Pennsylvania Department of Health
 ROCHESTER RESIDENCE AND CARE CENTER
Patient Care Inspection Results

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ROCHESTER RESIDENCE AND CARE CENTER
Inspection Results For:

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ROCHESTER RESIDENCE AND CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance, and an Abbreviated survey in response to 3 complaints completed on July 10, 2026, it was determined that Rochester Residence 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
§483.60(i) Food safety requirements.
The facility must -

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

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the main kitchen which created the potential for cross contamination.

Findings include:

During an observation 3/2/26 at 9:20 a.m. of the main kitchen the following was observed:
Kitchen drain by three compartment sink was blocked, causing water backup.
Walk in freezer-several areas of ice build up
(5) kitchen carts - residue covering all areas

During an interview on 7/6/26 at 11:30 a.m., Dietary Manager Employee E10 confirmed that the facility failed to maintain sanitary conditions which created the potential for cross contamination in the main kitchen.

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














 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: Kitchen drain by three compartment sink was unclogged. Ice build up in walk in freezer was removed and kitchen carts were cleaned and sanitized.

House Wide Corrective Action: Kitchen drain areas, freezers and kitchen carts will be audited to ensure proper cleanliness and function by Dietary Manger or designee.

Education:Food service director will be re-educated by NHA or designee on ensuring equipment and storage areas are clean and functioning properly.

Performance Monitoring: Dietary manager or designee will audit the kitchen weekly x 4 weeks to ensure proper cleanliness and function of equipment and storage areas. The results of these audits will be reviewed at monthly QAPI for review and recommendation of need for continued monthly auditing.


483.70(p)(1)-(5) REQUIREMENT Payroll Based Journal:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
§483.70(p) Mandatory submission of staffing information based on payroll data in a uniform format.
Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

§483.70(p)(1) Direct Care Staff.
Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long term care facility (for example, housekeeping).

§483.70(p)(2) Submission requirements.
The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following:
(i) The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);
(ii) Resident census data; and
(iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).

§483.70(p)(3) Distinguishing employee from agency and contract staff. When reporting information about direct care staff, the facility must specify whether the individual is an employee of the facility, or is engaged by the facility under contract or through an agency.

§483.70(p)(4) Data format.
The facility must submit direct care staffing information in the uniform format specified by CMS.

§483.70(p)(5) Submission schedule.
The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.
Observations:

Based on review of facility documents and staff interview, it was determined that the facility failed to submit direct care staffing information in the Payroll-Based Journal (PBJ) system for one of three quarters reviewed (Quarter 2).

Findings include:

Review of the PBJ staffing data reports revealed that the facility did not submit data for Quarter 2 (January 1, 2026 - March 31, 2026).

During an interview on 7/10/2026, at 11:26 a.m. the Nursing Home Administrator was informed that the facility failed to submit direct care staffing information in the Payroll-Based Jornal system as required.

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








 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: PBJ reporting will be completed by NHA for Q1 of 2026.

Education: NHA and DON will be re-educated on ensuring PBJ reporting is completed as required by Regional Vice President.

Performance Monitoring: NHA or designee will complete quarterly audits x 1 year to ensure reporting has been completed as required. Results of these audits will be reviewed during facility quarterly QAPI for further monitoring needs.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication pharmacy medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for four of five residents (Residents R8, R9, R14, and R27).

Findings include:

Review of facility policy "Medication Regimen Review" dated 3/2/26, indicated the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of resident's medical chart. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: a review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities.

Review of the clinical record indicated Resident R8 was admitted to the facility on 9/10/24.

Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/26, indicated diagnoses of diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels), paranoid schizophrenia (subtype of schizophrenia characterized primarily by paranoia and delusions), and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems).

Review of facility provided documents and clinical record review failed to reveal that a MRR was completed for Resident R8 for May 2026.

Review of Resident R8's MRR "Note to Attending Physician/Prescriber" on 4/7/26, revealed that Certified Registered Nurse Practioner (CRNP) Employee E9 signed this form indicating "See above", however when reviewed above, there was no documented evidence what "See above" refers too, failing to address recommendations from pharmacy's MRR.

Further review of Resident R8's MRR's "Note to Attending Physician/Prescriber" on the following dates, were signed by a Certified Registered Nurse Practitioner (CRNP) and not by the physician as required on: 4/7/26, and 6/26/26.

During an interview on 7/9/26, at 10:18 a.m., the Director of Nursing (DON) confirmed that Resident R8's 4/7/26, MRR "Note to Attending Physician/Prescriber" was not addressed properly; confirmed that a CRNP signed pharmacy MRR documents requiring the attending physician to complete, and that the facility failed to provide monthly MRR for May 2026.

Review of the clinical record indicated Resident R9 was admitted to the facility on 9/7/25.

Review of Resident R9's MDS dated 6/11/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and repeated falls.

Review of Resident R9's MRR dated 3/30/26, indicated the following recommendation from pharmacist to physician:
The resident has been receiving Depakote (an anticonvulsant medication used to decrease manic episodes, affecting neurotransmitters in the Central Nervous System) 250 mg (milligrams) by mouth every morning and by mouth every evening since 9/2025. Please review current medication regimen and doses to ensure resident is using the lowest possible effective dose with minimal side effects. Please review for a Gradual Dose Reduction (GDR) and document if any change in therapy is contraindicated for that resident.
Review of Resident R9's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 3/30/26. On 4/7/26, facility CRNP Employee E9 addressed the MRR, stating, "Patient has good response to current treatment which maintains baseline function. Dose reduction is not indicated due to benefits outweigh risks, likely to impair the resident's function or cause psychiatric instability. Continue monitoring."

Review of Resident R9's MRR dated 3/30/26, indicated the following recommendation from pharmacist to physician:
The resident has been receiving Seroquel 25 (an antipsychotic medication used to stabilize mood) mg by mouth every evening since 9/2025 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below.

Review of Resident R9's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 3/30/26. On 4/7/26, facility CRNP Employee E9 addressed the MRR, stating, "The drug, dose, duration and indications are clinically appropriate; further reductions are contraindicated due to" with no further documentation available.

Review of facility provided documents and clinical record review failed to reveal that a MRR was completed for Resident R9 for May 2026.

Review of Resident R9's MRR dated 6/15/26, indicated the following recommendation from pharmacist to physician:
The resident has been receiving Depakote 250 mg in morning and 500 mg at bedtime, Zoloft (a medication used to treat depression) 50 mg daily, and Seroquel 50 mg at bedtime. Please consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document risk vs. benefit of continued therapy with current regiment.

Review of Resident R9's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 6/15/26. On 6/26/26, facility CRNP Employee E9 addressed the MRR, stating, "Decrease Depakote to 250 mg BID (twice a day) for GDR trial."

Review of the clinical record indicated Resident R14 was admitted to the facility on 5/7/26.

Review of Resident R14's MDS dated 6/11/26, indicated diagnoses of high blood pressure, anxiety, and depression.

Review of facility provided documents and clinical record review failed to reveal that a MRR was completed for Resident R14 for May 2026.

Review of Resident R14's MRR dated 6/15/26, indicated the following recommendation from pharmacist to physician:
The resident has been receiving Melatonin (a medication given to treat sleep disorders) 3 mg at bedtime. Please consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document risk vs. benefit of continued therapy with current regimen.

Review of Resident R14's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 6/15/26. On 6/24/26, facility CRNP Employee E9 addressed the MRR, stating, "Disagree - has failed GDR in past."

Review of the clinical record indicated Resident R27 was admitted to the facility on 11/20/25.

Review of Resident R27's MDS dated 5/27/26, indicated diagnoses of high blood pressure, anxiety, and depression.

Review of facility provided documents and clinical record review failed to reveal that a MRR was completed for Resident R27 for May 2026.

During an interview on 7/9/26, at 10:21 a.m. the DON confirmed the facility failed to complete MRRs for May 2026 for Residents R9, R14, and R27 and failed to ensure the attending physician addressed monthly MRRs for Residents R9, R14, and R27.

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code 211.5(f) Medical records.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.






 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: Facility secured a new provider to complete monthly MMR reviews. MMR reviews were completed for R9, R14 and R27 by the attending physician.

House Wide Corrective Action: Current residents will be audited by DON or Designee to ensure an MMR has been completed and physician has reviewed said MMR.

Education: Nursing administration has been re-educated by Regional Director of Clinical Services on ensuring monthly MMR's have been completed and reviewed by physician, and recommendations have been implemented as instructed.

Performance Monitoring: DON or designee will complete monthly audits x 4 months of MMR's to ensure an MMR has been completed and implemented as instructed by the physician. The results of audits will be reviewed in monthly QAPI meeting for need for continuing monthly auditing.
483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(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 document review, clinical record review, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to inform those residents of items and services no longer deemed eligible for coverage under Medicare Part-A for two of three sampled resident records (Residents R5 and R100).

Findings include:

Review of facility policy "Advance Beneficiary Notices", dated 3/2/26, indicated the facility is to provide timely notices regarding Medicare eligibility and coverage. The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay, before the facility provides:
An item or service that is usually paid for by Medicare, but may not be paid for in a particular instance because it is not medically reasonable and necessary, orCustodial care.
Review of Resident R5's admission record indicated he was originally admitted on 9/3/21, recently readmitted 4/23/26.

Review of Resident R5's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/30/26, indicated diagnoses of diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels), respiratory failure, and anemia (condition characterized by a deficiency of healthy red blood cells or hemoglobin, leading to insufficient oxygen delivery to the body's tissues).

Review of facility provided SNF Beneficiary Notification Review for Resident R5 indicated she was issued a NOMNC (Notice of Medicare Non-Coverage: a form provided to residents to inform them of the facilities determination to end a Medicare based services) with last covered day of 6/4/26. Resident R5 continued to remain in the facility long-term care.

Review of Resident R100's admission record indicated he was originally admitted on 2/5/26, recently readmitted 3/8/26.

Review of Resident R5's MDS assessment dated 5/14/26, indicated diagnoses of aphasia (language disorder that affects and individuals ability to communicate), necrotizing fasciitis (bacterial infection), and dementia (syndrome characterized by a decline in cognitive function).

Review of facility provided SNF Beneficiary Notification Review for Resident R100 indicated she was issued a NOMNC with last covered day of 4/30/26. Resident R100 continued to remain in the facility long-term care.

Review of facility documentation did not include evidence that Skilled Nursing ABN forms (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage: SNF-ABN, a form providing information that at a specific date Medicare coverage ends and the specific amount of financial liability will be passed onto the residents) were provided to Resident R5 and Resident R100.

During an interview on 7/9/26, at 10:28 a.m., the Business Office Manager (BOM) Employee E6 confirmed that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to inform those residents of items and services no longer deemed eligible for Residents R4 and R57 as required.

28 Pa. Code 201.14 (a) Responsibility of licensee







 Plan of Correction - To be completed: 08/31/2026

Immediate corrective action: Unable to correct.

Housewide corrective action: A 30 day look back will be completed of residents that require an ABN to ensure it was administered as required.

Education: MDS staff and social worker will be re-educated on ABN administration requirements by NHA or Regional Director.

Performance Monitoring: NHA or designee will complete weekly audits x 4 weeks of residents that require an ABN to ensure it was administered as required. Results will be reviewed during the facility's monthly QAPI meeting. QA meeting will determine the need for continued auditing.


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment on one of two nursing units (3rd floor nursing unit).

Findings include:

During observations on 7/6/26, at 11:56 a.m., the following was identified:
Missing ceiling tiles by the nurse's station and further down the hallway were observed with a container on the floor underneath the missing tile indicating caution wet floor, a drip was noted and there were ceiling tiles that were stained brown.

During an interview on 7/6/26, at 12:06 p.m. NHA (Nursing Home Administrator) confirmed that there was a leak from the ceiling and there were multiple missing ceiling tiles. During the interview the NHA confirmed that the leak started approximately three weeks ago.

During an interview on 7/6/26, at 12:09 p.m. NHA confirmed that there was a leak from the ceiling and there were missing ceiling tiles and ceiling tiles were stained brown and that the facility failed to provide a safe, clean comfortable and homelike environment for 3rd floor nursing unit.

28 Pa. Code 201.14(a)Responsibility of Licensee
28 Pa. Code 201.18(b)Management








 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: Missing and stained ceiling tiles were replaced and leak was repaired.

House Wide Corrective Action: Audit will be completed by Maintenance and NHA of nursing units to ensure there are no missing or stained tiles. Tiles will be replaced as necessary.

Education: Maintenance staff will be re-educated by NHA on replacing missing and stained tiles upon notification of damage to tiles.

Performance Monitoring: NHA or designee will audit each nursing unit weekly x 4 weeks to ensure stained or missing ceiling tiles are replaced. The results of the audits will be reviewed during facility QAPI to determine the need for continued monthly auditing.
483.10(e)(1),483.12(a)(2),483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints: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(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 record review, and staff interview, it was determined that the facility failed to ensure that a residents medication regimen was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for one of five residents (Resident R9).

Findings include:

Review of facility policy "Medication Regimen Review" dated 3/2/26, indicated Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. Facility shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Review of facility policy "Use of Psychotropic Medications" dated 3/2/26, indicated residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any dug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. When a medication(s) is used that can affect brain activity (e.g., antihistamines, anti-cholinergic medications, and central nervous system agents for use in conditions such as seizures, mood disorders, pseudobulbar affect (PBA), and muscle spasms or stiffness) and the documented use appears to be a substitution for another psychotropic medication rather than for the original or approved indication, then the medication(s) is subject to the requirements pertaining to psychotropic medications. Residents who use psychotropic drugs shall receive gradual dose reduction (GDR), unless clinically contraindicated, in an effort to discontinue these drugs.

Review of the clinical record indicated Resident R9 was admitted to the facility on 9/7/25.

Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and repeated falls.

Review of a physician order dated 4/3/26, indicated Depakote (an anticonvulsant medication used to decrease manic episodes, affecting neurotransmitters in the Central Nervous System) Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (milligrams) give 2 capsules (250 mg) by mouth one time a day related to major depressive disorder.

Review of a physician order dated 4/3/26, indicated Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg give 4 capsules (500 mg) by mouth at bedtime related to major depressive disorder.

Review of Resident R9's MRR dated 6/15/26, indicated the following recommendation from pharmacist to physician:
The resident has been receiving Depakote 250 mg in morning and 500 mg at bedtime, Zoloft (a medication used to treat depression) 50 mg daily, and Seroquel (an antipsychotic medication used to stabilize mood) 50 mg at bedtime. Please consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document risk vs. benefit of continued therapy with current regiment.
Review of a response completed by the facility Certified Registered Nurse Practitioner (CRNP) Employee E9 dated 6/26/26, indicated decrease Depakote to 250 mg BID (twice a day) for GDR trial.

Review of Resident R9's clinical record revealed the GDR for Depakote ordered 6/26/26, was not implemented until 7/8/26.

During an interview on 7/9/26, at 10:21 a.m. the Director of Nursing confirmed that the facility failed to ensure Resident R9's medication regimen was free from unnecessary psychotropic medication.

28 Pa Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.10(c) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.







 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: R9's medication regimen recommendations were followed as per provider instructions on MMR.

House Wide Corrective Action: MMRs that were completed in June were reviewed by DON or designee to ensure recommendations were completed as documented upon by provider.

Education: Nursing administration staff were re-educated on ensuring timely completion of MMR recommendations by Regional Director of Clinical Services.

Performance Monitoring: DON or designee will complete monthly audits x 4 months of MMR recommendations to ensure timely completion of recommmendations as documented. Ther results of the audits will be reviewed during the facility's monthly QAPI meeting to determine the need for continued monthly auditing.
483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 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 observation, review of clinical records and staff interview, it was determined that the facility failed to follow physician orders for two of six residents (Resident R19 and Resident R40) reviewed.

Findings include:

Clinical record review revealed Resident R19 was admitted to the facility on 11/29/24, with diagnosis to include, Diabetes Mellitus (condition that happens when blood sugar is to high), and hemiplegia (paralysis that affects one side of your body).

Review of physician orders dated 6/10/26, included Trulicity Subcutaneous Solution Auto-injector 0.75 MG/0.5ML Inject 0.75mg subcutaneously one time a day every Mon for DM.

A review of Resident R19's Medication Administration Record (MAR) for June 2026, revealed medication was not administered the following days: 6/15, 6/22, 6/29.
A review of Resident R19's MAR for July 2026, revealed medication was not administered the following days: 7/6.

A review of clinical record progress notes indicated medication not received from the pharmacy.

Clinical record review revealed Resident R40 was admitted to the facility on 1/15/25, with diagnosis to include, hypertension (force of blood against artery walls is consistently too high), Alzheimer's (progressive mental deterioration, due to degeneration of the brain) and chronic kidney disease.

Review of physician orders dated 6/16/26, included the following:
Terazosin HCl Oral Capsule 5 MG, Give 1 capsule by mouth

A review of Resident R40's Medication Administration Record (MAR) for June 2026, revealed medication was not administered the following days:

6/16/26, 6/19/26, 6/20/26, 6/21/26, 6/22/26, 6/24/26, 6/29/26

A review of clinical record progress notes indicated the medication was unavailable from pharmacy, unavailable in pyxis.

During an interview with Director of Nursing (DON) on 7/10/26, at 11:30 a.m. confirmed physician orders were not followed for Resident R40 as required.

28 Pa. Code 211.10(a)(c) Resident policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.







 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: R19 and R40's physician was made aware of missed medication.

House Wide Corrective Action: Current residents' medications will be audited by DON or designee to ensure medications were delivered and are present at the facility. Missing medications will be re-ordered as necessary.

Education: Licensed nurses will be re-educated by DON or designee on the facility's policy for medications that are not available and instruction for pulling medication from the Pyxis when possible if mediations have not yet been delivered to the facility will also be provided.

Performance Monitoring: DON or designee will audit 10 residents weekly x 4 weeks to ensure their medicaitons are present and administered per physicians order. The results of the audits will be reviewed during the facility's monthly QAPI meeting to determine the need for continuing monthly auditing.
483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of four residents (Resident R3).

Findings include:

Review of facility policy "Documentation of Wound Treatments", dated 3/2/26, indicated that the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment.

Review of the clinical record indicated Resident R3 was admitted to the facility on 9/30/25.

Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/26/26, indicated diagnoses of dementia (syndrome characterized by a decline in cognitive function), and pulmonary hypertension (type of high blood pressure that affects the arteries of the lungs and the right side of the heart).

Review of facility provided document "Pressure Sore List", dated 7/6/26, revealed the Resident R3 has an unstageable (full-thickness wound in which the base is completely obscured by slough or eschar, preventing accurate staging until debridement reveals the true depth) pressure sore on his sacrum, with date of onset 6/4/26.

Review of Resident R3's care plan dated 6/20/26, revealed a sacral wound, with an intervention to administer treatments as ordered and monitor for effectiveness.

Review of physician order dated 6/5/26, discontinued 6/18/26, indicated to cleanse sacrum wound with NSS (normal saline solution - sterile isotonic solution)/wound cleanser. Pat dry. Apply layer of silver gel (topical antimicrobial treatment that helps prevent infection and maintains a moist healing environment) to wound bed and cover with bordered dressing. Change every day shift for wound care.

Review of Resident R3's Treatment Administration Record (TAR) for June 2026, revealed the above treatment was not signed off as completed or refused on the following day shifts: 6/5/26, 6/7/26, 6/9/36, and 6/12/26.

During an interview on 7/9/26, at 9:51 a.m., the Wound Care Nurse (WCN) Employee E7 confirmed that the facility failed to make certain that residents received proper treatment for pressure ulcers for Resident R3.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10 (c)(d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(5) Nursing services.






 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: R3's physician was made aware that wound treatment was not signed out on 6/5, 6/7, 6/9, and 6/12/26. Those wounds wer re-evaluated by provider with new treatments ordered as necessary.

House Wide Corrective Action: Current residents with wound treatments will be audited by DON or designee to ensure treatments have been completed and documented as ordered.

Performance Monitoring: DON or designee will complete weekly audits x 4 weeks of 10 residents with wounds which will include 2 resident observations with documentation review to ensure treatments have been signed as completed on the TAR. The results of the audits will be reviewed during the facility's monthly QAPI meeting to determine the need for continued monthly auditing.
483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(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 review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility one of four residents (Resident R6).

Findings include:

Review of facility policy "Restorative Nursing Programs" dated 3/2/26, indicated the facility is to provide maintenance and restorative services designated to maintain or improve a resident's abilities to the highest practicable level. Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to: maintaining proper positioning and body alignment and assisting residents in adjustment to their disabilities and use of any assistive devices.

Review of the clinical record indicated Resident R6 was admitted to the facility on 5/17/13.

Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/26, indicated diagnoses of high blood pressure, arthritis (inflammation of one or more joints, causing pain and stiffness), and hemiplegia (paralysis on one side of the body).

Review of a physician order dated 5/15/26, indicated RUE (right upper extremity) rolled wash cloth in R (right) hand at all times as tolerated except for hand hygiene and skin checks.

Review of Resident R6's comprehensive care plan dated 5/15/26, indicated the resident has ADLS (Activities of Daily Living)/deficit for self-care related to: weakness/debility, suprapubic catheter, allergic rhinitis, cardiac history, CVA (a stroke) with right side hemiplegia, depression/anxiety, DJD (Degenerative Joint Disease). Interventions include RUE rolled wash cloth in R hand at all times except for hand hygiene and skin checks.

During an observation on 7/9/26, at 10:53 a.m. Resident R6 was observed lying in bed without a rolled wash cloth in their right hand.

Review of Resident R6's clinical record failed to include documentation that the resident refused or did not tolerate the rolled wash cloth to their right hand.

During an interview on 7/9/26, at 11:24 a.m. Licensed Practical Nurse Employee E5 confirmed the above observation and that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility one of four residents (Resident R6).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.






 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: R6 was re-assessed by therapy to determine the need for rolled wash cloth to right hand. Current orders now state: "RUE Rolled Wash cloth to R hand at all times as tolerated, may remove for hygiene and skin checks" Order was placed onto the TAR for Qshift documentation of use or refusal.

House Wide Corrective Action: Residents with orders for adaptive mobility equipment such as hand rolls and splints will be audited by therapy to ensure equipment is present and in place as ordered.

Education: Licensed nurses and CNA's will be re-educated by DON or designee on ensuring residents utilize supportive adaptive equipment as ordered/tolerated to maintain or improve mobility and the importance of documentation of use or refusal of said devices.

Performance Monitoring: DON or designee will audit residents with orders for adaptive equipment weekly x 4 weeks to ensure equipment is in use as ordered and documentation of use or refusal is being completed. The results of the audits will be reviewed during the facility's monthly QAPI meeting to determine the need for continued monthly auditing.
483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate treatment and services were provided for two of four residents (Residents R6 and R27) with an indwelling urinary catheter (a tube inserted in the bladder to drain urine).

Findings include:

Review of facility policy "Catheter Care" dated 3/2/26, indicated it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.

Review of the clinical record indicated Resident R6 was admitted to the facility on 5/17/13.

Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/26, indicated diagnoses of high blood pressure, neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), and anxiety.

Review of a physician order dated 1/9/26, indicated catheter/suprapubic foley (a catheter inserted into the bladder via a small incision in the lower abdomen) order: change every month: balloon; 5 cc (cubic centimeter), 16 French change monthly in the evening every 20 months starting on the 28th for 28 days. Review of treatment documentation revealed the order was transcribed to be administered every 20 months instead of every one month per physician order.

Review of Resident R6's comprehensive care plan dated 7/15/24, indicated the resident demonstrates an alteration in urinary elimination related to: suprapubic catheter due to neurogenic bladder. Interventions include cath size: 18 French with 5 cc balloon. Change every month.

During an interview on 7/10/26, at 11:34 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E8 confirmed Resident R6's catheter order was entered incorrectly and the facility failed to update the resident's care plan to accurately reflect the resident's current status.

Review of the clinical record indicated Resident R27 was admitted to the facility on 11/20/25.

Review of Resident R27's MDS dated 5/27/26, indicated diagnoses of high blood pressure, anxiety, and depression.

Review of a physician order dated 4/21/26, indicated suprapubic catheter French 16, 10 cc balloon every shift related to retention of urine.

During an observation on 7/6/26, at 10:12 a.m. Resident R27 was observed lying in bed. The resident's catheter drainage bag was observed attached to the right side of the bed with no privacy cover.

During an interview on 7/6/26, at 10:20 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed Resident R27's catheter drainage bag did not have a privacy cover.

Review of Resident R27's comprehensive care plan dated 4/22/26, indicated suprapubic catheter, I will be free from adverse effects related to suprapubic catheter. Interventions included Catheter - type: supra French 16F 10CC. The care plan failed to include any additional interventions related to Resident R27's indwelling urinary catheter care and usage.

During an interview on 7/10/26, at 11:34 a.m. RNAC Employee E8 confirmed the facility failed to develop an individualized care plan for Resident R27's indwelling urinary catheter care and usage.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.






 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: R6 and R27's orders and care plans were updated to reflect resident's current status. R 27's drainage bag was placed inside his dignity bag.

House Wide Corrective Action: Residents with indwelling urinary catheters will be audited by DON or designee to ensure orders, care plans and catheters are reflective of residents' current status and that dignity covers are in place. The facility has also purchased "fig leaf" bags that have a dignity cover built into the bag itself. These bags are currently being placed into service as each bag is changed.

Education: Licensed nurses will be re-educated on ensuring orders, care plans and catheters are reflective of resident's current status by DON or designee. DOn or designee will also re-educated CNAs on ensuring all urinary drainage bags have dignity covers in place at all times.

Performance monitoring: Don or designee will audit residents with indewlling urinary catheters weekly x 4 weeks to ensure orders, care plans and catheters are all reflective of resident's current status and audit that dignity covers are in place with each drainage bag. The results of the audits will be reviewed during the facilty's monthly QAPI meeting to determine the need for continued monthly auditing.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(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 review of facility policy, clinical records, and staff interview, it was determined that the facility failed to timely assess the nutritional status of two of five residents (Residents R9 and R14).

Findings include:

Review of facility policy "Nutritional Management" dated 3/2/26, indicated a comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed.

Review of the clinical record indicated Resident R9 was admitted to the facility on 9/7/25.

Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and repeated falls. Section A0310: Type of Assessment, A. Federal OBRA Reason for Assessment, was coded "02" Quarterly Assessment.

Review of Resident R9's clinical record failed to reveal documentation of nutritional status monitoring associated with MDS dated 6/11/26.

Further review of Resident R9's clinical record failed to reveal any Medical Nutritional Therapy documentation since 3/9/26.

Review of the clinical record indicated Resident R14 was admitted to the facility on 5/7/26.

Review of Resident R14's MDS dated 6/11/26, indicated diagnoses of high blood pressure, anxiety, and depression. Section A0310: Type of Assessment, A. Federal OBRA Reason for Assessment, was coded "02" Quarterly Assessment.

Review of Resident R14's clinical record failed to reveal documentation of nutritional status monitoring associated with MDS dated 6/11/26.

Further review of Resident R14's clinical record failed to reveal any Medical Nutritional Therapy documentation since 3/9/26.

During a telephonic interview on 7/9/26, at 1:35 p.m. Registered Dietitian Employee E11 confirmed the facility failed to timely assess the nutritional status of Residents R9 and R14.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.






 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: R9 and R14's nutritional status was assessed.

House Wide Corrective Action: Current residents will be audited by Registered Dietician or designee to ensure nutritional assessments are up to date per regulation.

Education: Dietician and MDS nurse will be re-educated on ensuring a nutritional assessment is completed with MDS completion by NHA or DON.

Performance Monitoring: NHA or designee will audit completed MDS assessments weekly x 4 weeks to ensure nutritional assessments have been completed. Audit results will be reviewed in monthly QAPI meeting to determine the need for continued monthly monitoring.


483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R27).

Findings include:

Review of facility policy "Oxygen Administration" dated 3/2/26, indicated staff shall change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy as needed if they become soiled or contaminated. Keep delivery devices covered in plastic bag when not in use.

Review of the clinical record indicated Resident R27 was admitted to the facility on 11/20/25.

Review of Resident R27's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/26, indicated diagnoses of high blood pressure, anxiety, and depression.

Review of a physician order dated 1/6/26, indicated oxygen maintenance per orders. Change tubing and filter weekly every night shift every Tuesday.

Review of a physician order dated 1/21/26, indicated nebulizer (a machine used to deliver aerosolized medications) maintenance, change tubing and filter weekly.

Review of a physician order dated 4/7/26, indicated to administer oxygen at 3 LPM (liters per minute) via n/c (nasal cannula - a lightweight tube that delivers oxygen through the nostrils) for O2 sat (blood oxygen saturation) greater than 90% as needed.

Review of a physician order dated 6/11/26, indicated to administer Ipratropium-Albuterol 0.5-2.5 (3) MG/3ML (milligrams per milliliter) 3 ml inhaled orally via nebulizer three times a day for wheezing and every 4 hours as needed for shortness of breath/wheezing.

During an observation on 7/6/26, at 10:12 a.m. Resident R27 was observed receiving oxygen at 3 LPM via nasal cannula. No date was observed on the nasal cannula tubing. The humidifier bottle attached to the oxygen concentrator was empty and did not have a date. An empty plastic belongings bag was observed hanging from the oxygen concentrator with the date "5/27/26".

During this observation, Resident R27's nebulizer machine was observed on an overbed table out of the resident's reach. No date was observed on the nebulizer tubing, and the mouthpiece was placed inside of the carboard tubing of an upright paper towel roll that was placed next to the nebulizer machine.

During an interview on 7/6/26, at 10:12 a.m. Resident R27 stated, "That is my nebulizer machine. I get breathing treatments twice a day."

During an interview on 7/6/26, at 10:20 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above observations and that the facility failed to provide appropriate respiratory care for Resident R27.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.






 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: R27's, O2 tubing, nebulizer setup and humidifier bottle was replaced and dated. a new setup bag was provided for storage.

House Wide Corrective Action: Current residents requiring oxygen and nebulizer treatments will be audited by DON or designee to ensure a new storage bag is in place and tubing, equipment and humidification bottles are stored, dated and changed as per policy.

Education: Licensed nurses will be re-educated by DON or designee on ensuring oxygen and nebulizer tubing, setup, hydration bottles and equipments is changed, dated and stored properly.

Performance Monitoring: DON or designee will audit 10 residents with respiratory needs weekly x 4 weeks to ensure tubing, hydration bottles, neb setups, and other necessary equipment is dated and stored properly. The results of the audits will be reviewed during the facility's monthly QAPI meeting to determine the need for continued monthly monitoring.
483.40 REQUIREMENT Behavioral Health Services:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on review of resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of six sampled residents (Resident R71).

Findings include:

Review of the admission record indicated agitated Resident R71 admitted to the facility on 2/6/26.

Review of Resident R71s Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/15/26, indicated the diagnoses anxiety disorder, major depressive disorder and hyperlipidemia (abnormally high levels of lipids).

Review of Resident R71's clinical record revealed the following:

2/8/26 client has been caught multiple times this shift with her fingers down her throat trying to make herself vomit, attempted to redirect client and she has had an emesis from sticking her fingers down her throat.

2/8/26 Rt midline covered in emesis. Patient stated she is not happy to be in this facility.

3/4/26 Nurse walked into this resident's room and observed resident having her index and middle finger down her throat and gagging.

3/21/26 resident is yelling out this shift for no apparent reason.

During an interview 7/9/26 at 10:30 a.m. Social Worker E12 indicated the facility was without psychiatric services for about a month. Nursing will usually refer a resident to social services and then they will refer to behavioral health.

During an interview 7/9/26 at 10:45 a.m. Social Worker E12 confirmed Resident R71 was not referred to behavioral health maintain the highest practicable well-being as required.

28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 211.12(d)(3) Nursing services






 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: Unable to correct for R71, resident has since been discharged. Alternatively RMV has secured the services of a new Psychiatric Provider.

Housewide Corrective Action: Current residents were audited for need for Psych services in a meeting with Therapy Director, Activities, DON, Unit Manager, and IP. Consults were placed as necessary.

Education: Social Worker and Nursing administration were re-educated on ensuring psychiatric services are provided to residents in need of said services by Regional Director of Clinical Services.

Performance Monitoring: DON or designee will complete weekly audits of residents that require psych services x 4 weeks to enures services have been consulted in a timely manner. The results of the audits will be reviewed during monthly QAPI meeting to determine if there is a need for continued monthly auditing.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(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 policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of three medications carts (Rosewood Medication Cart) and one of two medication rooms (Third Floor Medication Room).

Findings include:

Review of facility policy "Medication Storage" dated 3/2/26, indicated it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room.

Review of United States Food and Drug Administration (FDA) approved manufacturer prescribing information for Latanoprost (an eye drop medication used to reduce elevated pressure inside the eye) dated 7/2017, indicated to store unopened bottle under refrigeration 2 to 8 degrees Celsius (36 degrees to 46 degrees Fahrenheit). Protect from light. During shipment, the bottle may be maintained at temperatures up to 40 degrees Celsius (104 degrees Fahrenheit) for a period not exceeding 8 days. Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for 6 weeks.

During an observation on 7/6/26, at 9:40 a.m. the following was observed in the Rosewood Medication Cart:
Resident R25's unopened box of Latanoprost eye drops. The box was sealed and the label contained a large pink sticker that read "REFRIGERATE".

During an interview on 7/6/26, at 9:43 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above observation and stated, "I noticed that this morning, I'm going to call the pharmacy later to ask for another to be sent. It's not open, I don't know why it isn't in the refrigerator." During this interview, LPN Employee E1 confirmed that the facility failed to properly store medications in the Rosewood Medication Cart.

During an observation on 7/6/26, at 12:03 p.m. of the Third Floor Medication Room, an opened bottle of tuberculin solution (a medication used to test for tuberculosis) was observed in the medication room refrigerator with no open date.

During an interview on 7/6/26, at 12:04 p.m. LPN Employee E1 confirmed the above observation and that the facility failed to properly store medications in the Third Floor Medication Room.

28 Pa. Code: 201(a) Responsibility of licensee.
28 Pa. Code: 211.9(a)(1) Pharmacy services.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.






 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: The eyedrops and TB solution were removed and disposed of. New medications were ordered.

House Wide Corrective Action: All medication carts and refrigerators were audited by DON or designee to ensure proper storage, labeling and dating of medications.

Education: Licensed nurses will be re-educated by DON or designee on proper storage, labeling and dating of medications.

Performance Monitoring: DON or designee will audit all medication carts and refrigerators weekly x 4 weeks to ensure medications are stored appropriately, and have proper labeling and dates. The results for the audits will be reviewed for the need for continued monthly auditing in monthly QAPI meeting.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R45).

Findings include:

Review of facility policy "Enhanced Barrier Precautions" dated 3/2/26, indicated it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs target gown and gloves during high contact resident care activities. High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care: any skin opening requiring a dressing.

Review of facility policy "Hand Hygiene" dated 3/2/26, indicated hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Review of facility policy "Clean Dressing Change" dated 3/2/26, indicated set up clean field on the overbed table with needed supplies for wound cleansing and dressing application. If the table is soiled, wipe clean. Place a disposable cloth or linen saver on the overbed table. Wash hands and put on clean gloves. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. Losen the tape and remove the existing dressing. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. Wash hands and put on clean gloves. Cleans the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound. Pat dry with gauze. Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered. Secure dressing. Mark with initials and date. Discard disposable items and gloves into appropriate trash receptacle and wash hands.

Review of the clinical record indicated Resident R45 was admitted to the facility on 6/7/19.

Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/29/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and depression.

Review of a physician order dated 7/6/26, indicated Enhanced Barrier Precautions related to sacral (sacrum - triangular bone in the lower back formed from fused vertebrae and situated between the type hipbones of the pelvis) wound.

Review of a physician order dated 6/18/26, indicated to apply Santyl (an ointment used to help remove dead skin tissue and aid in wound healing) External Ointment 250 unit/gram, apply to sacral wound topically every day shift for sacral wound, cleanse wound with NSS (normal sterile saline)/wound cleanser, pat dry and apply Santyl and bordered foam (an absorbent adhesive dressing) to sacrum.

During an observation on 7/8/26, at 1:45 p.m. a sign posted outside of Resident R45's room indicated the resident is ordered Enhanced Barrier Precautions. A plastic box full of personal protective equipment (PPE - gloves, gowns, etc.) was observed outside of the resident's room.

During a dressing change observation on 7/8/26, from 1:49 p.m. to 2:10 p.m. Licensed Practical Nurse (LPN) Employee E3 and LPN Employee E4 did not don gowns prior to entering Resident R45's room and performing the wound care treatment as ordered. LPN Employee E3 did not establish a clean field using the overbed table. LPN Employee E3 placed a paper field on the resident's nightstand and placed the dressing supplies on the paper field. LPN Employee E3 did not cleanse the nightstand prior to placing the paper field and supplies on the nightstand. After cleansing the sacral wound, LPN Employee E3 removed their gloves and did not perform hand hygiene prior to donning a new pair of gloves and applying Santyl to the wound bed. After the treatment was complete, LPN Employee E3 did not cleanse the resident's nightstand after discarding the dressing supplies.

During an interview on 7/8/26, at 2:12 p.m. LPN Employee E3 confirmed the above observations and that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for Resident R45.

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.







 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: Employees E3 and E4 were re-educated by IP on enhanced barrier precautions, hand hygeine, and wound treatment procedures and the importance of following said precautions and procedures for resident safety.

House Wide Corrective Action: Licensed and certified staff will be audited and competencies completed by IP regarding enhanced barrier, hand hygiene, and wound treatment procedures and policies.

Education: Licensed and certified staff will be re-educated on enhanced barrier precaution procedures, hand hygeine and wound treatment procedures by IP.

Performance Monitoring: DON or designee will complete weekly observation of wound care including hand hygiene and observe proper execution of enhanced barrier precautions with 2 nurses x 4 weeks. The results of these audits wil be reviewed during facility QAPI for need for continued monthly auditing.

LICENSURE Qualified social worker:State only Deficiency.
Qualified social worker-As defined in 42 CFR 483.70(p).

Observations:

Based on review of facility documentation, and staff interview it was determined that the facility failed to employ a qualified social worker on a full time basis.

Findings include:

Review of the facility documentation job description for "Social Service Director" was signed on 9/23/25.

Interview with the Nursing Home Administrator (NHA) on 7/10/26, at 10:23 a.m. revealed that the current employee who is the only full-time social worker for the facility has a degree in Bachelor of Arts in History with a minor in Anthropology.

During the interview on 7/10/26, the NHA was informed that a degree in History with a minor in Anthropology does not meet for qualifications for social worker and the facility has failed to employ a qualified full-time social worker.





 Plan of Correction - To be completed: 08/31/2026
Education was provided to the HR Director by the NHA/Designee regarding the qualifications specific to the SSD role.
A new qualified social service director will begin work 8/14/26.
NHA/designee will audit weekly x 4 then monthly x 3 to ensure continued compliance.


§ 211.5(f)(i)-(xi) LICENSURE Medical records.:State only Deficiency.
(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on a review of two closed clinical records (Resident R70, R 71) and interviews with facility staff, it was determined the facility failed to ensure the clinical records included a minimum of information.

Findings include:

A review of resident R70 closed clinical record revealed the resident was admitted to the facility on September 15, 2025. The resident ceased to breathe April 23, 2026.

A review of the resident's closed clinical on July 9, 2026, revealed the resident's record did not contain a physician's discharge summary

A review of resident R71 closed clinical record revealed the resident was admitted to the facility on February 6, 2026. The resident was discharged April 22, 2026.

A review of the resident's closed clinical on July 9, 2026, revealed the resident's record did not contain a physician's discharge summary

An interview with the Director of Nursing on July 9, 2026, at 1:00 p.m. confirmed the facility could not provide physician discharge summary documentation for Resident R 70, R71.





 Plan of Correction - To be completed: 08/31/2026

Immediate Corrective Action: Discharge summaries will be completed by provider for R70 and R71.

House Wide Corrective Action: A 60 day look-back of residents that were discharged from the facility will be completed by DON or designee to ensure discharge summaries were completed.

Education: Medical Director and providers will be re-educated on ensuring timely completion of discharge summaries for all residents leaving the facility by NHA.

Performance Monitoring - NHA or designee will complete audits of residents that have been discharged from the facility to ensure discharge summaries have been completed in a timely manner weekly x 4 weeks. The results of those audits will be reviewed in facility QAPI to determine the need for continuing monthly auditing.


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