-6/22/26 to confirm falls with major injury were accurately reflected on the MDS. RN/LPN Assessment Coordinators re-educated on MDS assessment and accuracy. Random weekly audit of 5 residents MDS assessments for falls including falls with major injury for 4 weeks then monthly for 3 months. Results of audit to be reviewed during QAPI

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on facility policy review, resident and staff interviews and review of resident clinical records it was determined that the facility failed to provide assistance with activities of daily living for 1 of thirty-five residents reviewed (Resident 99).

Findings include:

Facility policy titled Activities of Daily Living (ADLs), last reviewed December 2024, notes it is the policy of the facility to understand the principals of quality of life, and honor and support these principals for each resident, and that the care and services provided are person centered, and honor and support each resident's preferences, choices, values and beliefs.
The facility will provide care and services for hygiene-bathing, and toileting care.

Resident 99 was admitted to the facility on November 17, 2018, with medical diagnoses that include Parkinsons's Disease (movement disorder of the nervous system), difficulty walking, need for assistance with personal care, unsteadiness on feet, and abnormality of gait (deviation from normal walking pattern.)

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 99, dated May 14, 2026, revealed that the resident utilizes a wheelchair, requires partial to moderate assistance with toileting hygiene, and substantial to maximum assistance with sit to stand and toilet transfers.

Review of Resident 99's care plan revealed a focus dated November 11, 2025, noting the resident exhibits toileting deficits, putting them at risk for reduced independence with activities of daily living (adls).

Further review of Resident 99's care plan revealed a focus dated November 24, 2025, noting the resident has an ADL self-care performance deficit related to depression, Parkinson's Disease, and asthma. Interventions included Resident 99 requires the assistance of 1 staff for personal hygiene, transfers and toilet use.

Observations made on June 9, 2026, at 6:30 a.m. revealed Nurse Aide Employee E9, and Unit Manager Licensed Practical Nurse Employee E10 sitting behind the nurses station with Resident 93.

Observations made on June 9, 2026, at 6:50 a.m., revealed Resident 99 sitting in his/her room, in their wheelchair, a clear liquid was observed pooling on the floor. Closer observation revealed the resident's clothes and wheelchair were wet. Resident 99 stated he/she needed assistance with continence care and no staff came to assist him/her during the entire night shift. Observation was made of Resident 99 activating his/her call bell at 6:52a.m.
At 6:54 a.m., Employee E9 was observed leaving the nurses' station and walking towards Resident 99's room. Employee E9 immediately returned to the nurses' station.

At 6:55 a.m. Resident 99's call bell was observed to be turned off. During interview Resident 99 stated Employee E9 came in the room, turned the call bell off, and told Resident 99 he/she had to wait for assistance with continence care.

During interview at 6:58 a.m. Employee E9 confirmed he/she went into Resident 99's room, observed the resident required continence care, turned the call bell off, and told the resident he/she had to wait for assistance. Employee E9 stated he/she could not leave Resident 93 because he/she was a fall risk. Unit Manager Licensed Practical Nurse Employee E10 was observed sitting behind the nurses' station with Employee E9 since this Surveyor's 6:30 a.m. arrival on the unit.

During interview conducted at 10:15 a.m. Resident 99 confirmed that Employee E9 never returned to assistant the resident. Resident 99 stated he/she did not receive continence care until the dayshift started.

During interview with Resident 99 on June 10, 2026, at 12:10 p.m. the resident stated he/she did not receive continence care during the entire night shift again.

Review of resident 99's 30-day toileting task form revealed no documentation of the resident receiving overnight toileting care for June 9, 2026, and June 10, 2026.

Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 5, 2026, at 2:05 p.m., when the above information was presented, the NHA and DON stated they would investigate the matter.

Quality of Care 483.24(b)(1)

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Plan of Correction - To be completed: 07/21/2026

Resident 99 was immediately assessed for toileting and continence care needs. Audit of residents requiring extensive assistance with toileting, transfers, and continence care was completed to identify any residents who may have experienced delayed or missed toileting assistance. Nursing staff educated on ADL Policy. DON/Designee will conduct random audit toileting documentation, and 5 residents requiring assistance with ADLs. Audits will be completed weekly for 4 weeks, then monthly for 3 months. Results of audit to be reviewed during QAPI and corrective action will be implemented immediately for any identified concerns.

483.25 REQUIREMENT Quality of Care:

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

Plan of Correction - To be completed: 07/21/2026

Residents R1 was assessed and ear mates were immediately applied to the Oxygen tubing. R16 and 262 had their medication orders reviewed by provider and dialysis schedules to ensure medications are administered per orders. Resident 56 colostomy care orders and care plans were immediately reviewed. Housewide audit completed of physician orders for all residents on O2 requiring special equipment, residents with colostomies and residents receiving Dialysis services with scheduled medications. Licensed Nurses educated on Medication Administration, Dialysis and Isolation Steps: Categories of Transmission Based Precautions Policies. DON/Designee will conduct random weekly audits on oxygen equipment orders, dialysis residents medication administration record and treatment documentation weekly x 4 weeks then monthly x 3 months. Results of audit to be reviewed during QAPI

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on observations, clinical records review, and staff interviews, it was determined that the facility failed to follow a wound treatment order correctly and in a timely manner for one of ten residents reviewed (Resident 259).

Findings:

A review of Resident 259's active care plan revealed the resident was at risk for skin integrity impairment related to immobility and incontinence. The interventions, including an air mattress, repositioning, and treatment as ordered, were put in place.

Additional interventions include applying Calamine-Zinc Oxide External Lotion, applied to the buttocks topically every day and evening shift for protectant (Dermaseptin ointment- A soothing skin protectant used to treat and prevent minor skin irritations by creating a protective, moisture-repelling barrier).

A review of the nursing progress notes dated April 1, 2026, at 2:32 p.m., revealed the resident was observed with a new skin area of concern to the sacrum a large, (triangular bone located at the base of the spine, just below the lumbar vertebrae and between the hip bones), a DTI (Deep Tissue Injury - Persistent non-blanchable deep red, maroon or purple discoloration) to the sacrum (The triangular bone just below the lumbar vertebrae), dry, with a measurement of 2.8 x 2.0 x 0 cm. The area was deep purple. Wedge pillows are used for positioning and out of bed restrictions to four hours three times a week.

A review of the wound consult dated April 7, 2026, revealed that the sacral wound progressed to a Stage II (Partial-thickness skin loss with exposed dermis). A Triade Hydrophilic wound dressing (A zinc oxide-based, containing petrolatum, carboxymethylcellulose, and dimethicone paste that manages light-to moderate wound drainage) to the sacrum was recommended.

A review of Resident 259's physician's order revealed that the wound specialist recommendations on April 7, 2026, for the Triade treatment were not put in as an order and therefore was not followed.

A review of the wound consult dated April 14, 2026, revealed the resident's sacral wound remained a stage II, continue Triade Hydrophilic treatment.

A review of Resident 259's physician's order revealed that the wound specialist recommendations on April 14, 2026, to continue the Triade treatment to the resident's' sacral wound was not followed.

A review of the wound consult dated April 21, 2026, revealed sacral wound stage III (full-thickness skin loss) measuring 1.0 x 0.5 x 0.1 cm. dry with 70% slough (A non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. A wound treatment of honey hydrogel was recommended.

A review of Resident 259's April 2026 Treatment Administration Record (TAR) revealed that recommended wound treatment for honey hydrogel was not started until April 23, 2026, two days after the sacral wound was identified as stage III.

An interview was conducted with the Assistant Director of Nursing (ADON) on June 11, 2026, at 1:00 p.m. The ADON confirmed that the Triade Hydrophilic paste recommendation was not followed, and the honey hydrogel wound treatment was not followed in a timely manner.

The facility failed to ensure that Resident 259's wound treatment, as recommended by the wound specialist, was followed correctly and in a timely manner.

28 Pa Code 211.5 (f) Clinical records

28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/21/2026

Residents 259s wound orders reviewed for accuracy. All recommendations for wound care treatments from Hickory audited for accuracy. Licensed Nurses educated on Skin Integrity Policy. Random weekly audits of Hickory recommendations audited weekly x 4 weeks then monthly. Audits to be reviewed during QAPI

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring of fluid restrictions for two of three residents reviewed for nutrition/hydration needs (Resident 108, and Resident 259).

Findings:

Review of facility policy, titled "Restricting Fluids" last revised November 11, 2025, documents the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health.

A review of the facility's policy titled "Weight Assessment and Intervention", last revised on March 11, 2025, revealed that weights will be measured monthly unless discontinued by the physician. Significant weight changes are defined as more or less than 5% within 30 days; more or less than 7.5% over 3 months, and more or less than 10% within 6 months. I the weight change meets the definition of Significant, the Dietitian should discuss with the IDCP team and make recommendations. The resident's physician will be made aware of the weight loss.

Review of Resident 108's medical diagnoses revealed diagnoses that included mild protein-calorie malnutrition (insufficient intake of protein and calories), atherosclerotic heart disease of native coronary artery (plaque buildup in coronary arteries), end stage renal disease (chronic kidney disease where kidneys no longer function adequately to sustain life without treatment), hypertensive heart and chronic kidney disease with heart failure (when high blood pressure cause damage to both the heart and kidneys) stage 5 chronic kidney disease or end stage renal disease, (kidney failure requiring dialysis), and fluid overload (too much water, blood or lymphatic fluid in the body).

Review of Resident 108's physician orders revealed an order dated May 28, 2026, for 1500 milliliters (ml) fluid restriction: nursing staff to provide a total of 540 ml per day, 180 ml during day shift, 180 ml during evening shift, and 180 ml during night shift. Dietary staff provide a total of 960 ml per day, 360 ml with breakfast, 240 ml with lunch, and 360 ml with dinner.

Review of Resident 108's May and June 2026, Medication Administration Reports (MAR) and 30-day task documentation for amount of fluid intake obtained from nursing staff for the past 30 days, in addition to the amount of fluids provided with meals, revealed that the combined fluid intake either exceeded the ordered amount or failed to document the resident's fluid intake amounts.

During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on June 5, 2026, at 2:05 p.m., the DON confirmed that staff was not accurately documenting the resident's fluid intake.

A review of Resident 259's weights and vitals revealed a weight of 123.2 pounds on December 2, 2025, and a weight of 110.6 pounds on April 23, 2026, a 10.23% significant weight loss in four months. Further review revealed the resident's weight was not taken in March 2026.

The significant weight loss identified on April 23, 2026, was not addressed, and physicians were not notified until May 15, 2026.

An interview was conducted with the Registered Dietitian Employee E13 on June 12, 2026, at 1:55 p.m. The RD reported that their company just started seeing residents in the facility on May 4, 2026, and therefore cannot provide an explanation why the resident's weight was not monitored in March 2026, and why significant weight loss identified on April 23, 2026, was not addressed until May 15, 2026.

An interview with the Nursing Home Administrator conducted on June 12, 2026, at 1:56 p.m., confirmed that Resident 259's March 2026 weight was not monitored, and significant weight loss identified on April 23, 2026, was not timely addressed.

The facility failed to ensure Resident 259's weight was consistently monitored and that significant weight loss was addressed and communicated with the physician in a timely manner.

201.18(b)(1) Management

211.10(c) Resident care policies

211.12(d)(1)(2)(5) Nursing services

Plan of Correction - To be completed: 07/21/2026

Residents R108 and R259 physician orders and care plan immediately reviewed. Housewide audit was completed for residents on fluid restrictions and/or weight loss from 5/1/26- 6/22/26. Nursing Staff and Dietician educated on Enteral Feeding and Restricting Fluids Policy. Dietician/Designee to audit residents receiving enteral feeding and/or fluid restrictions weekly for 4 weeks then then monthly for 3 months to ensure orders are being followed and documented as prescribed. Results to be reviewed at QAPI

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

§483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Observations:

Based on facility policy review, clinical record review and staff interview it was determined the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of one resident reviewed enteral feeding care. (Resident 14)

Findings include:

Review of facility policy and guidelines titled "Enteral Feeding" last revised April 15, 2024, documents the licensed nurse is responsible to assure patency of the feeding tube, administration of nutritional products and medications per physician orders, assessment of the tube and skin site and documentation of the enteral feeding process.

Per the policy, documentation of the enteral feeding orders, volume, amounts, and care will be completed on the Medication Administration Record.

Review of Resident 14's medical diagnoses revealed the resident admitted from the hospital on November 17, 2025, with medical diagnoses that include Traumatic Subarachnoid Hemorrhage (bleeding into the fluid-filled space between the brain and the protective tissue covering it, caused by physical head injury), Diffuse Traumatic Brain Injury (a disruption in normal brain function caused by a bump, blow, jolt to the head, or penetrating head injury), Mild Protein Malnutrition, and Dysphagia (difficulty swallowing),

Review of Resident 14's weights revealed Resident 14 lost 23 pounds between November 19, 2025, and June 12, 2026.

Review of Resident 14's physician orders revealed an order dated March 5, 2026, for every evening shift give Glucerna 1.5 at 80 milliliters (ml) per hour for 12 hours via PEG tube up at 7pm and down at 7am or once total volume (TV) of 960 ml is infused and every day-shift document TV infused daily once feeding completed.

Review of resident 14's Medication Administration Record (MAR) for the month of June 2026, revealed documentation of total infusions ranging between 0 ml and 960 ml.

Review of resident 14's physician orders revealed an order dated March 5, 2026, for Enteral Feed every day-shift document TV infused daily once feeding is completed.

Review of Resident 14's May and June 2026, MAR revealed 15 days when staff documented a total volume of NA. Total volume was noted as 0 ml for 5 days, 300 ml for one day, 100 ml for one day, and 712 ml for one day.

Observations made on June 12, 2026, at 11:50 a.m. revealed Resident 14's was still connected to his/her feeding pump. The pump was flashing inactive for 10 minutes. The Glucerna bag was dated June 11, 2026. 200 ml of the 1000 ml bag remained on the pump.

Interview with Unit Manager Registered Nurse Employee E8 on June 12, 2026, at 11:57, when observations were made of Resident 14's feed pump and MARS, Employee E8 confirmed Resident 14's feed pump orders weren't being followed and/or documented as prescribed.

Interview with the Nursing Home Administrator and Director of Nursing on June 12, 2026, at 2:00 p.m. when the above was presented, the DON confirmed the resident's enteral feed orders were not being followed and/or documented properly.

28 Pa Code: 211.5(f) Clinical records

28 Pa code: 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/21/2026

Resident R14 physician orders and care plan immediately reviewed. All residents with enteral feed orders audited to ensure orders are being followed and documented as prescribed. Nursing Staff and Dietician educated on Enteral Feeding and Weight Assessment and Intervention Policy. Dietician/Designee to audit residents receiving enteral feeding weekly for 4 weeks then then monthly for 3 months to ensure orders are being followed and documented as prescribed. Results to be reviewed at QAPI

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Plan of Correction - To be completed: 07/21/2026

All undated, expired, and improperly stored insulin products found on medication carts were immediately removed and discarded in accordance with facility policy and manufacturer recommendations. All medication carts and treatment carts were audited for proper labeling, dating, and expiration. Resident 12's self-administered homeopathic remedies were reviewed. Audit of all medication carts, treatment carts, medication storage areas, and resident rooms authorized for self-administration was completed to identify any additional undated medications, expired medications, unsecured medication/treatment carts, or improperly stored self-administered medications. Residents with physician orders for self-administration were reviewed to ensure compliance with facility policy, including secure storage and documentation requirements. Licensed Nurses educated on Medication Labeling, Medication Storage and Self Administration of Drugs Policies. UMs/Designee will complete audits of medication carts, treatment carts, medication storage areas, and residents approved for self-administration weekly for 4 weeks, then monthly for 3 months. Results to be reviewed at QAPI.

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