Pennsylvania Department of Health
ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are 226 surveys for this facility. Please select a date to view the survey results.

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ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated Survey in response to three complaints, completed on June 5, 2026, it was determined that St. Francis Center for Rehabilitation and Healthcare, was not in compliance with the 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 related to the health portion of the survey process.

Plan of Correction:

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

�483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

�483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

�483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Observations:
Based on review of facility policy, observation, review of clinical record, and interview with staff it was determined that the facility failed to ensure that residents/resident's next of kin/legal guardian/power of attorney are notified of changes in resident's care related to ankle monitoring bracelet for one of 37 residents reviewed (Resident R175).

Findings Include:

Review of facility policy on notification and change of condition, revised May 2025, revealed that the facility shall utilize a notification process when there is change in the resident's medical condition and or status. Unless otherwise instructed by the resident, a nurse will notify the residents' representative

Review of Resident R175's clinical record revealed that Resident R175 has a diagnosis of anxiety disorder (intense, excessive, persistent worry or fear) and unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities).

Observation conducted on June 2, 2026, at 11:24 a.m. revealed Resident R175 was in his/her room and was wearing a monitoring device on his/her ankle.

Review of Resident R175's physician orders revealed orders dated April 3, 2026, to check function and placement of "Veri Chip Function" (monitoring device) to the right ankle, daily to prevent elopement.

Further review of Resident R175's clinical record revealed no documented evidence that the family was notified of the wander guard use.

Interview June 4, 2026, with Director of Nursing (DON), Employee E2, confirmed that the unit manager did not call the family to inform them of the wander guard applied to Resident R175's ankle.

28 Pa Code 211.10 (c) Resident care policies

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

Plan of Correction - To be completed: 07/22/2026

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident R175 Responsible party was notified of the wander guard use.
2. Residents who utilize wander-guards were audited by the assistant director nursing or designee to ensure notification of use was completed. Audit revealed no concerns.
3. Nursing staff were educated on the importance of notifying responsible party of use of wander-guards.
4. Director of Nursing or designee will audit wander-guard notifications to responsible party once a week for four weeks. The results of the audit will be reviewed at the monthly quality assurance meeting.

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

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

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

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

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

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

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

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

Observations:
Based on review of facility policy, observations, and interview with staff, it was determined that the facility failed to implement an effective infection control program related personal protective equipment for one of 37 residents observed (Resident R2).

Findings Include:

Review of facility policy on personal protective equipment revealed that personal protective equipment appropriate to specific task requirements is available at all times. Further review of facility policy revealed employees required to perform tasks that may involve exposure to blood/body fluids will be provided appropriate protective clothing and equipment.

Review of Resident R2's clinical record revealed that Resident R2 was admitted to the facility on June 16, 2023, with diagnoses of, but not limited to, Anoxic Brain Damage (when the brain is deprived of oxygen) and Chronic Respiratory Failure with Hypoxia (the lungs cannot supply enough oxygen to the blood).

Observation conducted on June 5, 2026, at 9:52 a.m. revealed that an enhanced barrier precaution sign (infection control measures that expand the use of gowns and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms) was posted outside Resident R2's bedroom door with available personal protective equipment, including re-washable cloth gowns

Observation on June 5, 2025, at 9:53 a.m. revealed Resident R2 was in bed and had a tracheostomy (a surgically created hole in your trachea that allows for breathing).

Observation on June 5, 2026, at 9:58 a.m. revealed that yellow re-washable cloth gowns, and a plastic bag containing yellow cloth gowns were on top of the chair inside Resident R2's room.

Interview on June 5, 2026, at 9:58 a.m. with Licensed Nurse, Employee E9, confirmed that that yellow re-usable cloth gowns and a plastic bag containing yellow cloth gowns were on top of the chair inside Resident R2's room. Further, Licensed Nurse, Employee E9, confirmed the gowns should be used only once and then properly disposed of for laundering.

Licensed Nurse, Employee E9, subsequently placed the gowns in plastic bag, and took them out of the room to dispose of properly.

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

Plan of Correction - To be completed: 07/22/2026

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. The PPE on the chair in resident R2 room was removed.
2. All rooms were checked for proper disposal of used PPE and no concerns noted.
3. Nurse educator educated nurses on the importance of properly disposing of PPE. Infection control preventionist or designee will complete routine rounds to ensure PPE are disposed of appropriately.
4. Director of nursing or designee will audit resident rooms for proper disposing of PPE once a week for thirteen weeks. Results of the audit will be reviewed at the monthly quality assurance meeting.

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:

�483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

�483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

�483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Plan of Correction - To be completed: 07/22/2026

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident R105 and responsible- party were notified of the room change.
2. Room change notifications were audited by the social worker for the last month and no concerns were noted.
3. Social Services staff were educated on the importance of notifying residents or residents of room changes.
4. Director of nursing or designee will audit room changes once a week for notifications for four weeks. The results of the audit will be reviewed at the monthly quality assurance meeting.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

�483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in �483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in �483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in �483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

�483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in �483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under �483.15(c)(9).

Observations:
Based on review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide proper notification to the physician in a timely manner for one of 37 residents reviewed (Resident R26).

Findings Include:

Review of Resident R26's comprehensive Minimum Data Set (MDS federally mandated resident assessment and care screening) dated May 14, 2026, revealed the resident has severe cognitive impairment and diagnoses of anemia (lack of healthy red blood tissues), osteoarthritis (degenerative joint disease), and malnutrition (lack of sufficient nutrients in the body). Resident R26 was admitted to the facility on May 7, 2026.

Continued review of Resident R26's comprehensive MDS dated May 14, 2026, revealed the resident required partial/moderate assistance from staff for rolling left/right and sitting to lying.

Review of Resident R26's comprehensive care plan revealed the resident is on anticoagulant therapy and is at risk of bleeding and bruising.

During an interview on June 3, 2026, at 10:00 a.m. Resident R26 reported a bump to the top of his/her head because nurses were careless during care.

Review of Resident R26's clinical record revealed a nursing note dated May 31, 2026, at 7:45 a.m. that indicated Resident R26 complained of head pain. Per the nursing note, an assessment revealed a quarter size hematoma on the top of Resident R26's head. Resident R26 alleged he/she was dropped at home being carried up the steps by family.

Further review of Resident R26's clinical record revealed a nursing note dated May 31, 2026, at 11:30 a.m. that Resident R26's representative was seeking information about the hematoma and further alleged Resident R26 was manhandled.

Review of facility documentation revealed a facility incident report for Resident R26 "Bruise" dated May 31, 2026, that indicated while Resident R26 was being repositioned in bed, staff unintentionally hit his/her head on the headboard. The incident report indicated that the incident happened on May 31, 2026.

Review of "Employee Statement Via Telephone" dated May 31, 2026, by Nurse Aide, Employee E11, revealed with assistance from Registered Nurse, Employee E12, Resident R26 was repositioned in bed. When moving Resident R26, he/she hit the headboard by accident. The statement was not signed by the employee.

Review of "Employee Statement Via Telephone" dated May 31, 2026, by Registered Nurse, Employee E12, revealed when assisting Nurse Aide, Employee E11, to reposition Resident R26 in bed and pulling him/her up, the staff unintentionally hit Resident R26's head on the headboard. The statement was not signed by the employee.

Review of facility staffing punch reports revealed Registered Nurse, Employee E12, did not work on the date the alleged incident occurred (May 31, 2026).

Interview on June 5, 2026, at 10:30 a.m. with Director of Nursing, Employee E2, and Regional Staff, Employee E13, and E14, revealed based on a follow-up interview with Nurse Aide, Employee E11, and Registered Nurse, Employee E12, the incident happened on May 30, 2026, during the 3:00 p.m. to 11:00 p.m. shift.

Interview on June 5, 2026, at 10:30 a.m. with Director of Nursing, Employee E2, and Regional Staff, Employee E13, and E14, confirmed Nurse, Aide, Employee E11, and Registered Nurse, Employee E12, did not promptly notify the physician or document accidentally hitting Resident R26's head on the headboard. It was not until they were questioned after a hematoma was found in the morning of May 31, 2026, that staff reported hitting Resident R26's head on the headboard.

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

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

Plan of Correction - To be completed: 07/22/2026

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Unit Manager notified the doctor about Resident R26 incident, and no new orders given by the doctor.
2. Assistant Director of Nursing or Designee reviewed Incident reports for the month of May for doctor notification of injuries. No concerns noted for the review.
3. Nursing was educated on promptly notifying doctor when there is an accident resulting in an injury.
4. Director of nursing or designee will audit progress notes that the resident's doctor is being notified promptly of any injuries. The audit will be completed once a week for four weeks. The results of the audit will be reviewed at the monthly quality assurance meeting.

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

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

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

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

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

Observations:
Based on review of facility policy, review of clinical records, and staff and resident interviews it was determined that the facility failed to conduct a complete, accurate, and thorough investigation of alleged abuse and neglect for two of 37 residents reviewed (Resident R37 and R26).

Findings Include:

Review of facility policy "Abuse Prevention/Reporting" revised February 25, 2025, revealed the facility will investigate of all suspected cases of abuse. Further review of the facility policy revealed the facility will collect written documentation such as signed witness statements, statements of accused personnel, medical records, incident reports and other pertinent information.

Review of Resident R37's quarterly MDS (an assessment of resident needs) dated May 3, 2026, revealed the resident was severely cognitively impaired and diagnosed with obstructive uropathy (blockage in the urinary system). Review of the MDS revealed Resident R37 used a supra pubic catheter for urinating (a tube inserted through a small incision in the lower abdomen to drain urine directly from the bladder) and was incontinent of bowel needing staff assistance with toileting.

Review of Resident R37's care plan revealed a history of falls with interventions that included keeping the resident's bed in the lowest position (lowering the bed closer to the floor shortens the distance a person would fall, which lessens the severity of potential injuries).

Review of Resident R37's nursing progress note dated May 12, 2026, at approximately 4:00 a.m. revealed the resident was found on the floor next to his/her bed bleeding on the side of the head. The physician gave new orders to transfer Resident R37 to the hospital for further evaluation.

Review of facility documentation related to the incident, revealed a witness statement from Resident R37's nurse aide, Employee E15, revealed, "The patient was last taken care of at 2:30 a.m.", (does not state what type of care was provided) and was last seen at 3am.

Continued review of facility documentation revealed no documented evidence that the facility determined what was the positioning of the bed when Resident R37 was found on the floor an hour after care was provided.

Interview with the second-floor unit manager, Employee E6, on June 4, 2026, at 10:48 a.m. revealed Resident R37 sustained a 4-centimeter (cm) laceration to the head.

Interview with the Director of Nursing, Employee E2, on June 5, 2026, at 12:00 p.m. confirmed the facility failed to determine the position of Resident R37's bed after the fall.

Review of Resident R26's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 14, 2026, revealed the resident has severe cognitive impairment and diagnoses of anemia (lack of healthy red blood tissues), osteoarthritis (degenerative joint disease) , and malnutrition (lack of sufficient nutrients in the body). Resident R26 was admitted to the facility on May 7, 2026.

Continued review of Resident R26's comprehensive MDS dated May 14, 2026, revealed the resident required partial/moderate assistance from staff for rolling left/right and sitting to lying.
Review of Resident R26's comprehensive care plan revealed the resident is on anticoagulant therapy and is at risk of bleeding and bruising.

During an interview on June 3, 2026, at 10:00 a.m. Resident R26 reported a bump to the top of his/her head because nurses were careless during care.

Review of Resident R26's clinical record revealed a nursing note dated May 31, 2026, at 7:45 a.m. that indicated Resident R26 complained of head pain. Per the nursing note, an assessment revealed a quarter size hematoma on the top of Resident R26's head. Resident R26 alleged he/she was dropped at home being carried up the steps by family.

Further review of Resident R26's clinical record revealed a nursing note dated May 31, 2026, at 11:30 a.m. that Resident R26's representative was seeking information about the hematoma and further alleged Resident R26 was manhandled.

Review of facility documentation revealed a facility incident report for Resident R26 "Bruise" dated May 31, 2026, that indicated while Resident R26 was being repositioned in bed, staff unintentionally hit his/her head on the headboard. The incident report indicated that the incident happened on May 31, 2026.

Continued review of facility documentation revealed employee statements were obtained by alleged perpetrators Nurse Aide, Employee E11, and Registered Nurse, Employee E12. Employee statements were electronically typed and noted to be via telephone with interviews conducted by the Director of Nursing, Employee E2.

Review of "Employee Statement Via Telephone" dated May 31, 2026, by Nurse Aide, Employee E11, revealed with assistance from Registered Nurse, Employee E12, Resident R26 was repositioned in bed. When moving Resident R26, he/she hit the headboard by accident. The statement was not signed by the employee.

Review of "Employee Statement Via Telephone" dated May 31, 2026, by Registered Nurse, Employee E12, revealed when assisting Nurse Aide, Employee E11, to reposition Resident R26 in bed and pulling him/her up, the staff unintentionally hit Resident R26's head on the headboard. The statement was not signed by the employee.

Review of facility staffing punch reports revealed Registered Nurse, Employee E12, did not work on the date the alleged incident occurred (May 31, 2026).

Further review of facility documentation revealed no witness statements were obtained from Resident R26, or other staff and residents.

Interview on June 5, 2026, at 10:00 a.m. with the Director of Nursing, Employee E2, confirmed the timeline of alleged incident was unclear and further confirmed no statement from Resident R26, or other staff and residents was obtained.

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) Nursing services

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

Plan of Correction - To be completed: 07/22/2026

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Incidents for R26 and R37 were thoroughly investigated by the clinical team.
2. Assistant Director of Nursing or Designee reviewed Incident reports for the month of May for completion. No concerns noted for the review.
3. Adon or designee will review Incidents and Accidents report to ensure they are comprehensive during clinical review meetings
4. Director of nursing or designee will audit incidents reports to ensure they complete. The audit will be conducted once a week for thirteen weeks. The audit will be reviewed at the monthly quality assurance meeting.

483.25 REQUIREMENT Quality of Care:

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

Observations:
Based on review of clinical records, observation, interviews with resident and staff it was determined that the facility failed to provide quality of care in accordance with physician orders for two of 37 residents reviewed (Resident R287 and R78).

Findings Include:

Review of Resident R287's clinical record revealed the resident was admitted to the facility on May 21, 2026, and had diagnoses of malignant neoplasm of the tongue (tongue cancer) and protein-calorie malnutrition (inadequate intake of protein and calories, leading to loss of fat and muscle).

Continued review of Resident R287's clinical record revealed a physician order dated May 24, 2026, to use "Infuvite Adult Intravenous (IV) Solution (multiple vitamin)" at 80 milliliter/hour (ml/hr) intravenously one time per day.

Further review of Resident R287's clinical record revealed a physician order dated June 2, 2026, for "Sodium Chloride Intravenous Solution 0.9% (Sodium Chloride - used to maintain fluid and electrolyte balance)" administered at 75 ml/hr intravenously every shift for four days.

Observations on June 2, 2026, at 11:45 a.m. revealed Resident R287 was in bed with the IV Sodium Chloride Solution running at 75 ml/hr. Observations revealed the contents of the Sodium Chloride Solution were discolored bright yellow.

Interview on June 2, 2026, at approximately 12:00 p.m. with Licensed Nurse, Employee E8, confirmed Resident R287's Sodium Chloride Solution bag was not properly labeled and was mixed together with the Infuvite Adult Intravenous (IV) Solution.

Further interview on June 2, 2026, at approximately 12:00 p.m. Licensed Nurse, Employee E8, confirmed that the physician order for infuvite did not indicate to mix it with the sodium chloride solution, but that that it was a recommendation by the pharmacy instructions to add infuvite to sodium chloride.

Review of Resident R78's clinical records revealed the resident was alert and oriented, admitted to the facility on November 18, 2021, and has a diagnosis of Prurigo nodularis (is a chronic skin condition characterized by extremely itchy, firm nodules that often result from persistent scratching).

During an interview with Resident R78 on June 2, 2026, at 10:00 a.m. the resident stated, "I have been itchy, I told them (the nursing staff) weeks ago. It is getting worse it hurts sitting in my wheelchair". The resident continued to say when he/she has an incontinent episode in the adult brief, the urine burns his/her rash. Observations of Resident R78's torso appeared to have linear red marks from the resident scratching.

Review of Resident R78's clinical record revealed a physician progress note dated, May 1, 2026, that noted a rash around the resident's "diaper areas" and ordered zinc oxide ointment to be applied topically to the resident's area. The ointment was applied two times a day from May 1, 2026, until May 11, 2026.

During this time (May 1, 2026, through May 11, 2026) there was no documented evidence of an ongoing assessment of the resident's response to the treatment. Review of the resident's weekly skin checks did not note any new or current skin changes.

Continued review of Resident R78's clinical record revealed there were no new treatment changes after the zinc order was completed, until 7 days later when the physician saw the resident again on May 18, 2026.

Review of Resident R78's clinical record revealed a physician note dated May 18, 2026, which revealed "Earlier this month, he/she developed a diaper-area rash and was started on zinc oxide BID (twice per day). Today, Resident R78 states the rash feels like it is getting worse instead of better. I spoke with patient and sister at bedside and discussed starting clotrimazole TID (three times a day) and they agreed. Clotrimazole 1% ointment to groin and inner thighs TID x 14 days."

Review of Resident R78's medication administration record revealed the resident's Clotrimazole cream was ordered for seven days and not 14 days, as initially prescribed.

Further review of Resident R78's clinical record revealed a physician note dated May 27, 2026, that revealed Resident R78 was seen due to worsening pain and irritation in the diaper-area rash. Resident R78 reported increased discomfort and states the rash is not improving with zinc oxide and clotrimazole. Based on worsening symptoms, the physician transitioned treatment to nystatin cream QID (four times a day) and for wound care nurse to evaluate.

Further review of Resident R78's wound notes revealed the resident was not assessed for the skin rash until June 4, 2026.

Interview with the Director of Nursing, Employee E2, on June 5, 2026, at 11:00 a.m. confirmed the above.

28 Pa. Code 211.12 (d)(5)

Plan of Correction - To be completed: 07/22/2026

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident R287 and R78 physician's orders were reviewed with the provider.
2. Unit Managers or designee reviewed resident orders for residents in the facility as of 6/21/2026, and no concerns were identified.
3. Nurse educator educated nurses on the importance of following physician orders. Unit manager or designee will review residents MARS and TARS and routinely monitor provider orders to ensure nurses are following as ordered.
4. Director of nursing or designee will audit physician orders to check that they are being followed. The audit will be conducted once a week for thirteen weeks. The audit will be reviewed at the monthly quality assurance meeting.

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, review of clinical records, and staff interviews it was determined that the facility failed to obtain a physician order for tracheostomy size for one of one resident reviewed with tracheostomy (Resident R2).

Findings:

Review of facility policy "Tracheostomy Care" revealed tracheostomy tubes should be changed as needed or as ordered. Preparation and assessment include checking the physician order.

Review of Resident R2's Minimum Data Set (MDS federally mandated resident assessment and care screening) dated May 1, 2026, revealed the resident was severely cognitively impaired and had a diagnosis of respiratory failure (not enough oxygen passes from your lungs to your blood). Review of Resident R2's MDS revealed the resident receives tracheostomy care (a surgically created hole in your trachea that allows for breathing).

Review of Resident R2's care plan revised June 11, 2025, revealed the resident had altered respiratory status related, but not limited to, tracheostomy and pulmonary edema.

Observations on June 3, 2026, at 12:30 p.m. revealed Resident R2 has a tracheostomy.

Review of Resident R2's clinical record revealed a physician order dated December 12, 2025, to change the tracheostomy disposable inner cannula every day shift.

Review of Resident R2's clinical record revealed no physician order for size of tracheostomy to be used.

Interview on June 4, 2026, at 1:20 p.m. with Resident R2's assigned Licensed Nurse, Employee E10, revealed the employee was unable to find a physician order for tracheostomy size and was further unaware what tracheostomy size Resident R2 required.

Interview on June 4, 2026, at 1:25 p.m. with the 4th floor Unit Manager Licensed Nurse, Employee E7, confirmed there was no physician order for Resident R2's tracheostomy size.

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

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

Plan of Correction - To be completed: 07/22/2026

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident R2 had a physician order obtained for tracheostomy size.
2. All tracheostomy resident orders were checked that there was a physician order for tracheostomy size. No concerns noted.
3. Nurse educator educated nurses on the importance of obtaining a physician order for tracheostomy size. Respiratory therapist or designee will check tracheostomy resident rooms weekly to ensure they have appropriate respiratory equipment at bedside
4. Director of nursing or designee will audit tracheostomy resident physician orders for tracheostomy size once a week for thirteen weeks. The results of the audit will be reviewed at the monthly quality assurance meeting.

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

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

�483.45(h) Storage of Drugs and Biologicals

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

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

Observations:
Based on review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards for 1 of 37 residents observed (Resident R287).

Findings Include:

Review of Resident R287's clinical record revealed the resident was admitted to the facility on May 21, 2026, and had diagnoses of malignant neoplasm of the tongue (tongue cancer) and protein-calorie malnutrition (inadequate intake of protein and calories, leading to loss of fat and muscle).

Continued review of Resident R287's clinical record revealed a physician order dated May 24, 2026, to use "Infuvite Adult Intravenous (IV) Solution (multiple vitamin)" at 80 milliliter/hour (ml/hr) intravenously one time per day.

Further review of Reisdent R287's clinical record revealed a physician order dated June 2, 2026, for "Sodium Chloride Intravenous Solution 0.9% (Sodium Chloride)" administered at 75 ml/hr intravenously every shift for four days.

Observations on June 2, 2026, at 11:45 a.m. revealed Resident R287 was in bed with the IV Sodium Chloride Solution running at 75 ml/hr. Observations revealed the contents of the Sodium Chloride Solution was discolored bright yellow.

Further observations on June 2, 2026, at 11:45 a.m. revealed a label "Intravenous Solution Additives" affixed to Resident 287's IV Sodium Chloride Solution bag, but did not indicate the additive.

Interview on June 2, 2026, at approximately 12:00 p.m. with Licensed Nurse, Employee E8, confirmed Resident R287's Sodium Chloride Solution bag was not properly labeled with the additive. Licensed Nurse, Employee E8, reported that the Sodium Chloride Solution had been mixed together with the Infuvite Adult Intravenous (IV) Solution for administration.

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

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

Plan of Correction - To be completed: 07/22/2026

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident 287 IV bag was properly labeled.
2. Nursing staff reviewed all IV bags for proper labeling and no other concerns were noted.
3. Nurse educator educated nurses on the importance of properly labeling IV bags. Unit manager or designee will monitor IV bags to ensure they are properly labeled routinely.
4. Director of nursing or designee will audit IV bags that they are properly labeled. The audit will be conducted once a week for thirteen weeks. The results of the audit will be reviewed at the monthly quality assurance meeting.

483.71(a)(1)(3)(b)(1)(c)(1)-(5) REQUIREMENT Facility Assessment:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

�483.71 Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.

�483.71(a) The facility assessment must address or include the following:
�483.71(a)(1) The facility's resident population, including, but not limited to:
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population, using evidence-based, data-driven "methods" that considering the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments as required under � 483.20;
(iii) The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population;
(iv)The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

�483.71(a)(2) The facility's resources, including but not limited to the following:
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies;
(iv) All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

�483.71(a)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach as required in �483.73(a)(1).

� 483.71(b) In conducting the facility assessment, the facility must ensure:
� 483.71(b)(1) Active involvement of the following participants in the process:
(i) Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and
(ii) Direct care staff, including but not limited to, RNs, LPNs/LVNs, NAs, and representatives of the direct care staff, if applicable.
(iii) The facility must also solicit and consider input received from residents, resident representatives, and family members.

�483.71(c) The facility must use this facility assessment to:
�483.71(c)(1) Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in � 483.35(a)(3).

�483.71(c)(2) Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population.

�483.71(c)(3) Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population.

�483.71(c)(4) Develop and maintain a plan to maximize recruitment and retention of direct care staff.

�483.71(c)(5) Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care.

Observations:
Based on review of facility documentation and staff interview it was determined that the facility failed to include active input from residents, their representative(s), family members, and representatives of direct care staff in the facility assessment process.

Findings Include:

Review of facility documentation titled, "Facility Assessment" dated April 22, 2026, states the people involved in the process are the Administrator, Director of Nursing, Governing Body Rep, and the Medical Director.

Review of the facility assessment and the sign-in sheet for individuals involved in completing the annual review of the facility assessment on April 22, 2026, revealed no documented evidence that the facility included input from residents/resident representatives, or active involvement from direct care staff (including but not limited to Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Nurse Aides (NA), input from resident.

Interview on June 5, 2026, at 1:00 p.m. with Nursing Home Administrator, Employee E1, confirmed no documentation was available to support evidence of active involvement from direct care staff or input from residents.

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

Plan of Correction - To be completed: 07/22/2026

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. The facility assessment was updated to include input from residents and direct staff.
2. The regional nurse reviewed the most recent facility assessment for concerns. No other concerns were identified.
3. Regional nurse educated the Administrator on updating facility assessment with input from resident/resident representatives or active involvement from direct care staff. Administrator will review facility assessment monthly to ensure appropriate personal are providing input.
4. Director of nursing or designee will audit facility assessment for appropriate input. The audit will be completed once a week for thirteen weeks. The results of the audit will be reviewed at the monthly quality assurance meeting.

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