Pennsylvania Department of Health
WECARE AT MURRYSVILLE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WECARE AT MURRYSVILLE REHABILITATION AND NURSING CENTER
Inspection Results For:

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WECARE AT MURRYSVILLE 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, and Civil Rights Compliance, and two complaints Survey completed on March 20,2026, it was determined that WeCare At Murrysville 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.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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(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 review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining a clean environment for three of three resident rooms (Residents R22, R50, and R65), and one of three resident wheelchairs (Resident R61).

Findings Include:

Review of the facility policy "Homelike Environment" dated 6/11/25, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike.

Review of the admission record indicated Resident R22 admitted to the facility on 9/5/25.

Observation on 3/16/26, at 9:19 a.m. Resident R22 was lying in bed. The resident's floor was sticky, stained with darkened areas, and covered in grime.

Interview on 3/16/26, at 9:20 a.m. Licensed Practical Nurse (LPN) Employee E11 confirmed Resident R22's floor was sticky, stained with darkened areas, and covered in grime.

Review of the admission record indicated Resident R50 admitted to the facility on 1/9/26.

Observation on 3/16/26, at 10:14 a.m. Resident R50 was sitting on the side of the bed. The resident's floor was sticky, stained with darkened areas, and covered in grime. The fall mat was sticky, had spots of dried liquids, and covered in grime.

Interview on 3/16/26, at 10:15 a.m. LPN Employee E12 confirmed Resident R50's floor was sticky, stained with darkened areas, and covered in grime and the fall mat was sticky, had spots of dried liquids, and covered in grime.

Review of the admission record indicated Resident R61 admitted to the facility on 1/10/23.

Observation on 3/18/26, at 10:26 a.m. Resident R61 was observed in the hallway in front of the television, sitting in a wheelchair. The wheelchair's seat and arm on the right side were completely covered in dried foods, crumbs, black grime, and were sticky.

Interview on 3/18/26, at 10:27 a.m. Nurse Aide (NA) Employee E1 confirmed Resident R61's wheelchair seat and arm on the right side were completely covered in dried foods, crumbs, black grime, and were sticky.

Review of the admission record indicated Resident R65 admitted to facility on 7/2/22.

Observation on 3/17/26, at 11:15 a.m., Resident R65 was not in her room, however he resident's floor was sticky, stained with darkened areas, and covered in grime. The fall mat was sticky, had spots of dried liquids, and covered in grime.

Interview on 3/17/26, at 11:19 a.m., LPN Employee E17 confirmed Resident R65's floor was sticky, stained with darkened areas, and covered in grime and the fall mat was sticky, had spots of dried liquids, and covered in grime.

Interview on 3/18/26, at 10:30 a.m. the Nursing Home Administrator confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining a clean environment for three of three resident rooms (Residents R22, R50, and R65), and one of three resident wheelchairs (Resident R61).

28 Pa. code: 201.14 (b) Responsibility of licensee.
28 Pa Code: 201.18 (e)(1)(2) Management.
28 Pa Code: 201.29 (a)(c) Resident Rights.

Plan of Correction - To be completed: 05/04/2026

1. Facility immediately cleaned identified wheelchairs and residents' rooms that required attention.
2. Deep clean schedule and wheelchair cleaning schedule will be reviewed to ensure proper cleaning and ensure a safe, clean, homelike environment.
3. EVS Director to educate EVS staff on safe, clean, homelike environment and cleanliness of resident wheelchairs.
4. EVS Director/designee to audit 3 resident rooms and 3 resident wheelchairs weekly x 2 weeks, then monthly x 2 months.
5. Results to be submitted to QAPI for review and approval.

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: 05/04/2026

1. Residents experienced no adverse effects.
2. DON immediately audited all medications not properly stored in medication carts and were disposed of per policy protocol immediately.
3. DON/designee to educate licensed staff on medication storage, including labeling and dating of meds/treatments upon opening for accurate use by date.
4. DON/designee to audit medication carts for appropriate med storage and proper med labeling/dating upon opening weekly x 2 weeks, then monthly x 2 months. Results to be submitted to QAPI for review and approval.

§483.35(d)(7) REQUIREMENT Nurse Aide Perform Review – 12Hr/Year In- ser:

§483.35(d)(7) Regular in-service education.

The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on review of personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluations for four of five sampled records (Nurse aide (NA) Employees E1, E2, E3 and E4).

Findings include:

Review of employee personnel files on 3/18/26, at 9:00 a.m. indicated the following:

Review of NA Employee E1's personnel record indicated a date of hire as 1/5/23. The last performance review completed annually was 2/23/25.

Review of NA Employee E2's personnel record indicated a date of hire as 9/5/22. The last performance review completed annually was 2/23/25.

Review of NA Employee E3's personnel record indicated a date of hire as 12/16/06. The last performance review completed annually was 1/6/25.

Review of NA Employee E4s personnel record indicated a date of hire as 1/8/18. The last performance review completed annually was 1/3/25.

Interview on 3/18/26, at 9:30 a.m. Assistant Director of Nursing Employee E16 confirmed the facility failed to complete annual nurse aid employee evaluations as required.

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

Plan of Correction - To be completed: 05/04/2026

1. Employee's E1, E2, E3, and E4 will have their annual employee evaluation completed.
2. CNA employee files from the beginning of the year will be audited to ensure compliance with annual employee evaluations.
3. NHA/designee to educate HR Director on need for annual employee evaluations to remain in compliance.
4. HR Director/designee to audit employee files in accordance with their annual employment date weekly x 2 weeks, then monthly x 2 months. Results to be submitted to QAPI for review and approval.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Plan of Correction - To be completed: 05/04/2026

1. Resident R4, R29, and R33 care plans have been amended and reviewed to accurately reflect the residents' status.
2. A whole house audit will be completed on comprehensive care plans to ensure accuracy reflecting the residents' status.
3. DON/designee to educate RNAC and licensed nursing staff on developing and implementing comprehensive care plans.
4. DON/designee to audit three (3) care plans to accurately reflect residents' status weekly x 2 weeks, then monthly x 2 months.
5. Results to be submitted to QAPI for review and approval.

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.

Plan of Correction - To be completed: 05/04/2026

1. Residents R4, R11, R33, R80, and R85 MDS assessments were immediately reviewed and corrected to accurately reflect the residents' status.
2. RNAC/designee to complete 2 week look back of currently opened MDS assessments to accurately reflect the residents' status.
3. Regional RNAC/designee to educate RNAC on MDS assessments, RAI manual, and accuracy of assessments.
4. RNAC/designee to audit three (3) currently opened MDS assessments for accuracy weekly x 2 weeks, then monthly x 2 months.
5. Results to be submitted to QAPI for review and approval.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on review of facility policy and documentation, resident and staff interview it was determined that the facility failed to address residents' council ongoing concerns for three of three months (March, February and January of 2026).

Findings include:

Review of facility policy "Skilled Nursing Care Facility Policy Grievances Policy" dated 6/11/25, indicated: "Residents and their representatives must be assured that; They can submit grievances orally or in writing/. Their concerns will be investigated and responded to promptly.

Review of facility documentation "Resident Council Minutes" indicated:

Meeting Date 3/5/.26: Call bells were an issue and continued to be an issues since last meeting - "call bells not being answered on time - wait time: (2 - 2 1/2 hours)(7 of 17 residents).

Employees on phones while working (6 of 17 residents), and snacks not being offered or passed to residents (7 out of 17 residents)."

Meeting Date 2/5/26: "call bells not being answered on time wait time (30 minutes - 2 1/2 hours - 5 out of 13 residents), Employees on phones while working (6 out of 13 residents), and snacks not being offered or passed to residents (8 out of 13 residents)."

Meeting Date 1/8/26: "call bells not being answered, 9 of 18 residents, Employees on phones while working, (11 of 18 residents)."

During a resident group interview on 3/18/26, at 1:30 p.m. Residents indicated the above concerns of call bells not being answered timely, snacks not being passed or offered and employees on their phones are on-going, that residents continue to express the same concern as each meeting without resolution.

During an interview on 3/20/26, at 9:05 a.m. Nursing Home Administrator confirmed that the residents' concerns during on resident council have been on going and that the facility failed to address resident council concerns for three of three months (January, February and March 2026).

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code:201.18(b)(1) Management.

Plan of Correction - To be completed: 05/04/2026

1. Resident Council Meeting minutes will be addressed by the NHA/designee.
2. Facility will sustain resolution by discussing with resident council president viable resolutions and prevent continued resident complaints during resident council meetings.
3. RCO/designee to educate NHA, DON, and Social Services Director on facility grievance policies and procedures.
4. Activities Director to audit Resident Council Minutes monthly x 2 months to note any new grievances and monitor any reoccurring grievances.
5. Social Services Director/designee to audit the grievance log weekly x 2 weeks, then monthly x 2 months to ensure grievances are addressed and resolved appropriately.
6. Results to be submitted to QAPI for review and approval.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:

§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three shower chairs (Resident R82).

Findings include:

Review of the facility policy "Assistive Devices and Equipment" dated 6/11/25, indicated device condition and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired.

Review of the admission record indicated Resident R82 admitted to the facility on 5/26/23.

Review of Resident R82's Minimum Data Set (MDS- a periodic assessment of care needs dated 12/29/25, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), Parkinson's Disease (disorder of the nervous system that results in tremors), and Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).

Observation on 3/16/26, at 10:35 a.m. Nurse Aide (NA) Employee E1 was pulling Resident R82 backwards down the hall.

Interview on 3/16/26, at 10:36 a.m. NA Employee E1 indicated being aware of not pulling resident backward; however, the wheels of the shower chair are all messed up and if staff push forward as required the chair drives out of control so it's easier to pull the chair backwards.

Interview on 3/16/26, at 3:00 p.m. the Director of Nursing confirmed the facility failed to make certain that equipment was in safe operating condition for one of three shower chairs (Resident R82).

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

Plan of Correction - To be completed: 05/04/2026

1. Residents or staff did not experience any adverse effects from shower chair being pulled backwards.
2. Whole house audit to be completed to repair any identified shower chairs needing service to safe operating condition.
3. NHA/designee to educate Maintenance Director on safe operating equipment procedures. DON/designee to educate CNA's on proper use of equipment/adaptive devices.
4. Maintenance Director/designee to audit shower chairs for function weekly x 2 weeks, then monthly x 2 months.
5. Results to be submitted to QAPI for review and approval.

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.

Observations:

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to use proper hand washing to prevent cross contamination during a dressing change for one of three residents (Resident R11).

Findings include:

Review of the facility policy "Handwashing/Hand Hygiene" dated 6/11/25, indicated use alcohol-based hand rub containing at least 62% alcohol and/or soap and water before handling clean or soiled dressings, gauze pads, etc.; After handling used dressings, contaminated equipment, etc.; The use of gloves does not replace hand washing/hand hygiene.

Review of the facility policy "Wound Care" dated 6/11/25, indicated wash and dry hands thoroughly. Put on clean gloves, loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly.

Review of the admission record indicated Resident R11 admitted to the facility on 5/9/23.

Review of Resident R11's MDS dated 1/14/26, indicated the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure.

Review of Resident R11's physician order dated 3/11/26, indicated to cleanse sacrum with saline. Pat dry, apply Dakins (antiseptic solution) packed gauze, cover with 4 x 4 border every day and as needed.

During a dressing change observation on 3/17/26, at 11:30 a.m. Licensed Practical Nurse (LPN) Employee E11 washed their hands, applied new gloves and removed the old, soiled dressing. Nurse then removed the gloves, did not wash hands, and applied new gloves. Cleansed the wounds with saline and removed the gloves, did not wash hands, and applied new gloves to complete the dressing change.

Interview on 3/17/26, at 11:35 a.m. LPN Employee E11 indicated washing the hands after each glove change would be a big waste of products.

Interview on 3/17/26, at 11:40 a.m. the Director of Nursing confirmed the facility failed to use proper hand washing to prevent cross contamination during a dressing change for one of three residents (Resident R11).

28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.28 (b)(1)(e )(1) Management.
28 Pa Code: 211.10 (d ) Resident care policies.

Plan of Correction - To be completed: 05/04/2026

1. Residents and staff experienced no adverse effects related to hand hygiene while performing wound care.
2. DON/designee to educate licensed staff on hand hygiene and cross contamination during dressing changes.
3. DON/designee to audit two (2) dressing changes to ensure proper hand hygiene and no cross-contamination weekly x 2 weeks, then monthly x 2 months.
4. Results to be submitted to QAPI for review and approval.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R9).

Findings include:

Review of facility policy " Trauma Informed Care and Culturally Competent Care" dated 6/11/25, indicated: "purpose: To address the needs of trauma survivors and/or re-traumatization. Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Trigger is a psychological stimulus that prompts recall of a previous traumatic event , even if the stimulus itself is not traumatic or frightening."

Review of the clinical record indicated Resident R9 was admitted to the facility on 8/15/25.

Review of Resident R9 MDS (minimum data set - a periodic assessment of care needs), dated 1/14/26, indicated diagnosis of PTSD (a mental health condition that caused by an extremely stressful or terrifying event) and TBI (happens when a sudden, external, physical assault damages the brain).

Review of Resident R9 care plan for PTSD identified that a traumatic event occurred, but failed to identify triggers for Resident R9's as related to PTSD.

During an interview on 3/20/26, at 9:28 a.m. Director of Nursing confirmed that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for Resident R9.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.

Plan of Correction - To be completed: 05/04/2026

1. Resident R9 was interviewed and care plan updated immediately to identify potential triggers.
2. Care plans for residents' with PTSD diagnosis were reviewed and updated to include the history of what causes the PTSD, monitoring for specific signs and symptoms that triggers PTSD, and plan for appropriate interventions to mitigate the onset from potential triggers.
3. DON/designee to educate Social Services Director and licensed staff on appropriate PTSD identification, triggers for awareness/prevention, and care planning PTSD.
4. DON/designee to audit new admissions weekly x 2 weeks, then monthly x 2 months to monitor PTSD diagnosis, triggers, and care plans.
5. Results to be submitted to QAPI for review and approval.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on review of facility policy, clinical records, and staff and resident interview, it was determined that the facility failed to ensure Total Parenteral Nutrition (TPN) was administered consistent with professional standards of practice and in accordance with physician orders for one of three residents (R96).

Findings include:

Review of the facility policy "Parenteral Nutrition" dated 6/11/25, indicated the purpose of PN is to provide guidelines for the safe and aseptic administration of partial nutrition to residents who have a need for supplemental nutrition. (PN or TPN is a sterile pharmacy-prepared form of nutrition that is delivered through an intravenous route.) A physician's order is necessary for this treatment. The PN order should include the formula, total volume and rate of administration.

Review of the admission record indicated Resident R96 admitted to the facility on 1/8/26, with the diagnoses of persistent small bowel obstructions (SBOs), small bowel mesenteric desmoid tumor (an abnormal mass of tissue. It forms when cells grow and divide more than they should or do not die when they are supposed to), and heart failure (heart doesn't pump blood as well as it should).

Review of Resident R96's physician order dated 1/8/26, indicated administer 2500 milliliters (ml) over 18hours. Infuse continuous over 18hours once daily at 74 ml/hr (ml/hour) for the first hour, 147 ml/hr for 16 hours, and then 74 ml/hr for the last hour via infusion pump intravenously (IV).

Review of Resident R96's progress note dated 1/9/26, at 11:50 a.m. indicated Resident R96 on TPN for SBO. Registered Nurse was alerted that the IV pump was beeping and complete. TPN initiated on at 8:00 p.m. on 1/8/26. Resident received correct medication and concentration with a rate discrepancy. Provider notified.

Review of facility provided "Medication Incident" form dated 1/9/26, indicated the TPN rate ordered at 147ml/hr for 16 hours was set at the rate of 174 ml/hr in error.

Interview on 3/17/26, at 1:00 p.m. the Director of Nursing confirmed that the facility failed to ensure TPN was administered consistent with professional standards of practice and in accordance with physician orders for one of three residents (R96).

28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services.

Plan of Correction - To be completed: 05/04/2026

1. Resident R96 was stable at the time of TPN administration, physician was notified and did not experience any adverse effects.
2. TPN treatment cannot retroactively be corrected.
3. DON/designee to educate licensed nursing staff on TPN administration at proper rate.
4. DON/designee to audit all IV's and TPN treatments for being administered at the proper rate weekly x 2 weeks, then monthly x 2 months.
5. Results to be submitted to QAPI for review and approval.

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.

Plan of Correction - To be completed: 05/04/2026

1. Resident R4 and R49 did not experience any adverse effects.
2. A whole house audit will be completed on appropriate diet orders and accurate tray tickets coinciding.
3. NHA/designee to educate Director of Dietary Services and Registered Dietician on accurate diet orders, diet portions, nutritional assessments, and nutritional supplement use.
4. Registered Dietician/designee to audit diet orders, diet portions, nutritional assessments, and nutritional supplement use weekly x 2 weeks, then monthly x 2 months.
5. Results to be submitted to QAPI for review and approval.

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 review of facility policy, clinical records and staff interview it was determined that the facility failed to make certain resident medication regimes were free from potentially unnecessary psychotropic medications for one of three residents (Resident R1 ).

Findings include:

Resident R1 was admitted on 12/29/25, and re-admitted to the facility on 1/28/26.

Review of Resident R1 MDS (minimum data set - a periodic assessment of resident needs) dated 1/8/26, indicated diagnosis of atrial fibrillation (irregular and often very rapid heart rhythm), and major depressive disorder recurrent (mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorders (group of mental health conditions that cause fear , dread and other symptoms that are out of proportion to the situation) included on Resident R1 admit sheet.

Review of Resident R1 clinical record MAR (medication administration record) for February 2026 indicated:

Hydroxyzine Pamoate Capsule 50 MG
Give 50 mg by mouth every 8 hours as
needed for Anxiety for 14 Days
-Start Date-
02/11/2026 2230
-D/C Date-
02/19/2026 1408

Lorazepam Oral Tablet 1 MG
(Lorazepam)
Give 1 mg by mouth every 8 hours as
needed for anxiety for 14 Days
-Start Date-
02/19/2026 1515
-D/C Date-
03/03/2026 1000

Review of the February MAR indicated: Hydroxyzine pamoate capsule 50 mg was given PRN (as needed) in February on the following days: 12, 13,14,15,16,17,18,and 19.

Review of the February MAR indicated: Lorazepam oral table 1 mg was given PRN (as needed) in February on the following days: 20,21, and 28.

Review of Resident R1 clinical records MAR for March 2026 indicated:
Lorazepam Oral
Tablet 1 MG
(Lorazepam)
Give 1 mg by mouth
every 8 hours as
needed for anxiety
for 14 Days
-Start Date-
02/19/2026 1515
-D/C Date-
03/03/2026 1000

Lorazepam Oral
Tablet 1 MG
(Lorazepam)
Give 1 mg by mouth
every 8 hours as
needed for anxiety
until 04/02/2026 23:59
-Start Date-
03/03/2026 1000

Review of the March MAR indicated Lorazepam oral tablet 1 mg was given PRN in March on the following days: 1, 2n,3,4,5,6,9,11,13,14,15,16,17, and 18.

Review of the MAR failed to include what behaviors Resident R1 was experiencing and other attempts to relive potential behaviors prior to Resident R1 being given the psychotropic medication.

Review of Resident R1 progress notes for February and March 2026 failed to include a description of behaviors, or non-pharmacological interventions that were given to Resident R1 prior to the psychotropic medications.

During an interview on 3/20/26, at 9:15 a.m. Director of Nursing confirmed that the facility
failed to provide non-pharmacological interventions prior to giving anti-anxiety medications to Resident R1.

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

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

Plan of Correction - To be completed: 05/04/2026

1. Resident R1 experienced no adverse effects.
2. Whole house audit of residents on psychotropic medications to be completed to determine behavior tracking and nonpharmacological interventions prior to administration of medication.
3. DON/designee to educate licensed nursing staff on behavior tracking and nonpharmacological interventions prior to administration of medication.
4. DON/designee to audit PRN antipsychotic use and documentation of nonpharmaceutical interventions weekly x 2 weeks, then monthly x 2 months.
5. Results to be submitted to QAPI for review and approval.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

§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 facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that will be charged for two of three residents (Residents R8, and R31).

Findings include:

Review of the facility policy "Advanced Beneficiary Notices" dated 6/11/25, indicated Medicare requires SNFs to issue the SNF-ABN to original Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for. The SNF-ABN provides information to the beneficiary so that they can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility.

Review of the admission record indicated Resident R8 was admitted on 8/1/22.

Review of Resident R8's Minimum Data Set (MDS -a periodic assessment of care needs) dated 1/5/26, indicated the diagnoses of chronic obstructive pulmonary disease (COPD- a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), aphasia (difficulty swallowing), and hyperlipidemia (elevated fat levels within the blood).

Review of Resident R8's SNF-ABN form dated 10/23/25, indicated beginning on 10/25/25, resident may have to pay out of pocket for this care if resident does not have insurance that may cover these costs. The facility estimates that these services will cost the resident "$ Current PL" per day/item or service.

Review of the admission record indicated Resident R31 was admitted on 10/13/25.

Review of Resident R31's MDS dated 2/17/26, indicated the diagnoses COPD, high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident R31's SNF-ABN form dated 11/26/25, indicated beginning on 11/29/25, resident may have to pay out of pocket for this care if resident does not have insurance that may cover these costs. The facility estimates that these services will cost the resident "$ At current rate" per day/item or service.

Interview on 3/17/26, at 12:51 p.m. the Business Office Manager Employee E10 confirmed the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that will be charged for two of three residents (Residents R8, and R31).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(2)(3) Management

Plan of Correction - To be completed: 05/04/2026

1. Facility immediately updated SNF-ABN form to specify the estimated amount of nursing services that will be charged.
2. SNF-ABN forms from the last 6 months will be audited and updated to specify the estimated amount of nursing services that will be charged.
3. NHA/designee to educate Business Office Manager on accurately completing SNF-ABN form with estimated amount of nursing services charges.
4. Business Office Manager/designee to audit SNF-ABN forms weekly x 2 weeks, then monthly x 2 months.
5. Results to be submitted to QAPI for review and approval.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview and review of the facility's Infection Control Committee attendance records, the facility failed to ensure that the nine required multidisciplinary members were present at the Infection Control meetings for two of four quarters (Quarter One - January - March 2025, and Quarter Two - April - June 2025).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members at infection control meetings includes medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member, and a member of the infection control team.

Review of the facility's Infection Control Committee Attendance Log for the last four Quarters revealed the following absent multidisciplinary members:

Quarter One: (January - March 2025) - interdisciplinary members that were not in attendance as required were a laboratory representative, pharmacy staff, and a community member.

Quarter Two: (April - June 2025) - interdisciplinary members that were not in attendance as required were a laboratory representative, pharmacy staff, and a community member.

During an interview on 3/18/26, at 1:00 p.m., the Infection Preventionist Employee E16 confirmed that the facility failed to ensure that the nine required multidisciplinary members were present at the Infection Control meetings for two of four quarters (Quarter One - January - March 2025, and Quarter Two - April - June 2025).

Plan of Correction - To be completed: 05/04/2026

1. Facility will have required attendees for quarterly Infection Control meetings.
2. NHA to educate DON/designee of required Infection Control attendees.
3. DON/designee to audit Infection Control meeting required attendees to ensure required interdisciplinary members are present monthly x 2 months.
4. Results to be submitted to QAPI for review and approval.

§ 201.19(4) LICENSURE Personnel policies and procedures.:

(4) A determination by a health care practitioner that the employee, as of the employee's start date, is free from the communicable diseases or conditions listed in § 27.155 (relating to restrictions on health care practitioners).

Observations:

Based on review of employee personnel records and staff interview, it was determined that the facility failed to ensure personnel records included a determination by a health care practitioner that the employee, as of the employee's start date, is free from communicable disease for five of five personnel files reviewed Licensed Practical Nurse (LPN) Employee E5, Van Driver Employee E6, Environmental Service Employee E7, and (Nurse Aides (NA) Employees NA E8, and NA E9).

Findings include:

Review of the personnel files on 3/18/26, at 9:00 a.m. indicated the hire date of all five employees as follows:

LPN Employee E5's original hire date 1/7/26.

Van Driver Employee E6's original hire date 2/4/26.

Environmental Service Employee E7 original hire date 2/25/26.

NA Employee E8 original hire date 11/19/25.

NA Employee E9 original hire date 11/26/25.

Upon request to review the determination by a health care practitioner that the employee, as of the employee's start date, was free from communicable disease, on 3/18/26, at 9:30 a.m. the facility could not produce valid physicals completed by a health care practitioner.

Interview on 3/18/26, at 3:00 p.m. the Nursing Home Administrator confirmed that that the facility failed to ensure personnel records included a determination by a health care practitioner that the employee, as of the employee's start date, is free from communicable disease for five of five personnel files reviewed Licensed Practical Nurse (LPN) Employee E5, Van Driver Employee E6, Environmental Service Employee E7, and (Nurse Aides (NA) Employees NA E8, and NA E9).

Plan of Correction - To be completed: 05/04/2026

1. No residents experienced adverse effects. LPN Employee E5, Van Driver Employee E6, Environmental Service Employee E7, and NA Employees E8 and E9 will have their physical completed.
2. Physical assessment signed by a provider will be required during the pre-employment process to determine that staff are free from communicable diseases.
3. NHA to educate HR Director/designee on need for physical assessment signed by a provider during the pre-employment process to determine that staff are free from communicable diseases.
4. HR Director/designee to audit new employee orientation folders weekly x 2 weeks, then monthly x 2 months.
5. Results to be submitted to QAPI for review and approval.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the daylight shift on five of 21 days reviewed, failed to provide one LPN for 30 residents during the evening shift on three of 21 days, and one LPN per 40 residents during the overnight shift on nine of 21 days (12/21/25 - 1/6/26, 3/1/26 -3/7/26 and 3/13/226 - 3/19/26). Findings include: Review of the facility census data and nursing time schedules revealed the following LPN staffing shortages: Daylight: 1/01/26: - census 77 2.10 - present 3.08 required 3/02/26: - census 89 3.17 - present 3.56 required 3/13/26: - census 85 3.33 - present 3.40 required 3/14/26- census 84 3.32 - present 3.36 required 3/15/26: - census 84 3.32 - present 3.36 required Evening: 12/31/25: - census 77 2.20 - present 2.57 required 3/1/26: - census 90 2.60- present 3.00 required 3/4/26: - census 88 2.69 - present 2.93 required Night: 3/1/26: - census 90 2.17 - present 2.25 required 3/2/26: - census 89 2.13 - present 2.23 required 3/3/26: - census 88 2.04 - present 2.20 required 3/4/26: - census 88 2.16 - present 2.20 required 3/5/26:- census 88 2.16 - present 2.20 required 3/6/26- census 88 2.18 - present 2.20 required 3/7/26: - census 89 2.02 - present 2.23 required 3/13/26: - census 85 1.62 - present 2.13 required 3/14/26: - census 84 1.97 - present 2.10 required Interview with the Nursing Home Administrator on 3/20/26, at 9:10 a.m. confirmed that thefacility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the daylight shift on five of 21 days reviewed, failed to provide one LPN for 30 residents during the evening shift on three of 21 days, and one LPN per 40 residents during the overnight shift on nine of 21 days (12/21/25 - 1/6/26, 3/1/26 -3/7/26 and 3/13/226 - 3/19/26).

Plan of Correction - To be completed: 05/04/2026

1. Facility cannot retroactively correct the LPN staffing ratios not being met on 12/21/25 - 1/6/26, 3/1/26 -3/7/26 and 3/13/226 - 3/19/26.
2. NHA/designee to educate DON/staffing coordinator on LPN ratio requirements and implement a contingency plan if needed by calling in off duty staff as needed to ensure sufficient nursing staff.
3. Facility conducts daily staffing meetings attended by NHA, DON, and HR Director to manage direct care staff and monitor ratios. Recruiting calls with the NHA, HR Director, and recruiter occur daily to update the status of new applicants and interviews.
4. Staffing coordinator/designee to audit staffing daily x 4 weeks to meet LPN ratio requirements.
5. Results to be submitted to QAPI for review and approval.

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