Pennsylvania Department of Health
CONCORDIA AT RP HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CONCORDIA AT RP HOME
Inspection Results For:

There are 123 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.


CONCORDIA AT RP HOME - 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 and two incidents completed Survey on August 14, 2026, it was determined that Concordia at RP Home was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities 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 a review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly maintain sanitary conditions which created the potential for cross contamination. (Main Kitchen)

Findings include:
Review of facility policy " Food Safety and Sanitation" dated 7/15/26, indicated all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department.

During an observation with Food Service Director Employee E5 in the main kitchen on 8/11/26, at 9:15 a.m., revealed five kitchen ceiling fans with brown debris.

During an observation with Food Service Director Employee E5 in the main kitchen on 8/11/26, at 10:00 a.m. revealed brown debris covering wall in the dishwasher area.

During an interview on 8/11/26, at 10:30 a.m., Dietary Manager Employee E5 confirmed that the facility failed to maintain sanitary conditions creating the potential for cross contamination.

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

Plan of Correction - To be completed: 10/01/2026

1) Dining services removed debris (mold) upon discovery on the wall of the dishwasher.

2) Fans were cleaned upon discovery by kitchen staff on 8/11/26.

3) All dining service staff will receive re-education to ensure sanitary conditions of the department. Education to be provided by Dining Service Manager. Signature sheets of education on file with NHA.

4) Weekly audits to be completed by dining services to inspect environment for sanitary conditions. Audits to be completed by Dining Services Manager or regional director. Audits on file with NHA.

5) Quality Assurance committee to be provided proof of audits and tracking.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:

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.

§483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Observations:

Based on review of the facility policy and staff interviews, it was determined that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (June 2025 to May 2026).

Findings include:

Review of facility "Antibiotic Stewardship Program" policy last reviewed 7/15/26, indicated the facility implements an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose if the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

Review of the facility's Infection Control Program from June 2025 to May 2026, failed to include documented evidence that antibiotic (medications used to treat infections) monitoring was completed timely. The previous month antibiotic report was utilized for tracking.

During an interview on 8/11/26, at 2:26 p.m. Registered Nurse (RN) Infection preventionist (IP) Employee E1 revealed antibiotic stewardship was completed after each month from June 2025 to May 2026. IP, Employee E1 stated every first of the month, the "previous month antibiotic report" were reviewed and residents who were prescribed antibiotics were tracked for length of time they received the antibiotic and indication for use. IP, Employee E1 stated the facility "started daily tracking in June 2026." IP, Employee E1 confirmed the facility failed to timely conduct antibiotic stewardship.

During an interview completed on 8/12/26, at 10:38 a.m. the Nursing Home Administration and Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (June 2025 to May 2026).

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: 10/01/2026

1) Infection Preventionist and DON were re-educated to protocol for tracking infections and antibiotic utilization. Signature of education on file with NHA as presented by NHA.

2) Infection Preventionist will review clinical data daily to track infections and antibiotic utilization.

3) Tracking of Infections will be provided to NHA monthly for review of data and compliance with practices. Tracking on file with NHA.

4) Quality Assurance committee will receive infection control tracking and monitor antibiotic stewardship program.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) REQUIREMENT Discharge Process:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

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

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

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

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

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

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

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

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

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

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:

Based on review of clinical record review, and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for one of six residents (Residents R54).

Findings include:

Review of the clinical record indicated Resident R54 was admitted to the facility on 6/4/26.

Review of Resident R54's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/8/26, indicated diagnoses of chronic respiratory disease, dysphagia (difficulty swallowing) and depression.

Review of the clinical record indicated Resident R54 was transferred to the hospital on 6/22/26, and returned did not return to the facility.

Review of Resident R54's clinical record, the facility failed to include documented evidence that the facility provided a written notification to the Office of Long-Term Care Ombudsman for the hospitalization on 6/22/26.

During an interview on 8/13/26, at 2:00 p.m. the Director of Social Services Employee E9 confirmed that the facility failed to provide written transfer notice to a representative of the Office of Long-Term Care Ombudsman for two of six residents as required (Resident R54).

28 Pa. Code: 201.14(a)Responsibility of licensee.
28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Plan of Correction - To be completed: 09/15/2026

1) Social Services and IDT were provided re-education to this requirement and facility policy. Training completed by NHA - signatures for proof of training on file with NHA.

2) Tracking Device in place and updated by Social Services. Monthly Tracking devices forwarded to NHA and on file.

3) NHA will audit monthly compliance with communication to OMBUDSMAN. Audits will continue until 100% compliance X 3 consec. Months.

4) QAPI Committee notified and will receive compliance tracking data.

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg:

§483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)

Observations:

Based on a review of Resident Assessments Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to conduct a Significant Change Minimum Data Set assessments for one of six samples residents (Resident R2).

Findings include:

Review of Resident Assessment Instrument (RAI) 3.0 User's Manual (reference used to complete an MDS) dated 10/1/25, indicated the significant change assessments (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes in hospice providers and remains a resident at the nursing home. The assessment reference date must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than).

Review of Resident R2's MDS assessment dated 8/1/26, indicated the following diagnosis: pulmonary hypertension, dysuria and heart failure.

Review of Resident R2's physician orders dated 7/24/26 indicated that she was ordered hospice care services.

Review of Resident R2's MDS assessments did not include a significant change MDS assessments that included hospice services for Resident R2.

During an interview on 8/13/26, at 1:30 p.m. RNAC (Registered Nurse Assessment Coordinator) Employee E4 confirmed that the facility failed to conduct a Significant Change Minimum Data Set assessment for Resident R2 as required.

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

Plan of Correction - To be completed: 09/15/2026

1) RNAC and IDT re-educated to reporting significant change requirements pertaining to hospice services. Re-education provided by NHA. Proof of education with NHA.

2) All residents currently on hospice services audited for compliance with MDS significant change reporting. Compliance on file with NHA.

3) Monthly, NHA will audit of residents admitted to hospice or discharged from hospice to monitor compliance with reporting. Will continue until 100% compliance X 3 consec. months.

4) QAPI committee will receive Compliance audits and tracking information for review.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to develop and implement a baseline care plan for a resident within 48 hours of a resident's admission for one of six residents reviewed (Resident R27).

Findings include:

Review of the facility policy "Care Plan-Baseline" last reviewed 7/15/26, indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care.

Review of the clinical record indicated Resident R27 was admitted to the facility on 7/30/26, with diagnoses of dementia, depression, and cerebral infarction.

Review of Resident R27's progress note dated 7/30/26, revealed the resident's ability to hear was highly impaired.

Review of Resident R27's progress note dated 7/30/26, revealed the resident arrived with a pocket talker.

Review of the Resident R27s Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/4/26, indicated the diagnoses were current. Section B0200. Hearing revealed the resident ability to hear (with hearing aid or hearing appliances of normally used) was highly impaired.

Resident R27's clinical record lacked evidence that a baseline care plan was implemented for Resident R27's difficulty hearing.

During an interview on 8/12/26, at 1:37 p.m. Registered Nurse Supervisor, Employee E3 stated if resident's are hard of hearing, a care plan with interventions related to the difficulty hearing should be implemented.

During an interview completed on 8/12/26, at 1:46 p.m. the Registered Nurse Assessment Coordinator, Employee E4 confirmed the facility failed to implement a baseline care plan within 48 hours for Resident R27's hearing difficulty.

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: 10/01/2026

1) IDT and Nurses will be re-educated to Baseline Care plan requirements and facility policy. NHA and DON to provide education- signatures on file with NHA to demonstrate training.

2) Resident R27 care plan communicates Pocket Talker and strategies for hearing loss.

3) New admission baseline care plans will be audited to ensure accurate and complete. IDT will audit baseline care plan during clinical meeting. Results on file with NHA- will continue auditing until greater than 95% accuracy X 3 conse. months.

4. Audit results communicated to QAPI Committee for tracking and trending.

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

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

Observations:

Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of eight residents (Resident R7).

Findings include:

Review of facility's policy "Comprehensive Care Plans" dated 7/15/26, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs.

Review of admission record indicated Resident R7 was admitted to the facility on 7/18/25, with diagnoses of right foot drop, depression, and high blood pressure.

Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/23/26, indicated the diagnoses were current.

Review of Resident R7's care plan dated 5/28/26, indicated to apply brace the resident's right lower extremity. It was indicated to apply on with morning care and off with evening care or as tolerated.

During an interview on 8/12/26, at 1:22 p.m. Resident R7 was observed without a right lower extremity brace. The resident's brace was observed sitting on the chair in the resident's room. Resident R7 stated no one had offered to put it on.

During an interview on 8/12/26, at 1:24 p.m. Registered Nurse Supervisor, Employee E3 confirmed Resident R7's right lower extremity brace was not applied as care planned.

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

Plan of Correction - To be completed: 10/01/2026

1) Review of R7 Plan - plan is specific to RNP. RNP will be re-educated to implement plan. Education by DON. Signatures on file with NHA.

2) Review of all resident splint/brace devices for accuracy with Care plan and placement. Audit to be completed by RNP Nurse/Therapy staff. Audit on file with NHA.

3) Restorative Nurse/Therapy will audit monthly residents with splints/braces to ensure accuracy with care plan and administration. Audit to be provided to NHA.

4) Quality Compliance Committee will be provided audits and tracking.

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

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

Observations:

Based on review of facility policy, clinical records, staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of eight sampled residents (Resident R17).

Findings include:

The facility "Activities of Daily (ADLs)" policy dated 7/15/26, indicated it is the facility policy to set goals with the resident make the goals specific to what is important to the resident.

Review of the clinical record revealed Resident R17 was admitted to the facility on 4/15/26.

Review of Resident R17's care plan dated 5/28/26, indicated to assist with ADL completion as needed.

Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/20/26, indicated diagnoses coronary artery disease (CAD- narrowing of the arteries that reduce blood flow to the heart), hypertension (high blood pressure) and depression.

Review of Resident R17's clinical nurse notes and ADL documentation did not indicate that he received a haircut or was offered for his beard to be shaved.

During an interview and observation on 8/11/26, at 10:05 a.m. Resident R17 was observed with disheveled long hair and a long beard. Resident R17 stated "I'd like to get it cut someday" and typically likes it shorter" when asked if he prefers his long hair and beard.

During an interview on 8/12/26, at 11:12 p.m. Registered Nurse Supervisor, Employee E3 confirmed Resident R17 needed hair services.

During an interview on 8/12/26, at 3:13 p.m. the Director of Nursing confirmed the facility failed to provide Activity of Daily Living (ADL) assistance to Resident R17.

28 Pa. Code: 211.12 (2)(5) Nursing services.

Plan of Correction - To be completed: 10/01/2026

1) Resident R17 offered a hair cut and beard trimming - and completed prior to 8/18/26

2) All residents will be audited to ensure they have received option for hair cut and facial trimming if requested. Audit results on file with NHA

3) Monthly audit of 30% of residents to ensure they have received hair cut/beard trimming to individualized preference. Will continue until 100% compliance for 3 consecutive months. Audit on file with NHA.

4) All nursing, activity, and therapy staff will be provided re-education to individualized preference of hair and facial trimming. Education to be completed by DON or NHA and signatures on file with NHA.

5) Quality Assurance Committee will receive outcome tracking.

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

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

Observations:

Based on review of facility policy, clinical records, observations, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers (PU/PIs -to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R50).

Findings include:

Review of facility policy "Pressure Injury Prevention and Management" dated 7/15/26, indicated the facility is committed to the prevention of avoidable pressure ulcers, and to provide treatment and services to heal the pressure ulcer, and prevent infection and the development of additional pressure ulcers. Interventions wil be based on specific factors identified will be implemented.

Review of Resident R50's admission record indicated he was admitted on 7/23/24.

Review of Resident R50's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/29/26, indicated the diagnoses high blood pressure, depression, and chronic obstructive pulmonary disease (COPD- is a progressive lung disease that makes it difficult to breathe). Section M-Skin Conditions indicated the resident had a stage III pressure ulcer.

Review of Resident R50's current physician orders dated 6/25/26, indicated to turn and repositioned every two hours.

Review of Resident R50's current physician orders dated 7/27/26, indicated to use wedge cushion to position resident form side to side.

During an observation on 8/11/26, at 10;14 a.m. Resident R50 was observed laying in bed supine, with no wedge or pillow in place for positioning.

During an observation on 8/12/26, at 11;13 a.m. Resident R50 was observed laying in bed supine, with no wedge or pillow in place for positioning.

During an observation on 8/13/26, at 8;50 a.m. Resident R50 was observed laying in bed supine, with no wedge or pillow in place for positioning.

During an interview on 8/13/26, at 9:34 a.m. Licensed Practical Nurse, Employee E? was asked if Resident R50 had a wedge to be turned and repositioned. LPN, Employee E2 stated "I haven't seen one."

During an interview on 8/13/26, at 9:35 a.m. Registered Nurse Supervisor, Employee E3 confirmed Resident R50 does not have a wedge and not turned and repositioned as ordered.

During an interview on 8/13/26, at 2:36 a.m., the Director of Nursing confirmed that the facility failed to make certain Residents R50 was provided necessary treatment and services for pressure ulcers.

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: 10/01/2026

1) R50 plan of care reviewed and care plan updated as needed. On file with EHR

2) All residents with wounds evaluated for accuracy of care plan. Audit completed by DON - audit on file with NHA.

3) Nurses re-educated to care plan to ensure accuracy with resident needs and physician orders. Signature sheets on file with NHA. DON to complete training

4) Audit 30% of resident charts monthly to ensure care plan are accurate for wound care/prevention. Audits on file with NHA

5) Quality Assurance Committee provided tracking and trending information.

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

§483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

Observations:

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of two residents (Resident R6).

Findings include:

Review of the facility policy "Enteral Feeding Procedure" last reviewed 7/15/26, indicated enteral feedings may be prescribed for residents who are physically or psychologically unable to take food by mouth in amounts that will support minimum nutrition. Enteral feedings should be administered under the close supervision of a physician and monitored by a Registered Dietitian and/or physician. Review of the clinical record indicated Resident R6 was admitted to the facility on 7/10/26.

Review of Resident R6's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/14/26, indicated diagnoses of adult failure to thrive, gastroesophageal reflux disease (GERD), and dysphagia (difficulty swallowing). Section K-Swallowing/Nutritional Status- revealed the resident had a feeding tube while a resident.

Review of Resident R6's care plan dated 7/14/26, indicated the resident received enteral feedings and to administer diet as ordered.

Review of Resident R6's physician order dated 4/21/26, indicated Enteral Feed (delivers liquid nutrition directly into digestive system using a flexible tube that bypasses normal swallowing) every shift Glucerna 1.2 (formula type) to run 24 hours continuous at 70 milliliter (ml) per hour. Free water flushes with 50 ml every six hours.

During an observation completed on 8/11/26, at 10:09 a.m. the enteral feeding pump was observed to be beeping. A "hold error" message was observed on the screen. 700 ml of Glucerna was observed in the bottle.

During an observation on 8/12/26, at 11:08 a.m. Resident R6's enteral feeding pump was paused. "Resume in 24 minutes" was observed on the screen.

During an interview on 8/12/26, at 11:15 a.m. Registered Nurse, Employee E3 stated Resident R6 is on a continuous tube feed. It was indicated staff pause the tube feed for an hour each shift. Nurses are responsible for placing the tube feed pump on hold, and responsible for restarting. It was indicated the nurse aides are not allowed to touch the pump, disconnect, or hold the enteral feeding. RN, Employee E3 stated she was the resident's nurse and was assigned the resident for day shift on 8/12/26.

During an interview on 8/12/26, at 11:25 a.m. Resident R6's enteral feeding was on hold.

During an interview on 8/12/26, at 11:34 a.m. RN, Employee E3 confirmed Resident R6's enteral feeding was on hold. RN, Employee E3 confirmed she did not place the enteral feeding on hold and was not aware it was placed on hold. RN, Employee E3 restarted the resident's enteral feeding.

During an interview on 8/12/26, at approximately 3:00 p.m. information was disseminated to the Director of Nursing that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services for one of two residents (Resident R6).

28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 10/01/2026

1) medication occurrence/Incident Report will be completed on R6. R6 discharged from the facility, no other updates can be made to their plan of care. Employee involved will receive re-education to process to holding tube feeding.

2) Audit of all residents with continuous feeding will be conducted to ensure documentation of time feeding is down. R6 had order in place to allow for 2 hours a down time per day.

3) Nurses will be re-educated to Enteral tube feeding and down time as ordered. Education completed by DON and signatures on file with NHA.

4) Will audit all residents with continuous enteral feeding monthly to ensure compliance with order. Audits on file with NHA. Audit to be completed by DON.

5) Quality Assurance Committee to be provided compliance information

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 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, clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of three sampled residents (Residents R50).

Findings include:

Review of Resident R50's admission record indicated he was admitted on 7/23/24.

Review of Resident R50's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/29/26, indicated the diagnoses of high blood pressure, depression, and chronic obstructive pulmonary disease (COPD- is a progressive lung disease that makes it difficult to breathe).

Review of Resident R50's current physician orders dated 6/5/26, indicated to check every week on Sunday evening, if humidifier has been changed.

Review of Resident R50's current physician orders dated 6/5/26, indicated to apply 2 liters of oxygen each shift.

Review of Resident R50's current physician orders dated 6/6/26, indicated to check oxygen humidification every shift and change/fill as needed.

During an observations on 8/11/26, at 10:14 a.m., Resident R50's humidification bottle dated 8/2/26, was observed empty.

During an observations on 8/12/26, at 11:00 a.m., Resident R50's humidification bottle dated 8/2/26, was observed empty. Resident R50 was not utilizing oxygen and the nasal cannula was observed hanging over the oxygen concentrator without a bag.

During an interview and observation on 8/12/26, at 11:13 a.m. Registered nurse Supervisor, Employee E3 confirmed Resident R50's humidification bottle was empty. RN Supervisor, Employee E3 confirmed Resident R50 was not receiving oxygen as ordered and the nasal cannula tubing was not stored properly when in use.

During an interview on 8/12/26, at 2:23 p.m. the Nursing Home Administrator confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment.

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: 10/01/2026

1) R50's humidification was replaced upon discovery and nasal cannula replaced.

2) Nurses and CNAs will be re-educated to oxygen equipment storage and cleaning. Education to be provided by DON or Infection Preventionist. Signatures on file with NHA.

3) Weekly audits to observe oxygen equipment for care and storage. Audits to be completed by Infection Control preventionist. Audits on file with NHA.

4) Quality Assurance Committee to be provided with audits and trends.

483.50(a)(1)(i) REQUIREMENT Laboratory Services:

§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Observations:

Based on review of clinical records, hospital records, physician orders, and staff interviews, it was determined the facility failed to ensure physician-ordered laboratory services were obtained in a timely manner and failed to follow through on ordered laboratory testing for one of six residents reviewed (Resident R10).

Findings include:

Review of the clinical record indicated Resident R10 was admitted to the facility on 10/6/23, with diagnoses of dementia (a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), anxiety, and depression.

Review of the Resident R10's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/30/26, indicated the diagnoses were current.

Review of Resident R10's progress note dated 8/8/26, revealed the resident had increased confusion, hallucinating and combative. The physician was notified and an order for a urinalysis was obtained.

Review of Resident R10's physician order dated 8/8/26, indicated to obtain urinalysis with culture one time only related to dementia without behavior disturbance.

There was no documented evidence that the facility obtained the physician-ordered urinalysis and culture and sensitivity or implemented alternative measures to ensure timely completion of the ordered laboratory testing between 8/8/26, to 8/12/26.

During an interview on 8/12/26, at 1:30 p.m. Registered Nurse Supervisor, Employee E3 stated when a urinalysis and culture is ordered, it is transcribed to alert of the clinical record as a task that needs to be completed. All supplies are located in the utility room. The order must be signed off in the clinical record when the specimen is obtained. The results are followed up and if any abnormal findings the physician is notified. RN, Supervisor, Employee E3 confirmed the facility failed to obtain Resident R10's urinalysis as ordered.

During an interview conducted on 8/12/26, at 3:13 PM, the Director of Nursing confirmed there was a delay in obtaining the physician-ordered urine specimen.

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

Plan of Correction - To be completed: 10/01/2026

1) Resident R10 lab order was discontinued per physician direction. Physician order on file with NHA.

2) Nursing Staff to receive re-education on lab services and follow-up if specimen cannot be collected. Education to be provided by DON or ADON.

3) Infection Preventionist and Clinical team will monitor lab ordered and audit for completion and/or discontinue of order compliance. Auditing until greater than 95% accuracy for greater than 3 conc. months.

4) Quality Assurance Team to be provided audits and tracking information.

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

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

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

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

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

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

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

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

Plan of Correction - To be completed: 10/01/2026

1) Enhanced Barrier precaution sign and supplies were returned to R6's room at the time of discover.

2) All residents who require Enhanced Barrier Precautions will be autied to ensure proper communication/supplies are available. Audit to be completed by Infection Preventionist. Audits to NHA.

3) weekly audits to be completed by Infection Preventionist to ensure proper precautions are available/in place. Will audit until 100% compliance 3 months.

4) Quality Assurance Committee will be provided audits results.

5) Water Management program will be updated to include control measure monitoring and logs. Monitoring will include weekly water temperatures at the boiler (to ensure greater than 140 degrees) monitor to ensure water flushes at vacant rooms, monthly. Maintenance Director, Infection Preventionist a Directors will be re-educated to this plan. NHA will provide re-education

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations:

Based on a review of facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered a pneumococcal immunization for one of five residents reviewed (Residents R11).

Findings include:

A review of facility policy, "Infection Prevention and Control Program," dated 7/15/26, indicated residents will be offered the pneumococcal vaccines recommended by the CDC upon admission unless contraindicated or received the vaccines elsewhere. Documentation will reflect the education was provided and details regarding whether or not the resident received the immunizations.

A review of the clinical record indicated Resident R11 was admitted to the facility on 9/2/25, with diagnoses that included cancer, high blood pressure, and anxiety.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/9/26, indicated the diagnoses were current. Section O0300 Pneumococcal Vaccine revealed the resident was not up to date and the resident was not offered the pneumococcal vaccine.

A review of R11's electronic clinical record "Immunizations" documentation on 8/12/26, at 11:00 a.m., did not include information that the pneumococcal vaccine was offered or declined.

During an interview on 8/12/26 at 1:19 p.m., the Director of Nursing confirmed the above findings, and that the facility failed to document each resident was offered pneumococcal immunization for Residents R11.

28 Pa. Code 211.5(f)(i)-(xi) Medical records.
28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 10/01/2026

1) R11 provided education by Infection Preventionist and offered Pneumococcal vaccination as resident prefers. Documentation on file in EHR.

2) All residents will be audited to ensure they have been offered pneumococcal vaccination and administered per their preference. Audit on file with NHA.

3) Infection preventionist and Nurses re-educated by NHA regarding offering pneumococcal vaccination at admission and as needed.

4) Monthly audit of all new admissions to ensure they are offered pneumococcal vaccination. Audit to be completed by DON or NHA and on file with NHA. Will continue until 100% compliance 3+ consecutive months.

4) Quality Assurance Committee will be provided tracking information

483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization:

§483.80 Infection control
§483.80(d)(3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses.
(v) The resident or resident representative, has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision; and
(vi) The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident, or
(C) If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.
(vii) The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

Observations:

Based on a review of facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered a COVID-19 vaccine for one of five residents reviewed (Residents R1).

Findings include:

A review of facility policy, "Infection Prevention and Control Program," dated 7/15/26, indicated residents will be offered the COVID-19 vaccine when vaccine supplies are available to the facility. Residents will be screened prior to offering the vaccination for prior immunization, medical precautions and contraindications to determine candidacy for the vaccination. The resident's medical record includes documentation that indicates at a minimum, the following:
-The resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine.
-Each dose of COVID-19 vaccine administered to the resident, or if the resident did not receive the vaccine due to medication contradiction or refusal.

A review of the clinical record indicated Resident R1 was admitted to the facility on 6/25/26, with diagnoses that included cancer, high blood pressure, and insomnia (difficulty staying or falling asleep).

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/29/26, indicated the diagnoses were current. Section O0350 Resident's COVID-19 vaccination is up to date revealed the resident was not up to date.

A review of R1's electronic clinical record "Immunizations" documentation on 8/12/26, at 11:00 a.m., did not include information that the COVID-19 vaccine was offered or declined.

During an interview on 8/12/26 at 1:19 p.m., the Director of Nursing confirmed the above findings, and that the facility failed to document each resident was offered COVID-19 vaccine for Residents R1.

28 Pa. Code 211.5(f)(i)-(xi) Medical records.
28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 10/01/2026

1) R1 was be offered COVID Vaccination and documented in EHR.

2) All resident audits to be completed to ensure offered and adminsitered COVID Vaccine as requested. Audit to be completed by Infection Control Preventionist. Audit result to NHA.

3) Re-education to Nurses and Infection Preventionist to offer vaccinations at time of admission as needed. Education to be provided by DON. Signatures on file with NHA.

4) Monthly audits of new admissions for compliance with being offered COVID vaccination. Audit to be completed by DON or INfection Preventionist. Audits to NHA.

5) Quality Assurance committee will be provided audits results and tracking.

§ 201.14(a) LICENSURE Responsibility of licensee.:

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

Observations:

Based on review of facility infection control policies and procedures, infection control surveillance, and staff interview, it was determined that the facility failed to comply with the following requirements of MCAREAct403(a)(1) for one of two residents (Resident CR200).

Findings include:

MCAREAct, Section 403(a)(1), 40 P.S. 1303.404(a) - Health Care Facility Reporting, states: Infections that meet the criteria in PSRS Manual (Chapter 4) must be reported to PA-PSRS within 24 hours of confirmation.

MCAREAct, Section 403(a)(1), 40 P.S. 1303.405(a) - Patient Safety Authority Jurisdiction, states: The occurrence of a healthcare-associated infection is deemed a serious event. Written notification to the resident/family member/responsible party within seven days of the serious event should be documented.

Review of the facility infection control surveillance (tracking of all infections within the facility in an effort to identify trends or to prevent further infections from developing) and submissions to PA-PSRS revealed the following:

Resident CR200 had a HCAI (Health Care Associated Infection), urinary tract infection, with an infection confirmation date of 1/6/26. This infection was not submitted to PA-PSRS until 5/13/26, 127 days later.

The facility documentation did not include evidence that written notification of the HCA infections were provided to the resident, family member, or other responsible party for Resident CR200.

During an interview on 8/12/26, at 10:38 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to submit reports to PA-PSRS of HCAIs timely, and failed to maintain documentation of notification of HCAIs to residents, family members, or other responsible parties.

Plan of Correction - To be completed: 10/01/2026

1) Infection Preventionist and DON re-educated by NHA to reporting requirements for PA-PSRS. Signatures on file with NHA.

2) DON/NHA will audit infection control data monthly to ensure appropriate cases are reported to PA-PSRS and to the Resident/resident representative. Audits will continue until 100% compliance for 3 or more consecutive months.

3) Quality Assurance Committee will receive monthly tracking of infection control tracking - including reportable events to PA-PSRS

§ 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 review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 10 residents during the day shift for six of 21 days (5/31/26, 6/2/26, 6/5/26, 7/4/26, 8/9/26, 8/10/26) and one nurse aide per 15 residents on evening shift for three of 21 days (5/31/26, 6/1/26, 7/4/26).

Findings include:
Review of facility census data and nursing time schedules from5/31/26-6/6/26, 6/28/26-7/4/26, 8/5/26-8/12/26 , revealed the following nurse assistant (NA) staffing shortages:

Day shift:
Date: Census: Hours required: Actual hours:
5/31/26 52 41.60 39.00
6/2/26 51 40.80 40.25
6/5/26 51 40.80 34.25
7/4/26 51 40.80 40.75
8/9/26 53 42.40 33.00
8/10/26 53 42.40 39.50

Night Shift:
Date: Census: Hours required: Actual hours:
5/31/26 52 27.73 25.50
6/1/26 51 27.20 25.00
7/4/26 52 27.73 25.25

During an interview on 8/13/26, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aide per 10 residents during the day shift for six of 21 days (5/31/26, 6/2/26, 6/5/26, 7/4/26, 8/9/26, 8/10/26) and one nurse aide per 15 residents on evening shift for three of 21 days (5/31/26, 6/1/26, 7/4/26) with no additional excess higher-level staff to compensate for this deficiency.

Plan of Correction - To be completed: 10/01/2026

1) Re-education to DON, Nurses and CNAs regarding attendance policy and scheduling process and required ratio by DOH. Signatures on File with NHA.

2) DON and Staffing Coordinator will review schedule weekly and daily to ensure facility is staffed according to DOH ratio requirements. Monthly Schedule and daily staffing sheets on file with NHA.

3) NHA will monitor compliance CNA ratios weekly. Tracking on file with NHA.

4) Quality Assurance Committee will be provided tracking information

5) Facility consistently recruits with job posting, employee referrals and interviewing walk-in applicants. Turn-over is monitored by NHA

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

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift on two of 21 days (5/31/26, 8/8/26), failed to provide a minimum of one LPN per 30 residents during the evening shift on one of 21 days (5/31/26) and failed to provide a minimum of one LPN per 40 residents during the night shift on two of 21 days (6/28/26, 7/4/26).

Findings include:
Review of facility census data, and nursing time schedules from 5/31/26-6/6/26, 6/28/26-7/4/26, 8/5/26-8/12/26 revealed the following LPN staffing shortages.

Day Shift
Date Census Actual Hours Minimum hours required
5/31/26 52 15.25 16.64
8/8/26 54 12.75 17.28

Evening Shift

Date Census Actual Hours Minimum hours required
5/31/26 52 7.50 13.87

Night shift:

Date Census Actual Hours Minimum hours required
6/28/26 54 8.25 10.80
7/4/26 52 8.00 10.40

During an interview on 8/13/26, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift on two of 21 days (5/31/26, 8/8/26), failed to provide a minimum of one LPN per 30 residents during the evening shift on one of 21 days (5/31/26) and failed to provide a minimum of one LPN per 40 residents during the night shift on two of 21 days (6/28/26, 7/4/26) with no additional excess higher-level staff to compensate for this deficiency.

Plan of Correction - To be completed: 10/01/2026

1) Re-education to DON, Nurses and CNAs regarding attendance policy and scheduling process and required ratio by DOH. Signatures on File with NHA.

2) DON and Staffing Coordinator will review schedule weekly and daily to ensure facility is staffed according to DOH ratio requirements. Monthly Schedule and daily staffing sheets on file with NHA.

3) NHA will monitor compliance Nurse ratios weekly. Tracking on file with NHA.

4) Quality Assurance Committee will be provided tracking information

5. Facility constantly recruits with job posting, employee referrals and interviewing walk-in applicants. Turn-over is monitored by NHA

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