Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT PALMYRA
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT PALMYRA
Inspection Results For:

There are 169 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.


KADIMA REHABILITATION & NURSING AT PALMYRA - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance survey and an Abbreviated survey, completed on March 5, 2026, it was determined that Kadima Rehabilitation and Nursing at Palmyra was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations. \~

Plan of Correction:

483.25(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 facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to investigate falls to prevent accident hazards for three of 14 sampled residents. (Residents 3, 7, and 10)

Findings include:

Review of a facility policy entitled, "Accidents and Incidents-Investigating and Recording," last reviewed November 2025, revealed that regardless of how minor and accident or injury may be, staff was to report it to the department supervisor, and an "Accident or Incident Report Form" was to be completed. In an interview on March 5, 2026, at 12:08 p.m., the Regional Clinical Director stated that staff were to also obtain witness statements from the resident involved, and from staff that were present during the incident or were the first to find the resident after the incident. The Regional Clinical Director stated the incident report and witness statements were used to investigate a fall to find the cause and prevent reoccurrence.

Clinical record review revealed that Resident 3 had diagnoses that included muscle weakness and a craniotomy (temporary removal of a bone flap). The Minimum Data Set (MDS) assessment dated February 18, 2026, indicated that the resident was cognitively intact and partially dependent on staff for activities of daily living. Review of the care plan revealed Resident 3 was at risk for falls. On February 2, 2026, a nurse noted that the resident was found on the floor in her room between beds after an unwitnessed fall. On February 28, 2026, a nurse noted that Resident 3 fell again when she was about to get a shower. The nurse aide was putting on her gloves and the resident stood up from her wheelchair, stumbled and fell backwards. There was no documented evidence that staff thoroughly completed an investigation to determine the circumstances of Resident 3's falls.

Clinical record review revealed that Resident 7 had diagnoses that included anoxic brain damage (when the brain is deprived of oxygen), respiratory failure with hypoxia (lack of oxygen in the blood), and persistent vegetative state (awake but shows no signs of awareness of themselves or their environment), and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The MDS assessment dated December 6, 2025, indicated that the resident was cognitively impaired and dependent on staff for bed mobility. Review of the care plan revealed Resident 7 was at risk for falls. On November 7, 2025, a nurse noted that the resident was found with his head on the floor and feet still on the bed in his room after an unwitnessed fall. There was no documented evidence that staff thoroughly completed an investigation to determine the circumstances of Resident 7's fall.

Clinical record review revealed that Resident 10 had diagnoses that included cerebral infarction (stroke), anxiety, and seizures. The MDS assessment dated February 4, 2026, indicated that the resident was dependent on staff for toileting and dressing. Review of the care plan revealed Resident 10 was at risk for falls. On February 9, 2026, a nurse noted that the resident was found on the floor near the bathroom door. There was no documented evidence that staff completed an investigation to determine the circumstances of Resident 10's fall.

In interviews on March 5, 2026, at 9:10 a.m., and 12:55 p.m., the Regional Clinical Director confirmed that there was no documented evidence that there was any investigation for the fall documented for Resident 10, the investigations for Residents 3's and 7's falls were incomplete, and that there should have been full, completed investigations for the previously mentioned residents.

CFR 483.25(d)(2) Free of Accident/Hazards/Supervision
Previously cited 7/3/25

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

Plan of Correction - To be completed: 04/01/2026

1. Completed thorough investigations for all falls involving Residents 3, 7, and 10, including witness statements, environmental review, and prevention recommendations. Updated care plans to include additional fall precautions.
2. Re-educated all nursing and clinical staff on fall investigation and documentation requirements (March 10–12, 2026 Nursing supervisors instructed to audit all fall reports weekly for completeness.
3. DON or designee to conduct weekly audits of all fall investigations for 90 days. Any incomplete investigations corrected immediately; staff receive additional education as needed. Audit results reviewed monthly at QAPI meetings to identify trends and implement corrective actions.
4. Regional Clinical Director – oversight of investigations and staff education DON – audits, monitoring, and reporting. Unit Managers/Nurse Supervisors – ensure proper reporting and investigation.

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 facility policy review, resident group interviews, and a review of facility resident council meeting minutes, it was determined that the facility failed to address grievances voiced by the resident group.

Findings include:

Review of a facility policy entitled, "Grievance Policy," dated November 2025, revealed that grievances may include formal, written grievance process or a resident's verbalized complaint to facility staff. The facility was to acknowledge complaints/grievances and actively work toward resolution of the complaint/grievance.

During a confidential group interview conducted on March 4, 2026, at 10:40 a.m., four of four residents reported that there were not enough chairs in the facility for visitors and two of four residents stated they were missing laundry. Review of resident council meeting minutes dated February 17, 2026, revealed that the residents reported not enough chairs around the building for their loved ones to sit when they visited and two residents reported missing laundry. There was a lack of evidence that the facility had addressed the residents' ongoing concerns of not enough chairs around the building and missing laundry.

CFR 483.10(f)(5)(i)-(iv)(A)(B) Resident/Family Group and Response
Previously cited 7/3/25

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

Plan of Correction - To be completed: 04/01/2026

1. Additional chairs were placed in common areas for visitors. Missing laundry concerns were reviewed and addressed with affected residents.
2. Residents were interviewed to determine if additional concerns regarding seating or missing laundry were present.
3. Staff were re-educated on the facility Grievance Policy, including documentation, investigation, and resolution of resident concerns. A grievance log will be maintained.
4. The Administrator or designee will review the grievance log weekly for four weeks and report findings through QAPI.

483.90(g)(1)(2) REQUIREMENT Resident Call System:

§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.

Observations:

Based on clinical record review and observation, it was determined that the facility failed to provide a working call bell for one of 14 sampled residents. (Resident 10)

Findings include:

Clinical record review revealed that Resident 10 had diagnoses that included cerebral infarction (stroke), anxiety, and seizures. The Minimum Data Set assessment dated February 4, 2026, indicated that the resident was dependent on staff for toileting and dressing. Review of the care plan revealed Resident 10 was at risk for falls with an intervention for staff to ensure the call light was within reach and encourage it's use. Observations on March 3, 2026 at 10:50 a.m., and 12:39 p.m., and on March 4, 2026 at 9:46 a.m., 10:35 a.m., and 11:52 a.m., revealed no call bell available.

28 Pa. Code 201.18(b)(3)(e)(2.1) Management.
28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 04/01/2026

1. A functioning call bell was immediately provided to Resident 10. Nursing staff were reminded to ensure call bells are accessible at all times.
2. Nursing staff will check call bell accessibility for all residents during daily rounds Maintenance will inspect call bells weekly to ensure proper operation.
Supervisors will include call bell checks in shift huddles and care plan reviews.
3. All nursing staff received in-service training on ensuring call bell accessibility, reporting malfunctions, and documenting in care plans.
4. DON or designee will audit call bell availability weekly for 4 weeks, then monthly for 3 months. Any issues will be corrected immediately, and staff retrained as needed. Audit results will be reviewed in QAPI meetings.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on facility documentation review and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings for one of two quarters reviewed.

Findings include:

According to the QAPI committee minutes for February 18, 2026, the Director of Nursing and the Medical Director were not present. In an interview on March 3, 2026, at 12:10 p.m., the Regional Clinical Director confirmed there is no documented evidence that the Director of Nursing and Medical Director attended the February 18, 2026, QAPI meeting.

CFR 483.75(g) Quality assessment and assurance
Previously cited 7/3/25

28 Pa. Code 201.18(e)(1)(2)(3) Management.

Plan of Correction - To be completed: 04/01/2026

1. The Administrator will review the QAPI attendance log for all meetings held in 2026 to ensure all required participants are documented. The Director of Nursing (DON) and Medical Director confirmed attendance for all subsequent meetings.
2. All future quarterly QAPI committee meetings will have a verified attendance roster. If the DON or Medical Director cannot attend, a documented designee will attend in their place, and the substitution will be noted in the meeting minutes.
3. Administrator – oversight of POC implementation QAPI Committee Chair – ensuring compliance with attendance documentation Director of Nursing – attending or delegating attendance.
4. Attendance for QAPI meetings will be reviewed monthly by the Administrator for the next 12 months to ensure compliance. Any missed attendance will trigger an immediate corrective action and documentation in the QAPI minutes.

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.

Observations:

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored per facility policy in a medication cart on one of one nursing units.

Findings include:

Review of the facility policy entitled, "Medication Administration," last reviewed November 2025, revealed medications were to be administered at the time they are prepared.

Observations during the medication pass on March 4, 2026, at 8:47 a.m., revealed Registered Nurse (RN) 1 retrieving medication cups with labels in black marker from her cart. In an interview at that time, RN 1 confirmed she had pre-poured the medications into medication cups.

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

Plan of Correction - To be completed: 04/01/2026

1. The pre-poured medications identified during the observation on March 4, 2026, were immediately removed and properly documented. RN 1 received immediate education regarding proper medication administration practices, emphasizing medications must be prepared at the time of administration.
2. Policy Review: All licensed nursing staff will review the facility Medication Administration Policy, last reviewed November 2025, by March 20, 2026. Staff Education: In-service training will be conducted on proper medication storage and administration, highlighting that pre-pouring medications is not permitted.
Completion of education will be documented and maintained in staff files.
3. Nursing management will conduct weekly audits of medication carts on all units for three months to ensure compliance with policy. Any deviations will be immediately corrected and addressed with staff through re-education.
4.Compliance with the policy will be reviewed monthly during routine Quality Assurance meetings. Adjustments to education or monitoring will be made based on audit results.

483.30(a)(1)(2) REQUIREMENT Resident's Care Supervised by a Physician:

§483.30 Physician Services
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

§483.30(a) Physician Supervision.
The facility must ensure that-

§483.30(a)(1) The medical care of each resident is supervised by a physician;

§483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician supervised care in a timely manner for one of 14 sampled residents. (Resident 35)

Findings include:

Clinical record review revealed that Resident 35 had diagnoses that included iron deficiency anemia and diabetes. Review of an appointment consult summary dated January 13, 2026, revealed the consultant doctor recommended the resident take epoetin alfa (a medication that helps produce red blood cells) once every seven days. There was no documented evidence that this recommendation was reviewed with the physician until March 4, 2026. In a interview on March 5, 2026 at 9:15 a.m., the Regional Clinical Director confirmed that the recommendation was not reviewed with the physician in a timely manner.

CFR 483.30(a) Physician Supervision
Previously cited 7/3/25

28 Pa. code 211.2(d)(3) Medical director.

Plan of Correction - To be completed: 04/01/2026

1. Resident 35: The physician was notified of the consultant recommendation on March 4, 2026, and appropriate orders for epoetin alfa were implemented immediately.
Nursing staff were instructed to monitor and document administration of epoetin alfa as ordered.
2. Review and Audit Process:
All new physician or consultant recommendations will be reviewed with the resident's attending physician within 48 hours of receipt. A weekly audit of physician review and response to consultant recommendations will be conducted by the Nursing Supervisor to ensure timely follow-up.
3. Nurses, nurse practitioners, and clinical staff will be in-serviced on the policy for timely communication of consultant recommendations to the physician. Education will emphasize documenting the review and physician acknowledgment in the medical record. Policy Update: The facility will update its policy to specify that all consultant recommendations must be communicated to the physician within 48 hours and documented in the resident's medical record.
4. Results of weekly audits will be reviewed by the Quality Assurance Committee Monthly Any deficiencies identified will trigger immediate corrective action and staff re-education.

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 clinical record review, observations, and staff interview, it was determined that the facility failed to provide adequate hydration for one of 14 sampled residents. (Resident 2)

Findings include:

Clinical record review revealed that Resident 2 had diagnoses that included dehydration. Review of the Minimum Data Set assessment dated December 4, 2025, revealed Resident 2 had cognitive impairment and required moderate assistance with eating. Review of the current care plan revealed Resident 2 was at risk for dehydration with an intervention for staff to keep water available at bedside at all times. On March 3, 2026, Resident 2 was observed in her room and found to have no fluids at 10:53 a.m. and on March 4, 2026, at 9:30 a.m., 10:45 a.m., 11:51 a.m., and 12:30 p.m.

In an interview on March 5, 2026, at 10:00 a.m., the Regional Clinical Director confirmed that Resident 2 was to have water at their bedside per care plan.

CFR 483.25(g)(2) Sufficient fluid intake to maintain proper hydration
Previously cited 7/3/25

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

Plan of Correction - To be completed: 04/01/2026

1. Resident 2 was immediately provided with water and other appropriate fluids on March 5, 2026. Staff were reminded of the care plan intervention requiring fluids at the bedside at all times for residents at risk for dehydration.
2. Nursing staff received in-service training on ensuring that residents with hydration needs, especially those with cognitive impairment or requiring assistance, have fluids available at all times. The facility reviewed and updated all residents' care plans to confirm hydration interventions are clearly documented and communicated. Nursing staff will verbally check and document that bedside fluids are available during each shift.
3. The Director of Nursing (DON) or designee will audit 100% of at-risk residents' rooms weekly for one month to ensure fluids are available, then monthly for three months.
4. Findings from audits will be reviewed in monthly Quality Assurance meetings, and additional staff education will be provided as needed.
Any non-compliance will be immediately corrected and documented.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of one sampled residents with limited range of motion (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). (Resident 7)

Findings include:

Clinical record review revealed that Resident 7 had diagnoses that included anoxic brain damage (when the brain is deprived of oxygen), respiratory failure with hypoxia (lack of oxygen in the blood), and persistent vegetative state (awake but shows no signs of awareness of themselves or their environment), and contractures. The Minimum Data Set assessment (a periodic evaluation of resident care needs) dated December 6, 2025, indicated that the resident had limitations in range of motion (ROM) on both sides of both upper and lower extremities (arms and legs). A review of the care plan revealed that the resident required assistance with activities of daily living (ADLs), with an intervention for staff to provide assistance as required for completion of ADL tasks, such as personal hygiene, transferring, and bed mobility. Review of the occupational therapy discharge summary from January 16, 2026, revealed that Resident 7 should utilize orthotics (using a supportive device on a body part to improve positioning, support function, or prevent worsening of a condition) to maintain ROM and skin integrity (condition of the skin being intact, healthy, and free from injury or breakdown). On January 13, 2026, the physician ordered that staff apply a Posey Soft elbow extension splint (non-rigid supportive device to prevent joint contracture) as tolerated and to alternate upper arm use during daytime hours. Observations on March 3, 2026, between 10:05 a.m. and 1:30 p.m., and March 4, 2026, between 9:00 a.m. and 12:30 p.m., revealed that Resident 7 was without the Posey Soft elbow extension splint. A review of the clinical record revealed no documented evidence that the Posey Soft elbow extension splint was implemented as ordered. On March 4, 2026, the Director of Occupational Therapy (OT) documented that Resident 7 had not been wearing the Posey Soft elbow extension splint and staff were unable to find it.

In an interview on March 5, 2026, at 9:45 a.m., the Director of OT confirmed that Resident 7's Posey Soft elbow extension splint was to be on as ordered.

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

Plan of Correction - To be completed: 04/01/2026

1. On March 6, 2026, staff located an appropriate Posey Soft elbow extension splint for Resident 7. The splint was applied as ordered, ensuring proper placement and alternating use of upper extremities. Resident 7's range of motion was assessed by nursing and occupational therapy staff to establish a baseline and ensure interventions were implemented promptly. Staff in-service was conducted immediately to reinforce the physician's order and proper use of splints and ROM interventions.
2. All residents with physician-ordered orthotics or ROM interventions will have orders reviewed daily during shift huddles to ensure implementation.
Nursing staff will document daily ROM interventions, including splint use, in the electronic medical record (EMR). Occupational therapy will perform weekly audits of all residents with contractures or orthotics to verify proper implementation. Staff education will be updated to include proper use, documentation, and accountability for orthotic devices and ROM interventions.
3. Director of Nursing (DON) or designee will review 100% of ROM documentation for residents with contractures weekly for 8 weeks, then monthly for 3 months.
Any discrepancies will be corrected immediately and reported to the Quality Assurance Committee. Results of audits will be presented at the monthly QAPI (Quality Assurance and Performance Improvement) meeting to ensure ongoing compliance.
4. Director of Nursing (DON): Oversight of nursing compliance with ROM interventions. Director of Occupational Therapy (OT): Oversight of proper orthotic use and staff education.
Charge Nurses / Assigned Nursing Staff: Daily implementation and documentation of ROM interventions and orthotic use.

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.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 14 sampled residents. (Residents 7, 37)

Findings include:

Clinical record review revealed that Resident 7 had diagnoses that included anoxic brain damage (when the brain is deprived of oxygen), respiratory failure with hypoxia (lack of oxygen in the blood), and persistent vegetative state (awake but shows no signs of awareness of themselves or their environment), and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The Minimum Data Set (MDS) assessment dated December 6, 2025, indicated that the resident was cognitively impaired and dependent on staff for dressing. On January 13, 2026, the physician ordered for staff to apply Derma Savers (skin protectors) to the right hand and right leg as tolerated. Observations on March 3, 2026, between 10:00 a.m. and 11:30 a.m., revealed that Resident 7 was in a reclining chair without the Derma Savers on his right hand or right leg. Multiple observations on March 4, 2026, between 9:30 a.m. and 12:30 p.m., revealed Resident 7 in bed, without the Derma Savers on his right hand or right lower extremity.

Clinical record review revealed that Resident 37 had diagnoses that included diabetes mellitus, congestive heart failure, and major depressive disorder. Review of the care plan revealed Resident 37 had congestive heart failure with an intervention for staff to report changes to the provider as necessary. A physician's order dated August 13, 2025, directed staff to weigh the resident daily and to call the cardiologist (doctor who specializes in heart disease) if the resident gained over 2 pounds (lbs.) overnight and 5 lbs. in one week. Review of the clinical record revealed Resident 37 weighed 196.8 lbs. on February 14, 2026, and 199.4 lbs. on February 15, 2026, a 2.6 lb. weight gain. On February 24, 2026, Resident 37 weighed 193.8 lbs., on February 25, 2026, the resident weighed 198 lbs., a weight gain of 4.2 lbs. On February 23, 2026, Resident 37 weighed 196.2 lbs., on March 2, 2026, the resident weighed 202.4 lbs., a weight gain of 6.2 lbs. There was no documented evidence that staff weighed Resident 37 as ordered on February 28 or March 1, 2026. There was no documented evidence that the cardiologist was notified of the weight changes.

In an interview on March 5, 2026, at 9:45 a.m., the Regional Clinical Director confirmed that there was no documented evidence that the Derma Savers were applied to Resident 7's right hand or right leg as ordered, that Resident 37 was weighed daily as ordered, and that the cardiologist was aware of Resident 37's weight changes.

CFR 483.25 Quality of Care

Previously cited 7/3/25, 2/4/26

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

Plan of Correction - To be completed: 04/01/2026

1. Derma Savers applied to Resident 7 on March 6, 2026. Resident 37 weighed daily starting March 6, 2026; cardiologist notified of all weight changes since February 14, 2026.
2. All nursing staff trained on March 7,2026, regarding: Following and documenting physician orders. Timely communication with physicians for condition changes (e.g., weight gains).
3. Daily Audit: Charge nurses verify completion and documentation of physician orders. Weekly Chart Review: Regional Clinical Director reviews a sample of residents' charts weekly for four weeks. Physician Communication Log: Maintained for timely notifications of condition changes.
4. Audit results and corrective actions reported to monthly QAPI meeting.
Immediate retraining if deficiencies are found.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 14 sampled residents. (Resident 7)

Findings include:

Review of the facility policy entitled, "Abuse Reporting and Investigation," dated November 2025, revealed that injuries of unknown origin were investigated to rule out potential abuse.

Clinical record review revealed that Resident 7 had diagnoses that included anoxic brain damage (when the brain is deprived of oxygen), respiratory failure with hypoxia (lack of oxygen in the blood), and persistent vegetative state (awake but shows no signs of awareness of themselves or their environment), and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The Minimum Data Set assessment dated December 6, 2025, indicated that the resident was cognitively impaired and needed staff assistance for bed mobility. On January 29, 2026, a nurse noted that the resident had an abrasion on the left knee that measured 2.3 centimeters (cm) long by 1.3 cm wide and that the origin of the wound was unknown. There was no documented evidence that the facility completed an investigation of Resident 7's injury of unknown origin to rule out potential abuse.

In an interview on March 5, 2026, at 12:53 p.m., the Regional Clinical Director confirmed that there was no documented evidence that an investigation was completed to rule out potential abuse for the injury of unknown origin.

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

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

Plan of Correction - To be completed: 04/01/2026

1. Resident #7's medical record was reviewed immediately upon citation. A retrospective investigation of the left knee abrasion (noted 1/29/2026) was completed to rule out potential abuse. No evidence of abuse or neglect was identified. Resident #7's care plan was updated to include: Ongoing monitoring for skin integrity, Immediate reporting of any new injuries or abrasions of unknown origin. Licensed nursing staff were re-educated on identifying, reporting, and documenting injuries of unknown origin in accordance with the facility policy "Abuse Reporting and Investigation" (dated 11/2025).
2. The Director of Nursing (DON) or designee conducted a facility-wide review of all residents' recent incident reports, skin assessments, and injuries over the past 30 days.
Any injury of unknown origin that had not been fully investigated was addressed immediately, and appropriate documentation was completed.
3. All licensed nursing staff and nursing assistants received mandatory in-service education on the policy "Abuse Reporting and Investigation," emphasizing: Prompt identification of injuries of unknown origin
Immediate reporting to supervisory staff, Initiation of a thorough investigation within 24 hours, Complete documentation of investigation findings. The DON or designee implemented a daily review of incident reports and injuries of unknown origin to ensure investigations are completed timely and documented according to policy.
4. The DON or designee will perform weekly audits of all incident reports and injuries of unknown origin for 4 weeks, then monthly audits for 2 months. Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee monthly.
Any deficiencies identified will result in immediate re-education of staff and corrective action to ensure ongoing compliance.

483.10(e)(1),483.12(a)(2) REQUIREMENT Right to be Free from Physical 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 physical . . . 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 physical . . . restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Observations:

Based on facility policy review, clinical record review, observation, and staff interview, it was determined the facility failed to assess a resident for a physical restraint and conduct an ongoing assessment of a restraint for one of 14 sampled residents. (Resident 10)

Findings include:

Review of the facility policy entitled "Restraints," last reviewed November 2025, revealed that physical restraints were defined as any device, material, or equipment attached to or adjacent to the resident's body that the resident cannot easily remove which restricts access to one's body. The policy further stated that restraint use would be assessed on admission and readmission, and at least quarterly for elimination, reduction or continued need.

Clinical record review revealed that Resident 10 had diagnoses that included cerebral infarction (stroke) and hemiplegia (paralysis on one side). Observations on March 3, 2026, at 10:50 a.m. and 12:39 p.m., and March 4, 2026, at 9:46 a.m. and 10:35 a.m., revealed Resident 10 was in bed with an abdominal binder (wide elastic compression belt that restricts access to a person's stomach area) in place. Observations on March 4, 2026, at 11:52 a.m., revealed Resident 10 in his wheelchair wearing an abdominal binder. In an interview on March 5, 2026, at 9:06 a.m., the Regional Clinical Director stated it was unknown if Resident 10 could remove the abdominal binder without assistance.

There was no documented evidence that the facility did an initial restraint evaluation and continued restraint assessments to determine if the restraint was needed per facility policy.

28 Pa. Code 201.12(d)(1) Nursing services.
28 Pa. Code 211.8(e)(f) Use of restraints.

Plan of Correction - To be completed: 04/01/2026

1. Resident 10 was assessed by the interdisciplinary team on March 20,2026 to determine if the abdominal binder met the definition of a restraint and to evaluate the continued need for use. The physician was notified and orders were clarified as appropriate. The resident's care plan and documentation were updated to reflect the assessment findings and interventions.
2. A 100% audit of residents using devices that may be considered restraints was conducted by the Director of Nursing or designee to ensure appropriate assessment, physician orders, and care planning were in place. Any identified concerns were addressed immediately.
3. Licensed nursing staff were re-educated on the facility's Restraint Policy, including the definition of a restraint and the requirement for assessment upon admission/readmission and at least quarterly for continued need, reduction, or elimination
4. The Director of Nursing or designee will audit residents using potential restraint devices weekly for four weeks and monthly for three months to ensure compliance. Findings will be reviewed through the facility QAPI process and corrective actions implemented as needed.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to establish clear advance directives for one of 14 sampled residents. (Resident 4)

Findings Include:

Review of the facility policy entitled, "Advance Directives," dated November 2025, revealed that all residents shall be presumed as having consented to cardiopulmonary resuscitation (CPR) unless there is documentation in the medical record that the resident has specified that a do not resuscitate (DNR) order be written. An advance directive must be accompanied by a physician's order documented in the resident's medical record.

Clinical record review revealed that Resident 4 was admitted to the facility on January 16, 2026, with diagnoses that included pressure ulcer of the left buttock, severe protein-calorie malnutrition, and schizophrenia. A review of Resident 4's care plan revealed that the resident had a presumed advance directive that CPR would be performed as needed. On January 20, 2026, a Pennsylvania Orders for Life-Sustaining Treatment (POLST, a form directing medical staff to complete life-sustaining treatment or allow a natural death), indicated that in the event the resident has no pulse and is not breathing do not attempt resuscitation (allow natural death). A review of Resident 4's current physician orders revealed no documented evidence of a physician order addressing Resident 4's advance directive of DNR. The facility failed to ensure that a physician's order reflected the resident's elected DNR status as documented on the POLST.

In an interview on March 5, 2026, at 10:09 a.m., the Regional Clinical Director confirmed there was no physician's order for Resident 4's advance directive of DNR and that the care plan and POLST were inconsistent.

28 Pa. Code 201.29(a) Resident rights.

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

Plan of Correction - To be completed: 04/01/2026

1. Resident #4's record was reviewed. The physician was notified and a physician order reflecting the resident's DNR status per the POLST was obtained. The care plan and medical record were updated for consistency.
2. The Director of Nursing (DON) or designee audited residents with advance directives/POLST forms to ensure a corresponding physician order is present. Any discrepancies were clarified with the physician and corrected.
3. Licensed nurses were re-educated on the Advance Directives policy, including the requirement that POLST or DNR directives must have a corresponding physician order and be reflected in the care plan.
4. The DON or designee will audit new admissions and advance directive updates weekly for four weeks to ensure physician orders match POLST/advance directive documentation. Results will be reviewed through QAPI.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for seven of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from November 16 through 22, 2025, December 28, 2025, through January 3, 2026, and February 25 through March 3, 2026, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on November 19, 2025.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on November 16, 2025, and February 26, 2026.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on December 28 and 29, 2025, January 1 and 2, 2026, and February 26, 2026.

During an interview on March 5, 2026, at 10:10 a.m., the Regional Clinical Director confirmed that the facility did not meet the required NA to resident ratios on the days identified.

Plan of Correction - To be completed: 04/01/2026

1. Immediate reassignment of staff on affected days to meet ratios. Adjusted staffing schedules to ensure compliance. Documented staffing adjustments in daily logs.
2. Weekly staffing audits by DON/designee to verify NA ratios.
Advance review of schedules one week prior to shifts. Maintain a float pool of trained nurse aides to cover absences.
3. Director of Nursing – oversee schedules and audits Nursing Supervisors – ensure shift coverage Regional Clinical Director – monitor and verify compliance.
4. Weekly review of staffing logs for six months; deficiencies corrected immediately and documented.

§ 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 a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 13 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from November 16 through 22, 2025, December 28, 2025, through January 3, 2026, and February 25 through March 3, 2026, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on November 18, 19, and 20, 2025, December 28, 29, and 30, 2025, January 3, 2026, February 28, 2026, and March 1, 2026.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11:00 p.m.) on November 16, 18, 19, and 20, 2025, December 28, 29, 30, and 31, 2025, and January 1 and 2, 2026.

During an interview on March 5, 2026, at 10:10 a.m., the Regional Clinical Director confirmed that the facility did not meet the required LPN to resident ratio on the days identified.

Plan of Correction - To be completed: 04/01/2026

1. Additional LPNs were scheduled immediately on identified days to meet regulatory staffing ratios. No resident harm was identified related to the staffing deficiency.
2. Nursing schedules will be reviewed weekly by the Director of Nursing (DON) to ensure compliance with required LPN-to-resident ratios. A staffing contingency plan is in place to cover absences or shortages using float LPNs, agency staff, or shift adjustments. All nursing staff have been educated on regulatory staffing requirements.
3. DON will audit schedules and staffing daily for three months to ensure compliance. Any deviations will be documented and corrected immediately.
4. Director of Nursing (DON): Scheduling oversight and compliance monitoring
Administrator: Ensures staffing resources are available Timeline: Corrective actions implemented immediately. Staff education completed by [insert date within 30 days].
Monitoring ongoing for three months.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement