Pennsylvania Department of Health
 QUALITY LIFE SERVICES - APOLLO
Patient Care Inspection Results

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QUALITY LIFE SERVICES - APOLLO
Inspection Results For:

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QUALITY LIFE SERVICES - APOLLO - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance, and an Abbreviated survey in response to a complaint and two incidents completed on August 21, 2026, it was determined that Quality Life Services - Apollo was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.






 Plan of Correction:


483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for three of three of the facilities crash carts (a cart that contains supplies in the event of an emergency), (Buttercup Hall, Rehab Road, and Angel Wing) and one of one Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias), (Rehab Road).

Findings include:

Review of facility "Emergency Cart" policy dated 4/16/26, indicated an emergency cart will be appropriately stocked and ready for use when attempting to resuscitate a resident. The cart will be readily available for use and its inventory maintained.

Review of facility "AED" policy dated 4/16/26, indicated an AED will be available for use in emergency situations and its function maintained. Daily Maintenance includes checking the status indicator to ensure that it is green.

During an observation of the facilities crash cart, located on Buttercup Hall, on 8/20/26, at 12:25 p.m. revealed the following:

(1) bottle of Glucose Strips (used to check blood sugar) expired 8/1/26.(3) 20-gauge needles expired 11/30/25.Ambu bag (a handheld manual resuscitator used to provide positive pressure ventilation) was missing.Missing crash cart checklist signatures from 7/14/26,7/15/26, 7/16/26, 7/17/26, 7/18/26, 7/25/26, 7/26/26, 8/7/26, 8/8/26, 8/9/26, 8/15/26, and 8/16/26.

During an interview on 8/20/26, at 12:29 p.m. Licensed Practical Nurse (LPN) Employee E10 confirmed the above findings on Buttercup Hall's crash cart.

During an observation of the facilities crash cart, located on Rehab Road, on 8/20/26, at 12:30 p.m. revealed the following:

(2) 20-gauge needles expired 7/31/26.Missing crash cart checklist signatures from 7/7/26, 7/11/26, 7/12/26, 7/14/26, 7/18/26, 7/21/26, 7/24/26, 7/25/26, 7/26/26, 7/27/26, 7/28/26, 7/31/26, 8/8/26, 8/10/26, 8/11/26, 8/15/26, and 8/18/26.

During an observation of the facilities crash cart, located on Angel Wing, on 8/20/26, at 12:40 p.m. revealed the following:

Missing crash cart checklist signatures from 7/5/26, 7/12/26, 7/13/26, 7/19/26, 8/5/26, 8/6/26, and 8/10/26.

During a review of facility provided document labeled "Crash Cart Checklist" of the facilities AED (Rehab Road) on 8/20/26, at 12:35 p.m. revealed no monitoring of the facilities AED on the flowing dates:

7/7/26, 7/11/26, 7/12/26, 7/14/26, 7/18/26, 7/21/26, 7/24/26, 7/25/26, 7/26/26, 7/27/26, 7/28/26, 7/31/26, 8/8/26, 8/10/26, 8/11/26, 8/15/26, and 8/18/26.

During an interview on 8/20/26, at 12:50 p.m. LPN Employee E1 confirmed the above findings on Rehab Road and Angel Wing's crash cart and missing signatures for the facilities AED.

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











 Plan of Correction - To be completed: 10/05/2026

F0908 - The facility shall ensure essential equipment is maintained in a safe operating condition. The facility crash cart and AED shall be checked daily for the presence of all necessary equipment and the equipment or supplies are within a viable date.
Education will be provided to facility licensed nursing staff by the facility Director of Nursing, or designee, regarding the practice of daily crash cart checks and Automatic External Defibrillation machine check sheet daily.
Audits will be completed by the facility Director of , or designee, of all facility crash carts and of the facility AED machine and sign off sheet stocking/functional status three times weekly for four weeks. Results of the audits will be reviewed at the facility monthly Quality Assurance Performance Improvement Committee meeting for tracking and trending purposes.
483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to accommodate the call bell needs for six of six residents (Residents R4, R16, R80, R92, R111, and R117).

Findings include:

Review of facility policy "Call Lights - NU 2.2" last reviewed 4/16/26, indicated residents have a call light or alternative communication device within their reach at all times when unattended. Care partners will answer a call light as soon as possible.

Review of the admission record indicated Resident R4 admitted to the facility on 1/13/20.

Observation on 8/17/26, at 9:26 a.m. Resident R4 was in bed, and the call bell was noted to be on the floor out of the resident's reach.

Review of the admission record indicated Resident R16 admitted to the facility on 12/6/24.

Observation on 8/17/26, at 9:29 a.m. Resident R16 was in bed, and the call bell was noted to be on the bedside stand out of the resident's reach.

Review of the admission record indicated Resident R80 admitted to the facility on 7/3/25.

Observation on 8/17/26, at 9:35 a.m. Resident R80 was in bed, and the call bell was noted to be on the floor out of the resident's reach.

Review of the admission record indicated Resident R111 admitted to the facility on 3/11/26.

Observation on 8/17/26, at 9:38 a.m. Resident R111 was in bed, and the call bell was noted to be on the roommate's bedside table out of the resident's reach.

Review of the admission record indicated Resident R117 admitted to the facility on 7/28/26.

Observation on 8/17/26, at 9:340 a.m. Resident R80 was in bed, and the call bell was noted to be on the floor out of the resident's reach.

Observation and interview on 8/17/26, at 9:42 a.m. Registered Nurse (RN) Employee E8 confirmed the call bells were not in the resident's reach for residents R4, R16, R80, R111, and R117.

During call bell observations on 8/20/26, at 2:25 p.m. the following was observed:
-at 2:26 p.m. observation of call bell light on for Resident R92's room. Resident R92's door to his room was open and he was observed sitting on the commode.
-at 2:27 p.m. Resident R92 was interviewed and stated: "I put myself on the commode. I have been waiting 30 minutes for help."
-at 2:29 p.m. Certified Nurse aide (NA) Employee E17 was interviewed and stated: "I did not put him on the toilet. I am not his assigned nurse aide."

During an interview on 8/20/26, at 2:41 p.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to accommodate the call bell needs for Resident R92 as required.

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









 Plan of Correction - To be completed: 10/05/2026

F0558 – Residents shall have the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Facility is unable to correct identified issues. Resident 4, 16, 80, and 111 were assessed by the facility Social Worker for any trauma associated with the experience. Resident 92 no longer resides in the facility.
Facility nursing staff shall be educated by the facility Director of Nursing, or designee, on providing for reasonable accommodation of needs and preferences, specifically providing the residents access and accommodation for call bell use.
Audits of resident call bell accommodations shall be performed by the facility Director of Nursing, or designee, weekly for four weeks. Results shall be reported to the facility Quality Assurance and Performance Improvement Committee for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization: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 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 facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for three of six residents (Resident R3, R14, and R54).

Findings include:

Review of admission record indicated Resident R3 was admitted to the facility on 6/27/17.

Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/29/26, indicated the diagnoses of heart failure, anxiety, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID vaccine was coded a "0"- resident not up to date.

During a review of Resident R3's immunization record on 8/18/26, at 11:15 a.m. indicated the last COVID -19 vaccine was offered on 11/1/22. The facility failed to include documented evidence that an updated COVID-19 vaccine was offered or refused and that education was provided to Resident R3.

Review of admission record indicated Resident R14 was admitted to the facility on 8/28/25.

Review of Resident R14's MDS dated 6/12/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Resident R14's MDS assessment section C0200 Brief Interview for Mental Status ("BIMS", a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R14's BIMS score was a "9" indicating Resident R14 was moderately impaired. MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID vaccine was coded a "0"- resident not up to date.

During a review of Resident R14's immunization record on 8/18/26, at 11:21 a.m. indicated that on 8/25/25, a covid consent was obtained by Resident R14. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated covid vaccine for Resident R14.

Review of the clinical record indicated Resident R54 was admitted to the facility on 12/27/25.

Review of Resident R54's MDS dated 8/7/26, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes. Resident R54's BIMS score was a "11" indicating Resident R54 was moderately impaired. MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID vaccine was coded a "0"- resident not up to date.

During a review of Resident R54's immunization record on 8/18/26, at 11:30 a.m. indicated that an undated covid consent was refused by Resident R54. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated covid vaccine for Resident R54.

During an interview on 8/18/26, at 1:14 p.m. Infection Preventionist Employee E3 confirmed that the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine three of six residents (Resident R3, R14, and R54).

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














 Plan of Correction - To be completed: 10/05/2026

F0887 – The facility will develop and implement policies related to COVID-19 immunizations. All residents will be offered a COVID booster this flu season. The last fifteen admissions will be audited by the facility Director of Nursing, or designee, to determine if a COVID vaccine was offered and given per consent. The audit will also include if the resident was cognitively able to give consent for the vaccine or if the responsible needs to be contacted for this consent.
Education will be given to nursing staff by the facility Director of Nursing, or designee, on the importance of ensuring residents are not cognitively impaired when asked to review/sign immunization consents.
All new admissions over the next thirty days will be audited by the facility Director of Nursing, or designee, to ensure COVID consent was reviewed with the resident or responsible party and given as indicated. Audits will be reviewed at the facility monthly Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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(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 facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Pneumonia vaccine for two of six residents (Resident R14 and R54), and failed to provide accurate and timely documentation related to the Influenza vaccine for three of six residents (Resident R3, R14, and R54).

Findings include:

Review of facility policy "Standing Orders for Administering Pneumococcal Vaccine to Adults" dated 4/16/26, indicated the purpose is to reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria.

Review of facility policy "Immunizations: Influenza vaccination of residents, staff, and volunteers" dated 4/16/26, indicated all residents, staff, and volunteers of our facility should receive the influenza vaccine annually, unless there is a documented contraindication.

Review of admission record indicated Resident R14 was admitted to the facility on 8/28/25.

Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/12/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Resident R14's MDS assessment section C0200 Brief Interview for Mental Status ("BIMS", a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R14's BIMS score was a "9" indicating Resident R14 was moderately impaired.

During a review of Resident R14's immunization record on 8/18/26, at 10:11 a.m. indicated that on 8/25/25, a pneumococcal consent was obtained by Resident R14. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated pneumococcal vaccine for Resident R14.

Review of the clinical record indicated Resident R54 was admitted to the facility on 12/27/25.

Review of Resident R54's MDS dated 8/7/26, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes. Resident R54's BIMS score was a "11" indicating Resident R54 was moderately impaired.

During a review of Resident R54's immunization record on 8/18/26, at 10:20 a.m. indicated that on 12/17/25, the pneumococcal consent was refused by Resident R54. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated pneumococcal vaccine for Resident R54.

During an interview on 8/18/26, at 1:14 p.m. Infection Preventionist (IP) Employee E3 confirmed that the facility failed to receive proper consents, failed to notify resident representatives, and failed to offer education for Resident R14 and R54's pneumococcal vaccinations.

Review of admission record indicated Resident R3 was admitted to the facility on 6/27/17.

Review of Resident R3's MDS dated 7/29/26, indicated the diagnoses of heart failure, anxiety, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness).

During a review of Resident R3's immunization record on 8/18/26, at 11:00 a.m. revealed that Resident R3's last Influenza refusal was from 11/1/22. No documented evidence that Resident R3's responsible party was given the choice of the last Influenza season vaccine and no evidence that education was provided.

Review of admission record indicated Resident R14 was admitted to the facility on 8/28/25.

Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/12/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Resident R14's MDS assessment section C0200 Brief Interview for Mental Status ("BIMS", a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R14's BIMS score was a "9" indicating Resident R14 was moderately impaired.

During a review of Resident R14's immunization record on 8/18/26, at 10:11 a.m. indicated that on 8/25/25, an influenza consent was obtained by Resident R14. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated influenza vaccine for Resident R14.

Review of the clinical record indicated Resident R54 was admitted to the facility on 12/27/25.

Review of Resident R54's MDS dated 8/7/26, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes. Resident R54's BIMS score was a "11" indicating Resident R54 was moderately impaired.

During a review of Resident R54's immunization record on 8/18/26, at 10:20 a.m. indicated that on 12/17/25, an influenza consent was refused by Resident R54. No documented evidence that the facility notified the responsible party due to low BIMS score to receive consent and no education was provided. The facility failed to receive proper consent and the resident failed to have an updated influenza vaccine for Resident R54.

During an interview on 8/18/26, at 1:05 p.m. the IP Employee E3 confirmed that the facility failed to obtain an updated influenza consent and provide education for Resident R3, R14, and R54's responsible party and that the facility failed to provide accurate and timely documentation related to the Pneumonia vaccine for two of six residents (Resident R14 and R54), and failed to provide accurate and timely documentation related to the Influenza vaccine for three of six residents (Resident R3, R14 and R54).

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













 Plan of Correction - To be completed: 10/05/2026

F0883 - The facility will ensure all residents are provided the option of vaccinations at admission. If vaccinations are declined it will be documented in the resident's clinical record by the facility Infection Preventionist (IP) Nurse, or designee.
Education regarding vaccination consents, BIMS scoring, and vaccination documentation will be provided to the facility Infection Preventionist (IP) Nurse by the facility Director of Nursing.
Audit will be completed by the facility Director of Nursing, or designee, weekly for four weeks, checking the status of vaccinations and consents for each respective admission. Audit results will be reviewed at the facility monthly Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow Isolation Precaution protocol to prevent the spread of infections for four of five residents (Resident R9, R15, R56 and R101), and failed to conduct testing for residents displaying respiratory symptoms during an outbreak for three of eight residents (Resident R9, R31, and R54).

Findings include:

Review of the facility policy "Droplet Precautions" last reviewed 4/16/26, indicated droplet precautions should be used in addition to standard precautions for residents with infections that can be transmitted by droplets. Droplets may be generated by the resident's coughing, sneezing, talking, or during the performance of procedures such as suctioning.

-The resident is placed in a private room or placed in a room with a resident who has active infection with the same organism but no other infection.

Review of facility "Contact Precautions" policy dated 4/16/26, indicated that it is the intent of this facility to use contact precautions for residents known or suspected to have serious illness easily transmitted by direct contact or by contact with items in the residents environment. Gowns and gloves should be worn prior to entering the room.

Review of facility "Infection Prevention Manual" dated 4/16/26, indicated the goals of the infection prevention program are to decrease the risk of infection to residents and personnel, monitor infections and implement appropriate control measures, and identify problems relating to infection prevention practices.

Review of Pennsylvania Department of Health "Respiratory Virus Outbreak Toolkit" dated 9/25/25, indicated a testing plan to ensure access to rapid-result respiratory viral testing. Prompt testing results can guide appropriate treatment and infection prevention and control measures. Test anyone showing signs or symptoms of a respiratory illness. At a minimum, tests should include Covid-19 and influenza viruses.

Review of the clinical record indicated Resident R9 was admitted to the facility on 7/27/18.

Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/29/26, indicated diagnoses of depression, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and multidrug resistant organism (MDRO- bacteria that does not respond well to antibiotics).

During a lunch observation on 8/17/26, at 12:10 p.m. Resident R9 was sitting on the side of his bed in the room. Resident had a contact precaution sign hanging on the wall beside the door. Personal Protective Equipment (PPE) was hanging on the door that included, gowns, gloves, masks, and sanitizer.

During an observation on 8/17/26, at 12:25 p.m. Nurse Aide (NA) Employee E13 and NA Employee E14 were observed in Resident R9's room and failed to utilize PPE as required to enter the room.

During an interview on 8/17/26, at 12:27 p.m. NA Employee E13 stated, "We are supposed to be protected and wear gowns and gloves. We are to put it on before you enter the room," and confirmed that no PPE was worn while in Resident R9's room.

During an interview on 8/17/26, at 12:28 p.m. NA Employee E14 stated, "You gotta put all the stuff on. Gown and gloves," and confirmed that no PPE was worn while in Resident R9's room.

During an interview on 8/17/26, at 12:30 p.m. Licensed Practical Nurse Employee E1 stated, "You need to have all the PPE on. Gowns, gloves, mask if needed and you put it on prior to going into the room. If you don't, you could contract the organism that they are carrying and get sick."

During a review of Resident R9's physician orders dated 8/17/26, indicated contact precautions for MRSA (methicillin-resistant Staphylococcus aureus- a type of infection that is resistive to some antibiotics and make it harder to treat) of the wound.

Review of the clinical record indicated Resident R15 was admitted to the facility on 8/23/24.

Review of Resident R15's MDS dated 7/8/26, indicated diagnoses of muscles weakness, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and cancer (a large group of diseases where abnormal cells divide without control).

During a review of Resident R15's physician orders dated 8/10/26, indicated contact isolation for VRE (vancomycin-resistant enterococci- a type of bacteria that can be hard to treat) and MRSA.

During an observation on 8/17/26, at 10:30 a.m. contact isolation signage failed to be displayed on Resident R15's door to notify staff and visitors of the proper PPE to wear.

During an interview on 8/17/26, at 10:33 a.m. Infection Preventionist (IP) Employee E3 confirmed that Resident R15 should have had a contact isolation signage on the door and that the facility failed to prevent cross contamination of possible infections for Resident R9 and R15.

Review of the admission record indicated Resident R56 admitted to the facility on 5/16/26.

Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs dated 8/3/26, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident R56's physician order dated 7/30/26, indicated droplet precautions related to pneumonia.

Review of Resident R56's care plan dated 7/30/26, indicated a mask with a face shield should be worn by my caregiver during procedures with a risk of splashes or droplet contamination of my bodily fluids.

Observation on 8/17/26, at 10:00 a.m. Resident R56's doorway failed to have a sign posted for droplet precautions.

Interview on 8/17/26, at 10:05 a.m. Registered Nurse (RN) Employee E8 confirmed there was not a sign posted on Resident R56's door for droplet precautions as ordered.

Review of the admission record indicated Resident R101 admitted to the facility on 3/12/26.

Review of Resident R101's MDS dated 5/24/26, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and diabetes.

Review of Resident R101's physician order dated 8/7/26, indicated droplet precautions for respiratory infection.

Review of Resident R101's care plan dated 8/14/26, indicated a mask with a face shield should be worn by my caregiver during procedures with a risk of splashes or droplet contamination of my bodily fluids.

Observation on 8/17/26, at 9:56 a.m. Resident R101's door had a sign for droplet precautions. It indicated everyone must make sure their eyes, nose, mouth are fully covered before room entry. Remove face protection before room exit.

Observation on 8/17/26, at 9:58 a.m. Nurse Aide (NA) Employee E11 was departing from Resident R101's room. NA Employee E11 had a gown, gloves, and mask in place, but failed to have eye protection as ordered.

Interview on 8/17/26, at 10:05 a.m. RN Employee E8 confirmed NA Employee E11 should have had a face shield or goggles on as required with droplet precautions.

Upon entering the facility on 8/17/26, at 9:00 a.m. signage was posted on front door alerting visitors of a respiratory outbreak at the facility.

During an interview on 8/17/26, at 9:33 a.m. IP Employee E3 confirmed that the facility was experiencing a respiratory outbreak and that a surveillance and tracking of the outbreak was being completed.

Review of the clinical record indicated Resident R9 was admitted to the facility on 7/27/18.

Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/29/26, indicated diagnoses of depression, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and multidrug resistant organism (MDRO- bacteria that does not respond well to antibiotics).

Review of Resident R9's progress note dated 7/9/26, at 4:45 p.m. indicated that resident stated, "beginning to feel sick" with upper respiratory symptoms. Rhinitis (stuffy nose, runny nose, sneezing, or postnasal drip), malaise (tired), non-productive cough, dry scratchy sinuses.

Review of Resident R9's clinical record failed to indicate that any testing for Covid, Flu A or Flu B were completed by the facility.

During an interview on 8/21/26, at 11:01 a.m. IP Employee E3 stated, "No rapid testing done because he has chronic coughing. We were thinking about aspiration pneumonia (a respiratory infection).

Review of the clinical record indicated Resident R31 was admitted to the facility on 6/26/26.

Review of Resident R31's MDS dated 7/2/26, indicated diagnoses of high blood pressure, Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness).

Review of Resident R31's progress noted dated 8/10/26, at 12:50 p.m. indicated that during medication pass resident observed not acting her normal self. Resident stated she didn't feel well and did not want to eat. Resident also had a productive cough. Resident placed on oxygen.

Review of Resident R31's clinical record failed to indicate that any testing for Covid, Flu A or Flu B were completed by the facility.

During an interview on 8/21/26, at 11:04 a.m. IP Employee E3 stated, "No rapid testing was done. We sent the chest xray to the physician and got no new orders. He didn't like using antibiotics."

Review of the clinical record indicated Resident R54 was admitted to the facility on 12/27/25.

Review of Resident R54's MDS dated 8/7/26, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of Resident R54's progress noted dated 7/9/26, at 7:30 a.m. indicated that resident presenting with dyspnea (difficult breathing) and a non-productive wet cough. Very loud rhonci (snoring like breathing sounds). Tired with confusion.

Review of Resident R54's clinical record failed to indicate that any testing for Covid, Flu A or Flu B were completed by the facility.

During an observation on 8/21/26, at 10:01 a.m. rapid Covid, Flu A and Flu B tests were available in the Infection Preventionist Employee E3's office.

During an interview on 8/21/26, at 11:07 a.m. IP Employee stated, "He was showing respiratory symptoms. He is a smoker with a chronic cough. We believed it to be from smoking. No rapid test was completed."

During an interview on 8/21/26, at 11:11 a.m. IP Employee E3 stated that the above rapid tests were available and that the facility failed to test Resident R9, R31, and R54 with respiratory symptoms during an outbreak.

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10 (d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.






 Plan of Correction - To be completed: 10/05/2026

F0880 – The facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment. The facility is unable to correct the deficient practice as time has elapsed. An inhouse audit of any current resident with respiratory signs and symptoms will be completed by the Director of Nursing, or designee, to determine if respiratory testing has been completed. An inhouse audit of all infections requiring droplet precaution will be completed by the director of nursing/designee to ensure each isolation station has protective eye wear available for use when entering the room.
Education will be completed by the facility Director of Nursing, or designee, on droplet precautions to include the use of a face shield or googles for eye protection. Education to be provided to the nursing staff on the importance of respiratory testing when a resident presents with respiratory symptoms.
Five staff observations will be completed by the facility Director of Nursing, or designee, weekly for four weeks of staff entering an isolation room to ensure they are using the correct protective gear.
Each resident with symptoms of respiratory illness will be audited for thirty days by the facility Director of Nursing, or designee, to ensure respiratory testing has been completed.
Audits will be reviewed at the facility monthly Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for four of five residents (Residents R4, R101, R135, and R152).

Findings include:

Review of the facility policy "Medication Regimen Review" last reviewed 4/16/26, indicated the consultant pharmacist performs a comprehensive review of each resident's medication regimen (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medication director and/or the administrator. Recommendations are acted upon and documented by the facility staff or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.

Review of the clinical record indicated Resident R4 was admitted to the facility on 1/13/20.

Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/26, indicated diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infraction (a stroke) affecting left non-dominant side, and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life).

Review of Resident R4's MRR dated 7/24/26, indicated diagnosis needed to support therapy for lorazepam (anxiety medication). The form was signed and dated 8/8/26, by Licensed Practical Nurse (LPN) Employee E1, not the attending physician as required.

Review of the clinical record indicated Resident R101 was admitted to the facility on 3/12/26.

Review of Resident R101's MDS dated 5/24/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident R101's MRR dated 3/23/26, indicated possible duplication of therapy for Tylenol as needed for pain orders. The form was signed and dated 4/23/26, by LPN Employee E1, not the attending physician as required.

Review of the clinical record indicated Resident R135 admitted to the facility on 5/6/26.

Review of Resident R135's MDS dated 8/12/26, indicated the diagnoses of heart failure, diabetes, and high blood pressure.

Review of Resident R135's MRR dated 5/15/26, indicated admission MRR, "Special instructions" how resident takes medication. The form had not been addressed upon review on 8/19/26.

Review of the clinical record indicated Resident R152 admitted to the facility on 5/28/26.

Review of Resident R152's MDS dated 6/4/26, indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), anxiety, and depression.

Review of resident R152's MRR dated 6/23/26, indicated diagnosis needed to support therapy for trazadone (antidepressant medication). The form was signed and dated 8/5/26, by Licensed Practical Nurse (LPN) Employee E1, not the attending physician as required.

Interview on 8/19/26, at 2:21 p.m. the Director of Nursing confirmed that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for four of five residents (Residents R4, R101, R135, and R152).

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







 Plan of Correction - To be completed: 10/05/2026

F0756 – The drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist. The facility is unable to correct the deficient practice related to Resident 101, Resident 135, Resident 152, as time has elapsed. The month of August pharmacy recommendations will be reviewed by the facility Director of Nursing, or designee, to ensure they have been addressed, as well as signed by the attending physician.
Education will be provided by the facility Director of Nursing to the facility Unit Coordinators on the importance of addressing each recommendation in a timely manner as well as having the attending physician sign each recommendation.
The facility Director of Nursing, or designee, will audit each month's pharmacy recommendations to ensure they are addressed as well as signed by the attending physician for the next three months.
Audits will be reviewed at the facility monthly Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
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 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.
§483.15(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 facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers (Residents R14, R15, and Closed Resident Record CR156), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of five resident hospital transfers (Resident R14, R15, and Closed Resident Record CR156).

Findings include:

Review of facility policy "Transfer of Resident to Another Care Community" dated 4/16/26, indicated the purpose is to promote continuity of care during transfer. Determine specific information requirements and prepare documents needed for transfer.

Review of admission record indicated Resident R14 was admitted to the facility on 8/28/25.

Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/12/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).

Review of the clinical record indicated Resident R14 was transferred to the hospital on 3/5/26, and returned to the facility on 3/11/26.

Review of Resident R14's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

During an interview on 8/19/26, at 11:15 a.m. Social Worker Employee E4 stated that hospital transfers were not included on the Ombudsman list and confirmed that there was no evidence that the State Ombudsman office was notified for Resident R14's transfer to the hospital.

Review of the clinical record indicated Resident R15 was admitted to the facility on 8/23/24.

Review of Resident R15's MDS dated 6/12/26, indicated diagnoses of muscles weakness, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and cancer (a large group of diseases where abnormal cells divide without control).

Review of the clinical record indicated Resident R15 was transferred to the hospital on the following dates:
2/12/26, and returned to the facility on 2/16/26.4/4/26, and returned to the facility on 4/17/26.6/4/26, and returned to the facility on 6/15/26.6/22/26, and returned to the facility on 6/23/26.

Review of Resident R15's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

During an interview on 8/19/26, at 11:18 a.m. Social Worker Employee E4 stated that hospital transfers were not included on the Ombudsman list and confirmed that there was no evidence that the State Ombudsman office was notified for Resident R15's transfer to the hospital.

Review of the clinical record indicated Closed Resident Record CR156 was admitted to the facility on 5/9/26.

Review of Closed Resident Record CR156's MDS dated 7/19/26, indicated diagnoses of high blood pressure, difficulty walking, and need for assistance with personal care.

Review of the clinical record indicated Closed Resident Record CR156 was transferred to the hospital on 7/22/26, and did not return to the facility.

Review of Closed Resident Record CR156's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of Closed Resident Record CR156's clinical record failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 7/22/26.

During an interview on 8/19/26, at 11:18 a.m. Social Worker Employee E4 confirmed there was no evidence that the State Ombudsman office was notified of Closed Resident Record CR156's transfer to the hospital on 7/22/26.

During an interview on 8/20/26, at 10:29 a.m. Assistant Director of Nursing (ADON) Employee E9 confirmed the facility failed to make certain that necessary resident information was communicated to the receiving health care provider for Closed Resident Record CR156.

During an interview on 8/19/26, at 2:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers (Residents R14, R15, and R156), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of five resident hospital transfers (Resident R14, R15, and R156).

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: 10/05/2026

F0628 – The facility shall ensure a resident's discharge or transfer is documented in the resident's medical record and appropriate information is communicated to the receiving healthcare institution or provider. An audit of all in-house residents will be completed by the facility Director of Nursing, or designee, over residents discharged to the hospital to ensure appropriate discharge paperwork was documented as sent with the discharging resident. The facility Social Worker shall notify the Ombudsman office of the hospital transfers of R14, R15, and R156.
Education will be provided to licensed nurses by the facility Director of Nursing, or designee, on documentation requirements and required documents that must be sent with each resident upon discharge or transfer to the hospital. Education will be provided to the facility Social Worker by the Administrator, or designee, on providing monthly written notification to the state Ombudsman office of all resident transferred to healthcare institutions or providers in addition to the residents discharged.
Audits will be completed by the facility Director of Nursing, or designee, on all discharges to the hospital for the next 30 days to ensure appropriate documents have been sent and the discharge was documented accordingly. Audits of the written notification to the state Ombudsman office will be performed by the facility Administrator monthly for three months. Results of audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes. The facility Director of Nursing and Administrator shall ensure compliance.
483.10(e)(1),483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical . . . restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free from physical . . . restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on review of facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to assess the functional status of the individual resident to determine if the use of a scoop mattress (a specialized medical bed designed with a concave surface and raised or sloped perimeter edges) is a restraint for two of two residents (Residents R4 and R94) and failed to determine if a bed against the wall is a restraint for one of two residents (Resident R125).

Findings include:

Review of facility policy "Physical Restraint Policy and Procedure" last reviewed 4/16/26, indicated physical restraints are defined as any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.

Review of the clinical record indicated Resident R4 was admitted to the facility on 1/13/20.

Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/26, indicated diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infraction (a stroke) affecting left non-dominant side, and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life).

During an observation on 8/19/26, at 9:20 a.m. Resident R4 was observed lying in bed and the mattress had bilateral (on both sides) raised perimeter.

Review of Resident R4's physician order dated 5/1/26, indicated Safety Device: Scoop mattress for safety every shift for prevention.

Review of Resident R4's current care plan indicated scoop mattress for safety.

Further review of Resident R4's clinical record failed to identify any assessment or ongoing evaluations for the usage of a scoop mattress on the resident's bed.

Review of the clinical record indicated Resident R94 was admitted to the facility on 4/13/22.

Review of Resident R94's MDS dated 6/29/26, indicated diagnoses of malnutrition (lack of sufficient nutrients in the body), depression, and need for assistance with personal care.

During an observation on 8/17/26, at 10:34 a.m. Resident R94 was observed lying in bed and the mattress had bilateral raised edges on the top and bottom portions.

During an interview on 8/19/26, at 12:52 p.m. Licensed Practical Nurse (LPN) Employee E1 stated, "Resident R94 has a scoop mattress. There should be an order and a care plan for the scoop mattress."

Review of Resident R94's clinical record failed to include a physician order for a scoop mattress or a plan of care related to the use of a scoop mattress. Further review of Resident R94's clinical record failed to identify any assessments or ongoing evaluations for the usage of a scoop mattress.

During an interview on 8/20/26, at 10:29 a.m. Assistant Director of Nursing (ADON) Employee E9 confirmed the facility failed to obtain a physician order, develop a person-centered plan of care, and assess the functional status of the individual resident to determine if the use of scoop mattress is a restraint for Resident R94.


Review of the clinical record indicated Resident R125 was admitted to the facility on 3/5/26.

Review of Resident R125's MDS dated 5/13/26, indicated diagnoses of Parkinson's Disease (disorder of the nervous system that results in tremors), chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), repeat falls.

During an observation on 8/19/26, at 12:15 p.m. Resident R125 was observed in bed. The bed's right side was against the wall.

Review of Resident R125's current physician orders failed to include an order for bed against the wall.

Review of Resident R125's current care plan failed to include a plan for bed against the wall.

Further review of Resident R125's clinical record failed to identify any assessment or ongoing evaluations for the usage of bed against the wall.

During an interview on 8/21/26, at 11:43 a.m. Assistant Director of Nursing (ADON) Employee E9 confirmed the facility failed to assess the functional status of the individual resident to determine if the use of a scoop mattress is a restraint for one of two residents (Residents R4) and failed to determine if a bed against the wall is a restraint for one of two residents (Resident R125).

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







 Plan of Correction - To be completed: 10/05/2026

F0604 – Resident Resident 4 and Resident 94's functional status will be reassessed, physicians notified, care plan developed and residents will be provided the appropriate bed mattress. Resident 125's bed was moved from the wall immediately. All other resident beds were reviewed for proper placement and not against wall if not physician ordered and assessed to be against wall. All residents will be reviewed by the facility Director of Nursing, or designee, for proper physician orders, care plan and assessment of proper mattress use.
The facility nursing staff shall be educated by the facility Director of Nursing, or designee, of the proper assessment, physician order, care plan in place for scoop mattress use. The facility staff shall be educated by the Administrator, or designee, on being aware of the risk of a possible restraint if the resident's bed is against the wall and the need for an assessment, physician order for the bed to be against the wall.
The facility Director of Nursing, or designee, shall audit resident for proper mattress use and bed placement weekly for four weeks. Results of the audits shall be reported to the facility Quality Assurance and Performance Improvement Committee for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on observation and staff interview it was determined that the facility failed to provide a dignified dining experience for two of eight residents (Resident R47 and R77).

Findings include:

Review of facility "Dining and Meal Service" policy date 4/16/26, indicated the dining experience will be person centered with the purpose of enhancing each individual resident's dining quality of life and being supportive of each individual's needs during dining.

Review of the face sheet indicated Resident R47 admitted to the facility on 6/11/25.

Review of Resident R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/26, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and depression.

Observation on 8/17/26, at 12:13 p.m. Resident R47 was in her wheelchair in the resident's room. Feeding Assistant Employee E18 was standing over her and the bedside table feeding the resident her lunch. No chair was present in the room.

Interview with Registered Nurse (RN) Employee E8 on 8/17/26, at 12:15 p.m. confirmed Feeding Assistant Employee E18 was not in a seated position while feeding Resident R47 the lunch meal and failed to provide a dignified dining experience.

Review of the clinical record indicated Resident R77 was admitted to the facility on 6/16/26.

Review of Resident R77's MDS dated 7/4/26, indicated diagnoses of high blood pressure, malnutrition (lack of sufficient nutrients in the body), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section GG Functional Abilities GG0130 Eating is coded "2", indicating that resident is substantial/maximal assistance - helper does more than half the effort.

During a lunch observation on 8/20/26, at 12:12 p.m. Resident R77 was lying in bed without a lunch tray. Resident R77's roommate was sitting at the edge of the bed, facing Resident R77, eating lunch.

During an interview on 8/20/26, at 12:15 p.m. Licensed Practical Nurse Employee E10 stated, "All the Nurse Aides are feeding other residents right now and confirmed that all qualified staff should be assisting to feed residents at lunch time." LPN Employee confirmed that Resident R77 was not being assisted in eating lunch and that the facility failed to provide a dignified dining experience for Resident R77.

28 Pa. Code 211.10(a)(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.







 Plan of Correction - To be completed: 10/05/2026

F0550 – Residents shall have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Employee E18 was immediately educated by the facility Director of Nursing on providing a dignified meal experience and refraining from standing over a resident while assisting with dining. Employee 18 shall not assist with dining until re-educated and approved by the facility Director of Nursing. Resident R47 was assessed by the facility Social Worker for any trauma associated with the experience. Resident R77 was assessed by the facility Social Worker for any trauma associated with the experience.
Facility nursing staff and designated feeding assistants shall be educated by the facility Director of Nursing, or designee, on providing a dignified dining experience, specifically refraining from standing over a resident while assisting with dining and providing meals to all residents in a room or table at one time.
Audits of resident dining experience shall be completed by the facility Director of Nursing, or designee, weekly for four weeks. Results shall be reported to the facility Quality Assurance and Performance Improvement Committee for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.

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

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

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

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

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

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

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

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

Based on observations, resident and staff interview, it was determined that the facility failed to maintain a safe, clean, homelike environment in one of three nursing units (Angel Wing).

Findings include:

Interview on 8/18/26, at 10:00 a.m. the Director of Nursing indicated the facility did not have a policy specific to safe, clean, and homelike.

Review of the admission record indicated Resident R133 admitted to the facility on 4/13/26.

Observation on 8/17/26, at 9:30 a.m. the ceiling of the hallway room 123 is on, had brownish/orange water dripping into three water basins placed on the floor below the leak.

Interview on 8/17/26, at 9:33 a.m. Resident R133 indicated she was afraid to come out of her room because the ceiling might fall on her.

Observation and interview on 8/17/26, at 9:38 a.m. Maintenance Employee E19 indicated the leak was reported late the night before and it was going to be taken care of.

Observation on 8/18/26, at 11:00 a.m. the ceiling of the hallway room 123 is on, had white plaster like debris on the floor under the previous leak area and shards of plaster approximately eight inches long hanging from the ceiling.

Observation and interview on 8/18/26, at 11:05 a.m. Maintenance Employee E19 confirmed the ceiling had pieces of plaster-like substance falling from the previous leak area and shards of plaster approximately eight inches long hanging from the ceiling.

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






 Plan of Correction - To be completed: 10/05/2026

F0584 – The residents shall have the right to a safe, clean, comfortable and homelike environment. The leaking air conditioner condenser was repaired on 8/17/2026 by facility Maintenance staff. The ceiling was repaired 8/18/2026 by facility Maintenance staff. A review of the facility for any other visible hazards was performed by the facility Administrator on 8/18/2026. None were identified.
Facility staff shall be educated by the facility Administrator, or designee, on identifying hazards, response and communication of the hazard to your supervisor. Audits of the facility for visible hazards shall be performed weekly for four weeks by the facility Administrator, or designee. Results shall be reported to the facility Quality Assurance and Performance Improvement Committee for tracking and trending purposes. The facility Administrator shall ensure compliance.
483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.
Observations:

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for one of five residents (Residents R4).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing MDS assessments, dated October 2025, indicated the following instructions:

H0100 Bladder and Bowel appliances: check all that apply. The definition of an external catheter is a female external catheter, or other non-invasive urine output management device or system that routes urine to a drainage bag.

Review of the clinical record indicated Resident R4 was admitted to the facility on 1/13/20.

Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/26, indicated diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infraction (a stroke) affecting left non-dominant side, and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section H0100 failed to indicate an external catheter was used.

Review of the Resident R4's current physician order indicated place Pure wick (a brand of external catheters) use every shift for incontinence and replace every 12 hours. Maintain proper placement every shift.

Review of Resident R4's current care plan indicated ensure Pure wick is replaced every 12 hours. Replace anytime Pure wick is dislodged.

Review of Resident R4's Treatment administration record dated June 2026, indicated the Pure wick was utilized daily as ordered.

Interview on 8/21/26, at 10:02 a.m. Assistant Director of Nursing (ADON) Employee E9 confirmed the external catheter was not indicated on the MDS dated 6/26/26, and the facility failed to ensure MDS accurately reflected the resident's status for one of five residents (Residents R4).

28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.






 Plan of Correction - To be completed: 10/05/2026

F0641 – The facility Assessment Nurse shall ensure that the resident assessment accurately reflects the resident's status. R4's Minimum Data Set (MDS) will be updated by the facility Assessment Nurse, or designee, to accurately reflect the resident's use of external catheter, Pure Wick system. The facility Assessment Nurse, or designee, shall review all similar residents utilizing an external catheter for accurate reflection in their Minimum Data Set (MDS).
Education of the facility Nurse Assessment team on ensuring the resident's Minimum Data Set accurately reflects their status by the facility Administrator, or designee.
Audits will be completed weekly for four weeks by the Administrator, or designee, of a sample of resident MDS's to ensure they accurately reflect the resident's status. Results of the audits will be reviewed at the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Administrator shall ensure compliance.
483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of five residents (Residents R2 and R163).

Findings include:

Review of facility policy "Skin Integrity and Wound Management" dated 4/16/26, indicated the implementation of an individual resident's skin integrity and wound management occurs within the care delivery process. Staff continually observes and monitors residents for changes and implements revisions to the plan of care as needed. Perform skin inspection on admission and weekly by a licensed nurse. Document in the electronic medical record. Perform wound assessment and complete proper forms upon initial identification of altered skin integrity, weekly, and with any deterioration of wound.

Review of the clinical record indicated Resident R2 was admitted to the facility on 4/23/25.

Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/5/26, indicated diagnoses of hyponatremia (low levels of sodium in the blood), chronic peripheral venous insufficiency (damaged leg veins fail to efficiently return blood to the heart, causing blood to pool in the lower extremities), and need for assistance with personal care.

Review of Resident R2's admission "Body Check" assessment dated 4/23/25, indicated the resident was admitted to the facility with scaly skin to the right lower leg. Skin is intact, resident does have a cast to LLE (left lower extremity) for fractures of the tibia and fibula (two bones of the lower leg).

Review of the clinical record indicated Resident R2 was transferred to the hospital on 4/24/25, and returned to the facility on 5/2/25.

Review of a Skin/Wound progress note dated 5/2/25, stated, "Assessed resident's right lower leg following admission. From knee to foot had a thick layer of xeroform (a sterile, non-adhesive medicated gauze dressing used to keep wounds moist and prevent infection) residue. Leg cleansed with wound cleaner, dry skin flakes are adhered with residue. 1x0.5 scabbed area to upper lateral (to the side) shin, 3 small scabbed areas to top of foot. Areas swabbed with betadine (an antiseptic solution used to prevent and treat infections), covered with non-adherent pad. Resident stated she prefers to have her leg wrapped. Loosely wrapped kerlix (woven gauze) from knee to ankle."

Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's right lower extremity wound for the weeks of 5/4/25, 5/11/25, and 5/18/25.

Review of the clinical record indicated Resident R2 was transferred to the hospital on 5/28/25, and returned to the facility on 6/3/25.

Review of Resident R2's admission "Body Check" assessment dated 6/3/25, indicated the resident was re-admitted to the facility with a three venous stasis ulcers (a wound that occurs when there is damage to the skin and underlying tissue caused by high pressure in the veins or impaired return of blood from the legs to the heart) to the front of the left lower leg and discoloration to the front of the right lower leg.

Review of a Skin/Wound note dated 6/4/25, stated, "Resident reported to have pressure wound to coccyx (base of spine) present on admission. This RN (Registered Nurse) and LPN (Licensed Practical Nurse) confirmed that there is no wound present to resident's coccyx. LPN had already changed the dressing to resident's left lower leg, will assess tomorrow during dressing change. Right lower leg has dry skin and xeroform residue present. There is a small dry scabbed area to the top of the foot. Otherwise, skin is intact.

Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's left lower leg wounds from 6/8/25, to 12/16/25.

Review of the clinical record indicated Resident R2 was transferred to the hospital on 12/17/25, and returned to the facility on 12/20/25.

Review of Resident R2's admission "Body Check" assessment dated 12/20/25, indicated the resident was re-admitted to the facility with a blister to the front right lower leg and a blister to the front left lower leg, left calf inner aspect with multiple raised blood red appearing areas, area measures 18 cm (centimeter) long by 13 cm wide with multiple blister like area noted inside area.

Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's right lower leg wound from 12/28/25, to 4/28/26.

Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's left lower leg wound from 1/11/26, to 4/28/26.

Review of the clinical record indicated Resident R2 was transferred to the hospital on 4/28/26, and returned to the facility on 5/1/26.

Review of Resident R2's admission "Body Check" assessment dated 5/2/26, indicated the resident was re-admitted to the facility with a vascular ulcer (venous stasis ulcer) to the front right lower leg and a vascular ulcer to the front left lower leg.

Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's left lower leg wound the week of 5/10/26 - 5/16/26.

Review of the clinical record failed to include documentation that a weekly wound assessment was performed on Resident R2's right lower leg wound from 5/3/26, to 6/6/26.

During an interview on 8/19/26, at 9:32 a.m. RN Employee E3 stated, "I do wound rounds every week, I only see pressure wounds and residents when they are first admitted. For a non-pressure wound, there is an assessment the floor nurse is supposed to do every week. Resident R2 goes out to the wound clinic to be seen."

During an interview on 8/19/26, at 10:16 a.m. RN Employee E3 confirmed the facility failed to perform weekly wound assessments on Resident R2's right and lower leg wounds on the dates listed above. During this interview, RN Employee E3 stated, "I'm still trying to figure out how often Resident R2 goes out to the wound clinic."

During an interview on 8/19/26, at 11:45 a.m. LPN Employee E1 stated, "Resident R2 goes out to the wound clinic every 2 to 3 weeks and sometimes refuses to go, she refused her last appointment."

During an interview on 8/19/26, at 2:40 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that Resident R2 was provided appropriate treatment and care by failing to complete weekly wound assessments for the resident's right and left lower leg wounds.

Review of the clinical record indicated Resident R163 was admitted to the facility on 8/10/26, with diagnoses of End Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and need for assistance with personal care.

Review of a physician order dated 8/14/26, indicated to ask resident for blood sugar and how many units given. Goes by carbs intake four times a day for type 2 diabetes mellitus.

Review of Resident R163's comprehensive care plan dated 8/17/26, indicated I have diabetes mellitus related to endocrine impairment. Interventions included ask resident for blood sugar and how many units given, goes by carb intake. I have an insulin pump (a wearable device used to administer rapid and short-acting insulin continuously and can provide additional bolus doses at meal times) to use when I discharge, offer me education, advice and instructions with nursing in regards to transition to glucometer and insulin administration during my stay. Monitor my ability to manage my treatment program regarding my medications, dietary needs, glucose monitoring, exercise and knowledge of complications.

During an interview on 8/18/26, at 8:45 a.m. Resident R163 stated, "I have an insulin pump on, it has been wonderful and I have had no issues with it. I also have a continuous blood glucose monitor (CGM, a wearable device used to track glucose levels in real time) on. I let the facility staff know what my blood sugar reading is and how many units of insulin I am going to bolus myself. I have Novolog insulin (a rapid-acting insulin) in my pump, I manage all of it on my own."

During an interview on 8/18/26, at 9:04 a.m. LPN Employee E2 stated, "Resident R163 has an insulin pump and a CGM, we ask him four times a day what his blood sugar is and how many units of insulin he is going to give himself, he counts his carbs. That information is communicated to the nurses through a physician order. The physician order should state what type of insulin the resident is receiving in the insulin pump."

During an interview on 8/18/26, at 9:10 a.m. LPN Employee E2 confirmed Resident R163's physician order failed to include what type of insulin the resident is receiving through the insulin pump.

During an interview on 8/18/26, at 9:21 a.m. LPN Employee E1 stated, "The physician order should probably state which type of insulin the resident is getting through the insulin pump. We only have an order to ask the resident what his blood sugar reading was and how much insulin he gave himself."

During an interview on 8/18/26, at 10:12 a.m. the DON confirmed that the facility failed to make certain Resident R163 was provided appropriate treatment and care by failing to obtain complete physician orders for the management of the resident's insulin pump.

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: 10/05/2026

F0684 - The facility shall ensure residents receive treatment and care in accordance with professional standards of practice. The facility is unable to correct deficient practice for this R2 R 163 as time has elapsed. An in-house audit will be completed by the facility Wound Nurse, or designee, for all current wounds, both pressure and non-pressure, to ensure no other weekly measurements has been omitted.
An in-house audit will be completed by the facility Director of Nursing, or designee, on any resident using an insulin pump to ensure the type of insulin that is in the pump has a physician order indicating the type of insulin in the pump.
Education will be provided to the facility Wound Nurse and licensed staff by the facility Director of Nursing, or designee, on the importance and regulation indicating wounds, both pressure and non-pressure, must be assessed and documented on a least every seven days.
Education will be given to the licensed nursing staff by the Director of Nursing, or designee, on ensuring the type of insulin being used in an insulin pump has a physician order to match.
The Director of Nursing, or designee, will audit five residents per week for four weeks for wounds to ensure documentation is complete and accurate. User defined assessments will also be reviewed five times a week for four weeks by the Interdisciplinary care team to ensure the assessment is complete. If it is incomplete, the Director of Nursing, or designee, will ensure it is assigned to be completed that day.
The Director of Nursing, or designee, will audit all insulin pumps weekly for four weeks to ensure physician order matches the insulin used in the pump.
Results of the audits will be reviewed at the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for two of five residents (Resident R19 and R31).

Findings include:

Review of facility policy "Oxygen Therapy" dated 4/16/26, indicated oxygen therapy will be provided when a resident needs oxygen at a concentration greater than room air. The purpose is to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Change prefilled humidification system at least weekly.

Review of facility policy "Small Volume Nebulizer" dated 4/16/26, indicated will be administered as appropriate. The purpose is to provide a mode for the delivery of aerosolized particles of medication into the airway, improve mucous clearance, and relieve bronchospasm. When treatment is completed, place in storage bag labeled with resident name and date. Replace equipment every seven days. Date connecting tubing.

Review of the clinical record indicated Resident R19 was admitted to the facility on 2/13/26.

Review of Resident R19's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/31/26, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), high blood pressure, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as "while a resident".

During an observation on 8/17/26, at 10:01 a.m. Resident R19 was lying in bed with oxygen on. The nasal cannula (NC- a lightweight, flexible tube used to deliver oxygen to people with breathing difficulties) was not dated.

Review of Resident R19's physician order dated 7/28/26, indicated change humidifier bottle, tubing, and wraps every week on Thursday night shift.

During an interview on 8/17/26, at 10:17 a.m. Licensed Practical Nurse (LPN) Employee E12 confirmed the nasal cannula was missing a date and should be changed weekly. LPN Employee E12 confirmed that the facility failed to provide appropriate respiratory care for Resident R19.

Review of the clinical record indicated Resident R31 was admitted to the facility on 6/26/26.

Review of Resident R31's MDS dated 7/2/26, indicated diagnoses of high blood pressure, Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness).

During an observation on 8/17/26, at 10:07 a.m. Resident R31 was sitting at bedside with oxygen on. The nasal cannula and humidification bottle were not dated. Resident R31's nebulizer machine (used to deliver medication) was sitting on the bedside table. The nebulizer tubing was not dated and not stored in a bag when not in use.

Review of Resident R31's physician order dated 6/26/26, indicated Ipratropium-Albuterol Inhalation Solution (a medication used to treat COPD) every four hours, as needed, for shortness of breath.

Review of Resident R31's physician order dated 8/10/26, indicated supplemental oxygen two to five liters per minute nasal cannula, as needed, every shift. Change humidifier bottle and tube weekly on night shift every Thursday.

During an interview on 8/17/26, at 10:19 a.m. LPN Employee E12 confirmed the nasal cannula, humidification bottle, and nebulizer tubing were missing dates and should be changed weekly. LPN Employee E12 confirmed the nebulizer was not stored in a bag when not in use. LPN Employee E12 confirmed that the facility failed to provide appropriate respiratory care for Resident R31.

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












 Plan of Correction - To be completed: 10/05/2026

F0695 – The facility shall ensure oxygen therapy and nebulizer equipment is replaced, dated, and stored as outlined in policies "Oxygen Therapy" and "Small Volume Nebulizer". Neither Resident 19 or Resident 31 had complications related to the deficient practice. An inhouse audit will be completed by the facility Director of Nursing, or designee, of all oxygen equipment.
Education shall be provided to the facility nursing staff on the appropriate replacing, dating, and storage of oxygen and nebulizer equipment every seven days by the facility Director of Nursing, or designee.
Audits of residents with oxygen equipment will be completed weekly for four weeks to ensure equipment is replaced, dated, and stored in accordance with our policy every seven days. Audits will be completed by the Director of Nursing, or designee.
Results of audits will be reviewed at the monthly facility Quality Assurance and Performance Improvement Committee meeting for track and trending purposes. The facility Director of Nursing shall ensure compliance.
483.25(l) REQUIREMENT Dialysis:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of resident clinical records, observations, and staff interview it was determined the facility failed to obtain a physician order to monitor a dialysis (treatment that helps body remove extra fluid and waste products) access site, failed to develop a comprehensive person-centered plan of care to address resident care needs, and failed provide consistent and complete communication with the dialysis center for one of one residents (Resident R163).

Findings include:

Review of the clinical record indicated Resident R163 was admitted to the facility on 8/10/26, with diagnoses of End Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and need for assistance with personal care.

Review of a physician order dated 8/12/26, indicated hemodialysis every Monday, Wednesday, and Friday.

Review of Resident R163's physician orders failed to include an order to monitor the resident's dialysis access site and failed to indicate what type of dialysis access site.

Review of Resident R163's comprehensive care plan dated 8/14/26, indicated the resident is receiving dialysis related to renal failure. Interventions included check my access site daily. Reinforce as needed and document. Maintain communication with my dialysis clinic. The comprehensive care plan failed to indicate what type of dialysis access site Resident R163 had.

Review of Resident R163's clinical record did not include complete communication forms for two days during the period of 8/10/26, through 8/18/26. The incomplete forms were on the following dates: 8/12/26, and 8/14/26. No communication form was located for 8/17/26.

During an interview on 8/18/26, at 9:20 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above dates did not include complete dialysis communication forms and that the facility failed to provide consistent and complete communication with the dialysis center for Resident R163.

During an interview on 8/18/26, at 10:12 a.m. the Director of Nursing confirmed the facility failed to obtain a physician order to monitor a dialysis access site and failed to develop a comprehensive person-centered plan of care to address resident care needs for Resident R163.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.
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: 10/05/2026

F0698 – The facility shall ensure residents on dialysis will have orders that indicate the type of dialysis site and monitoring of site for abnormality. Facility shall also ensure communication forms are completed by both the SNF facility and dialysis clinic with each treatment. Resident 136 had no complications related to the deficient practice.
Education shall be provided to the facility nursing staff by the facility Director of Nursing, or designee, regarding the necessity of obtaining orders for dialysis site monitoring, as well as, type of site in place.
Audits of treatment charts of residents receiving dialysis will be completed twice weekly for four weeks to ensure the presence of appropriate monitoring/site type orders. Audits will also include observation of all individual's dialysis books twice weekly for four weeks to ensure completion of communication forms. Audits will be completed by the Director of Nursing, or designee
Results of audits will be reviewed in the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
483.25(m) REQUIREMENT Trauma Informed Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to develop and implement an individualized person-centered plan of care to render trauma informed care for a resident who was at risk for re-traumatization for one of three residents (Resident R116).

Findings include:

Review of the facility "Trauma Informed Care" competency checklist indicated staff are to recognize there are multiple causes of trauma and varies from person to person and verbalize that trauma informed care is individual for each person, there is not a model of care that can be followed.

Review of the clinical record indicated Resident R116 was admitted to the facility on 10/23/25.

Review of Resident R116's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Post Traumatic Stress Disorder (PTSD a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions), and depression.

Review of a "Social Service Note" dated 7/18/26, indicated Resident R116 had a history of trauma/Post Traumatic Stress Disorder, resident claims he was sexually assaulted as a child by older brother and father committed suicide. Resident R116 gets angry when talking about identifying triggers of re-traumatization.

Review of Resident R116's comprehensive care plan dated 4/16/26, indicated Trauma Informed Care: I have a history of actual trauma (List trauma, for example; rape, family separation, abuse, neglect, PTSD). Goals included I will have less than (name of behavior that is exhibited as a result of anxiety/PTSD from the trauma). Resident R116's trauma informed care plan of care failed to include individualized focus, goals, and interventions related to the resident's PTSD.

During an interview on 8/20/26, at 12:38 p.m. Social Worker Employee E4 confirmed the facility failed to failed to develop and implement an individualized person-centered plan of care to render trauma informed care for a resident who was at risk for re-traumatization for Resident R116.

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






 Plan of Correction - To be completed: 10/05/2026

F0699 – Resident's trauma informed care plan shall include individualized focus, goals, and interventions related to the resident's trauma. Resident 116 care plan shall be updated by the facility Social Worker to provide for individualized plan of care related to trauma informed care. All residents identified at similar risk will be assessed by the facility assessment nurse, or designee, for a comprehensive individualized care plan related to trauma informed care and update as needed. The facility shall utilize the services of a Psychotherapeutic Nurse Practitioner to provide 'talk therapy' services to residents if needed. The Psychotherapeutic Nurse Practitioner will document services provided. Indicating if no psychotherapeutic interventions were indicated or provided during the visit. As the resident's needs were addressed through psychiatric evaluation, medication management, and / or monitoring of current symptoms and the resident was clinically stable and did not identify a need for additional therapeutic intervention at this time. Or, provide and document that supportive psychotherapy was provided during the visit. The Psychotherapeutic Nurse Practitioner shall document interventions included, such as active listening, emotional support, validation of the resident's concerns, exploration of current stressors, and / or reinforcement of current strategies. The Psychotherapeutic Nurse Practitioner shall document whether the resident was engaged and receptive to the intervention. Facility has also contracted with an outside healthcare organization to provide additional behavioral health services to supplement current services. We are currently awaiting the provider to secure a practitioner.
Education will be provided to the facility Interdisciplinary Care Team staff members by the facility Administrator, or designee, on developing and providing an individualized person-centered plan of care for resident's behavioral management program.
Audits will be completed weekly for four weeks by the Administrator, or designee, of resident care plan related to trauma informed care to ensure individualized focus with goals and interventions related to the resident's trauma. Results of the audits will be reviewed in the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
483.40 REQUIREMENT Behavioral Health Services:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of five residents (Resident R116).

Findings include:

Review of facility policy "Behavior Standard" dated 4/16/26, indicated the purpose is to develop and implement behavior plans and medication regimens, in efforts to optimize the functional abilities of residents while monitoring for adverse side effects and improve behaviors.

Review of the clinical record indicated Resident R116 was admitted to the facility on 10/23/25.

Review of Resident R116's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Post Traumatic Stress Disorder (PTSD a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions), and depression.

Review of Resident R116's comprehensive care plan dated 4/22/26, indicated I am/have potential to demonstrate verbally abusive behaviors related to. Interventions included: Evaluate me for the side effects of medications and notify my physician as necessary, evaluate my coping skills and support system, and provide me with psychiatric/psychogeriatric consult as needed. The comprehensive care plan failed to include information related to Resident R116's individualized behaviors and identified coping skills.

Further review of Resident R116's comprehensive care plan dated 7/26/26 indicated I use anti-psychotic medications related to disease process. Interventions included: I am on a behavior management program with (Specify: alternative to prn (as needed) medication use). Monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The comprehensive care plan failed to include information related to Resident R116's individualized behavior management program and behavior symptoms.

Review of Resident R116's clinical record from October 2025 through August 2026 revealed the following behavior documentation:
11/5/25: "Yelling at CNA (Certified Nurse Aide) and LPN (Licensed Practical Nurse). Resident stated the nurse is incompetent and the aide is useless. Went in to see what is going on with the resident he stated the LPN is incompetent and she needs fired or he needs to be discharged. When asked what I can help the resident stated that he needs something to nasal congestion and started yelling at me due to not being able to give him something right away and stated I'm incompetent just like everyone else. Resident requests antihistamines, resident is ordered zyrtec (a medical used to treat allergy symptoms) when notified resident he was already given his medication and something to help with his nasal congestion he started yelling. Second RN in the room confirmed resident's request of mediation and he yelled at the second nurse and the nurse asked just clarifying resident then stated only thing I need is a lobotomy since he can't get out of here."11/10/25: "Went to take resident his evening medication and he asked me, "can you give me a hysterectomy already,"11/13/25: "resident stated that he does not want his hearing aids, so I tried to get him to let me to keep them in the med cart to keep track of them and he shouted at me to leave his room and to leave him alone. he stated, "I hate female kind and wish my sister would find a plot and fertilize the earth." he would not let me assist him putting them in his ears either."12/2/25: "Resident was using tray table as a wheel walker in the hallway, he was redirected back to his room and asked to call for help. Resident's pant was wet and when help was offered to change him, he refused and was verbally abusive to both the supervisor and the aide and asked that they get out of his room and leave him alone. Resident was left alone, but would continue to monitor and offer care and assistance as needed when he is calmed down.12/4/25: "pt (patient) pushing breakfast tray into hallway. offered morning medications and pt started yelling at this writer. calling names and cussing and saying to leave the pills. explained i couldn't and pt yelled "what the fuck am i going to do with them steal them." educated pt that other pt's could get a hold of them and he said good they can all just fucking die. i hope you all just fucking die then you'll leave me alone in my own misery. pt did take medications."2/6/26: "This nurse took resident's medications into him this am (morning). Resident threw them on the bed stating he does not f'ing know why he has to take them as they do no good. Continued to yell about the medication and refused to take them."3/8/26: "resident was ambulating out of room on own, he put dinner tray on floor. rn (Registered Nurse) supervisor went back to room and attempted to speak with him about this, he stated "leave me alone." told one nurse that she is an idiot. he said to another nurse your all rulemaking fucking idiots. attempts to reassure resident ineffective."3/28/26: "Pt came through resident unit hallway yelling as he came through the hall about God not being real and if he is real he's doing a spectacular job with his rapist priests and bombing children and all the sick stuff of the world and was yelling gods a frog. He then saw pt from other room sitting in her doorway with a babydoll and said "now look at this one holding a babydoll jesus christ whats wrong with people" and went up to resident and told her "hey your baby is fucking dead you know that right" pt was immediately removed by an aide and taken back to his unit while yelling at the aide he should sue her for doing such a shitty job on this side of the building."3/28/26: Reported by a CNA that was sitting in the dining room during dinner reported that resident was complaining it was too loud in there. Then made the statement if he cut their throats they would be quiet. RN aware."3/30/26: "around dinner time CNA alerted this nurse resident was on nursing unit going through the dirty trash hamper. pulling out dirty briefs. around 0430 (4:30 a.m.) CNA informed his nurse resident had removed the mattress cover from his mattress and put it in the hall. his mattress is off of the bed and against the wall. i went to the residents room to ask him what he was doing. he said i made him nervous asking him questions. At the time i entered the room he was moving his nightstand. unable to redirect that he should not be moving around furniture that it increases his chances of another fall. call to RN to make aware."4/2/26: "resident angry at beginning of shift, was yelling and cursing at staff about linens missing from room. was loudly cursing in hallway, calling staff names. he was yelling that he wants an xray done from fall on 3/29. progress notes state that patient denied interventions after fall on this date. when this was explained to him, he angrily said "cant trust nurses". he forcefully put glass of water on night stand and continued to yell vulgarities and this nurse and can on leaving room."5/5/26: "screaming that he is not happy at facility. The AC (air conditioning) unit was not working, upon investigating AC unit was warm. Resident is expressing frustration with being in the facility and his past. Resident expressed he does not want to be in facility and would rather sleep under a tree. Expressed being a decorated Marine and been through a lot and doesn't want health to decline more. Assigned LPN was able to redirect the resident and help calm him down.6/22/26: " Resident came out into the hallway screaming at the CNA for going into his room and removing dirty laundry. was screaming" you need to go back to the country you came from or go to hell. you owe me $28 by noon and it better not be foreign currency."7/1/26: "Resident was in dining room at breakfast today cussing and stating he wanted a lawyer if he did not have regular utensils. He constantly is cussing and swearing in dining with other residents being very upset. Staff constantly try to encourage resident to be better with cussing with him not wanting to hear it."7/1/26: "Resident very uncooperative this evening shift. Refused meds and tx (treatments). Yelled at this nurse that he is tired of dealing with stupid people taking meds that don't work and stick them up my ass."7/8/26: "Resident came out into the hallway yelling that he's tired of waiting and wants to see the dermatologist right now. He's tired of this fucking place and we all belong in jail for not treating him better."8/13/26: "Resident was self propelling in his w/c (wheelchair) throughout the building upon returning to RR (resident room) resident was yelling about having a throbbing headache. Tylenol 650 mg (milligrams) offered and given. attempted to ask resident about his headache to assess the situation and resident started yelling just give me arsenic and old lace already. this place is fucking crazy full of fake doctors collecting money and doing shit. Resident headed towards his room. complaining as he was going into his room."8/15/26: "Resident refused care from staff, stating, "Get the fuck out my room. I'll let you know if and when I need help. Just leave me alone." Resident later observed in hallway independently propelling self in wheelchair. Bleeding was noted to right arm; resident has a known history of picking scabs. This nurse offered to assess and provide wound care; however, resident refused and directed profane and derogatory language toward this nurse. Resident also refused redirection back to room and used derogatory language toward other residents near nurse's station. Will continue to monitor and re-approach as tolerated. Supervisor made aware."8/16/26: "Resident refused meds as well as his dinner tray. Was yelling that the food needs sent to a Chinese concentration camp he's tired of being fed shit. Most people here are mentally ill and slobbery they don't know any better. Let him die before he gets that way."8/18/26: "Resident refused am meds and am care today, was verbally aggressive towards staff. He stated for staff "to get out of his life and go die, quickly." He is more calm and pleasant this afternoon. Will continue to monitor."
Review of a Medical Assessment dated 10/25/25, completed by Psychiatric Mental Health Nurse Practitioner (PMHNP) Employee E23 stated, "Pt was seen today by this provider to determine if pt has the capacity to make decisions. According to staff, Pt was brought from a hospital to this facility for failure to thrive and malnourishment. When asked pt why he came to this facility he proclaimed "last November I had heart failure and I had surgery. I then went home and slipped and fell. I got dizzy a little bit after the fall. I had a whole lot of stress at that time. Someone broke into my apartment and robbed me". Pt reports he lives with himself and his dog. Pt states he has neighbors that help him out but he lives alone. Pt states his medical diagnosis is hypertension. Pt reports his sister is his POA (Power of Attorney) but he doesnt want her. Pt states he was in the hospital and "my sister brought me forms to fill out and I didnt know what was happening." Pt reports the risks of going home is "anything" meaning that anything could happen. Pt reports the benefits of going home is he can live where he wants, it is where "I belong", I have my TV and my dog. Pt was calm and cooperative. Pt was pleasant and respectful during interaction. Pt focus was good and he was not distracted. Pt seems to be lacking details and recognition of order of events. Pt did not seem to be concerned that he fell at home once. Pt is just pressured to get out of facility. Plan is to keep pt in facility until he is deemed okay to live on his own. My concern is getting groceries, cleaning and taking care of himself if he leaves the facility. Pt has fallen in the past and does not find this a problem. Pt is fixated on getting out of the facility and nothing else. Also his mobility and ability to get around. The ability of this pt to live alone is questionable. Follow up in one month."

Review of a Medical Assessment dated 12/11/25, completed by PMHNP Employee E23 stated, "Pt was seen today due to refusing care and wanting to die. Pt was sitting on his bed watching TV. Writer asked pt to turn the TV down so we could talk and pt got angry with writer. Pt stated "I dont know who you think you are". Pt then stated "I shouldnt even be here this is my sisters doing". Writer tried to calm pt down and then pt told writer to leave his room. Writer then exited the room. Plan is to keep pt on psych meds and follow up in 1 month."

Review of a Medical Assessment dated 3/4/26, completed by PMHNP Employee E23 stated, "Pt was seen today due to apparently verbalizing suicide. Pt was laying in his bed, awake and alert. Pt reports "I hate this place." Pt reports appetite is "good" and sleep is "not good". When pt was asked about depression he stated "who wouldn't be depressed living in America today?" Pt was then asked if he was suicidal and pt responded "that is none of your business, now please get out of my room." Plan is to keep pt on psych meds and follow up in 3 months."

Review of a Medical Assessment dated 3/18/26, completed by PMHNP Employee E23 stated, "Pt was seen today due to apparently having anger outbursts. Pt was sitting in his wheelchair in the hallway. Pt reports mood is "alright". Pt reports sleep "very poorly. I have never been much of a sleeper. I get like 3 hours a day. I have had a lot of stuff happen to me. I witnessed my fathers suicide and been in combat". Pt denies depression. Pt denies anxiety. Pt denies psychosis. Per staff if you do not mention his sister he will stay calm. His sister sets him off and he could get angry. Plan is to keep pt on psych meds and follow up in 3 months."

Review of a Medical Assessment dated 4/1/26, completed by PMHNP Employee E23, stated, "Pt was seen today due to apparently having "cognitive change" per staff. Per staff he has been naked in his room with a blank stare on his face. Pt was sitting on his bed in just a brief. Pt states his mood is "alright but in a lot of pain due to falling face first on the floor". Pt reports sleep "it doesnt matter". Pt is getting increasingly angry with questions. "I want to get out of here". When writer asked pt "do you feel sad at all during the day?" pt responded "I dont want to hear your bullshit, get out". Writer left the room. Plan is to keep pt on psych meds and follow up in 3 months."

Review of Resident R116's clinical record failed to include further documentation that behavioral health services were provided to the resident from 4/2/26, through 8/20/26.

During an interview on 8/20/26, at 12:22 p.m. Social Worker Employee E4 stated, "PMHNP Employee E23 comes on Wednesdays and Thursdays if needed. She goes in and speaks with residents and adjusts meds, she talks quickly with residents for about five minutes. She mostly does medication management only. We currently do not have a provider for talk therapy services, we were working with an outside agency, but the job offer was declined. Resident R116 will talk with you, but you have to take time and show interest in what he's talking about and gain his trust."

During an interview on 8/20/26, at 12:22 p.m. Social Worker Employee E4 confirmed that the facility failed to develop an individualized person-centered plan of care for Resident R116's behavior management program, and failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for Resident R116.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.29(a) Resident rights.
28 Pa. Code: 211.16(a)Social services.






 Plan of Correction - To be completed: 10/05/2026

F0740 – Residents shall receive the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident 116 shall be reassessed for current behavioral health needs, triggers and preferences. Resident 116's care plan will be updated as needed. Resident 116 will be provided mental health services, including specialized consultations or therapy as care planned. The facility Social Service Director, or designee, shall review documentation of residents with behaviors over the past 30 days for reference to counseling services and adjust treatment plan accordingly.
Education will be provided by the facility Administrator, or designee, to the facility Interdisciplinary Care Team on developing an individualized person-centered plan of care for resident's behavioral health management. Education will be provided by the facility Administrator, or designee, to direct care staff and the facility Interdisciplinary Care Team regarding recognizing and documenting behavioral health needs and triggers, implementing and documenting non-pharmacological interventions, and proper monitoring and reporting of behavioral changes or side effects of psychotropic medications and referral pathways for specialized behavioral health or substance use services.
An audit will be conducted weekly for four weeks by the facility Administrator, or designee, of a random sample of behavioral health care plans and behavior tracking logs to determine if care plans need updated. Results of the audits will be reviewed at the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Administrator shall ensure compliance.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of three medications carts (Angel Front Medication Cart), two of five resident rooms (Resident R56 and R78), and one of three medication rooms (Angel Medication Room).

Findings include:

Review of the facility policy "Medication Administration - NU16.54" last reviewed 4/16 /26, indicated nurses administering medications are not to leave the medication at the resident's bedside unless it is ordered that way. Medications are properly labeled according to state regulations.

Review of the facility policy "Storage of Medications" last reviewed 4/16/26, indicated when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.

Observation on 8/17/26, at 12:30 p.m. of Angel Front Medication Cart indicated the following medications not labeled with a date:

-Trelegy inhalers (treats chronic respiratory disease) - two separate inhalers.

-Albuterol nebulizer solution (turns medication into a fine mist that is breathed into the lungs for quick relief/rescue breathing).

Interview on 8/17/26, at 12:33 p.m. Licensed Practical Nurse (LPN) Employee E20 confirmed the medications were opened and not labeled with a date.

Review of the admission record indicated Resident R56 admitted to the facility on 5/16/26.

Observation of Resident R56's room on 8/17/26, at 10:00 a.m. indicated a container of nystatin cream (a prescription antifungal medication used to treat skin infections) on the bedside stand and another on the windowsill of the room.

Review of the admission record indicated Resident R78 admitted to the facility on 10/8/24.

Observation of Resident R78's room on 8/17/26, at 10:15 a.m. indicated a container of nystatin cream on the bedside stand.

Interview and tour with Registered Nurse (RN) Employee E8 on 8/17/26, at 12:13 p.m. confirmed the medications were left unsecure in the residents' rooms.

Observation of the Angel Medication Room on 8/18/26, at 11:08 a.m. with LPN Employee E7 indicated two foley catheters (thin tube used to drain urine from the bladder) with expiration dates of 7/28/25, and 12/26/24.

Interview on 8/18/26, at 11:09 a.m. LPN Employee E7 confirmed the foley catheters were expired on 7/28/25, and 12/26/24.

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







 Plan of Correction - To be completed: 10/05/2026

F0761 – The facility shall ensure medications are not left unattended by nurses in resident area, expired medical supplies are properly disposed of, and opened medications are properly dated. A review of the facility was completed by the facility Director of Nursing to ensure medications are secure and not left unattended.
Education will be provided to facility licensed staff on the facility policies "Medication Administration" and "Storage of Medications" within 30 days by the facility Director of Nursing, or designee.
Audits of each medication room, at least five resident rooms twice weekly for four weeks, for the presence of expired equipment, undated and opened medications, and unattended medications in resident occupied area. Audits will be completed by the Director of Nursing or designee.
Results of audits will be reviewed at the monthly facility Quality Assurance Performance Improvement Committee for tracking and trending purposes. The Director of Nursing shall ensure compliance.
483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs: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.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(3) Food prepared in a form designed to meet individual needs.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to prepare food in a form to meet physician ordered diets for one of six residents (Resident R153).

Findings include:

Review of the facility policy "Dining and Meal Service - CU2.2" last reviewed 4/16/26, indicated food will be at the proper texture/consistency to meet each individual's needs and desires. Mechanically altered diets, such as pureed diets (food has been ground, pressed, blended or sieved into a smooth creamy and uniform paste or liquid), are prepared and served as separate entritems.

Review of the clinical record indicated Resident R153 admitted to the facility on 7/2/26.

Review of Resident R153's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/31/26, indicated diagnoses of dysphagia, oropharyngeal phase (difficulty moving food and liquid from the mouth, through the throat and into the esophagus), pneumonia (lung infection), and urinary tract infection.

Review of Resident R153's physician order dated 7/30/26, indicated diet - Regular/General diet, Four Pureed texture, Two Mildly Thick (Nectar Thick) consistency of beverage.

Review of Resident R153's care plan dated 7/30/26, indicated to provide, serve diet as ordered. Monitor intake and record every meal.

Observation of the lunch service on 8/18/26, at 12:20 p.m. on the Angel Wing indicated Resident R153 asking the Survey Agency (SA) to grind her meat up. SA notified Nurse Aide (NA) Employee E21.

Interview and observation on 8/18/26, at 12:22 p.m. NA Employee E21 was helping Resident R153 with the lunch meal and indicated the resident was served the incorrect diet. The resident should have had a pureed diet and the food served was two meatloaf patties, one baked potato, and regular green beans.

Interview on 8/18/26, at 12:25 p.m. Dietary Director Employee E22 confirmed the incorrect diet was served to Resident R153 and that resident should have pureed meatloaf, mashed potatoes, and puree green beans.

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






 Plan of Correction - To be completed: 10/05/2026

F0805 – The facility shall provide food in a form to meet individual resident needs. We are unable to correct the deficient occurrence experienced by Resident 153. Resident diets shall be reviewed by the facility Dietary Manager to ensure correctness.
Education shall be provided by the facility Dietary Manager, or designee, to facility dietary and nursing staff on ensuring residents receive the correct diet as ordered, including form and consistency.
Audits of at least forty resident's meals shall be completed weekly for four weeks by the Dietary Manager, or designee, on serving the correct diet to said resident. Results of the audits will be reviewed at the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Administrator shall ensure compliance.
483.60(h)(1)-(3) REQUIREMENT Feeding Asst/Training/Supervision/Resident: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.
§483.60(h) Paid feeding assistants-
§483.60(h)(1) State approved training course. A facility may use a paid feeding assistant, as defined in § 488.301 of this chapter, if-
(i) The feeding assistant has successfully completed a State-approved training course that meets the requirements of §483.160 before feeding residents; and
(ii) The use of feeding assistants is consistent with State law.

§483.60(h)(2) Supervision.
(i) A feeding assistant must work under the supervision of a registered nurse (RN) or licensed practical nurse (LPN).
(ii) In an emergency, a feeding assistant must call a supervisory nurse for help.

§483.60(h)(3) Resident selection criteria.
(i) A facility must ensure that a feeding assistant provides dining assistance only for residents who have no complicated feeding problems.
(ii) Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings.
(iii) The facility must base resident selection on the interdisciplinary team's assessment and the resident's latest assessment and plan of care. Appropriateness for this program should be reflected in the comprehensive care plan.
Observations:

Based on observation, facility documents, and staff interview it was determined that the facility failed to make certain a feeding assistant provided dining assistance only for residents who have no complicated feeding problems including difficulty swallowing for one of six residents (Resident R47).

Findings include:

Interview on 8/18/26, at 10:00 a.m. the Director of Nursing indicated the facility does not have a policy on which residents a feeding assistant may feed.

Review of the face sheet indicated Resident R47 admitted to the facility on 6/11/25.

Review of Resident R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/26, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and dysphagia, oropharyngeal phase (difficulty moving food and liquid from the mouth, through the throat and into the esophagus).

Further review of the clinical record failed to include documentation that Resident R47's selection was based on the interdisciplinary team's assessment and the resident's latest assessment and plan of care.

Observation on 8/17/26, at 12:13 p.m. Resident R47 was in her wheelchair in the resident's room. Feeding Assistant Employee E18 was standing over her and the bedside table feeding the resident her lunch.

Interview on 8/18/26, at 10:00 a.m. the Director of Nursing confirmed the facility failed to make certain a feeding assistant provided dining assistance only for residents who have no complicated feeding problems including difficulty swallowing and could not produce documentation that Resident R47's selection was based on the interdisciplinary team's assessment and the resident's latest assessment and plan of care.

28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.






 Plan of Correction - To be completed: 10/05/2026

F0811 – The facility shall utilize trained paid feeding assistants who shall provide dining assistance in a dignified fashion to residents who have no complicated feeding problems. Resident 47 did not have complications related to the deficient practice. Feeding assistant use was stopped after the deficient practice was identified on 8/17/26. Residents who can be assisted by a paid Feeding Assistant shall be determined by the Interdisciplinary care team assessment and corresponding care plan.
Education shall be provided to the facility nursing staff and paid Feeding Assistants on the paid Feeding Assistant program, including dignified dining experience, proper supervision, and resident selection criteria by the facility Administrator, or designee.
Audits of a sample of resident meals assisted by paid Feeding Assistant shall be completed weekly for four weeks by the facility Administrator, or designee. Results of the audits will be reviewed at the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Administrator shall ensure compliance.
483.75(c)(1)-(4)d)(1)(2)(e)(1)-(3)(g)(2)(ii)(iii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:

Based on review of facility documentation, results of previous survey, and results of the current survey, it was determined that the facility Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed deficiencies.

Findings include:

The facility deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending May 22, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations.

Findings of the current survey ending August 21, 2026, included deficiencies that were repeated from the previous survey of May 22, 2025, which are as follows: F558, F604, F628, F695, F761, F880, and F908.

During an interview on 8/21/26, at 10:01 a.m. the Nursing Home Administrator confirmed that the facility had multiple repeat deficiencies from the previous survey, and that the facility failed to correct quality deficiencies and ensure that plans to improve the delivery of care services effectively addressed those deficiencies.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code211.12(c)(d)(3) Nursing services.







 Plan of Correction - To be completed: 10/05/2026

F0867 – The facility Administrator and Director of Nursing shall meet with the facility Governing Board to strategic plan the situation. The Interdisciplinary team shall conduct a root cause analysis to determine why prior corrective actions for F558, F604, F628, F695, F761, and F880 failed to achieve substantial compliance. System wide audits will be performed by the facility Administrator, or designee, of identified areas, including audits of: all resident call bell accommodations; audit of all residents with physical restrictive devices to verify medical necessity, physician orders, care plan updates and consent; audit of all in-house residents over residents discharged to the hospital to ensure appropriate discharge paperwork was documented as sent with the discharging resident; audit of residents receiving oxygen, or nebulizer therapy for correct settings, clean filters, labeled tubing and proper storage; inspection of all facility medication rooms, carts, and refrigerators for proper labeling, expiration dates, lock security and temperature tracking; and audit of infection control practices.
The Quality Assurance and Performance Improvement (QAPI) plan has been reviewed to ensure direct tracking of historical and repeat deficiencies. A dedicated Performance Improvement Project (PIP) has been instituted specifically targeting long term compliance for F558, F604, F628, F761, and F880.

Appropriate facility staff will be educated by the facility Administrator, or designee, of resident rights and dignity in daily care routines; identifying, assessment and alternatives to applying any restraints; providing and documenting transfer / discharge information timely; medication administration and storage; universal hand hygiene, standard precautions and barrier protocol. The facility Administrator and Director of Nursing will be educated by a corporate representative on utilizing the Quality Assurance and Performance Improvement process to ensure plans of correction achieve and maintain substantial compliance.
The facility Administrator, or designee, shall audit six random resident charts, or observations, weekly for four weeks across the five areas of repeat violation. Results of the audits will be reviewed at the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Administrator shall ensure compliance.
483.95(h) REQUIREMENT Training for Feeding Assistants: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.
§483.95(h) Required training of feeding assistants.
A facility must not use any individual working in the facility as a paid feeding assistant unless that individual has successfully completed a State-approved training program for feeding assistants, as specified in §483.160.
Observations:

Based on observation and staff interview it was determined that the facility failed to provide Feeding Assistant training to one of five feeding assistants (Feeding Assistant Employee E18).

Findings include:

Review of the face sheet indicated Resident R47 admitted to the facility on 6/11/25.

Review of Resident R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/26, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and depression.

Observation on 8/17/26, at 12:13 p.m. Resident R47 was in her wheelchair in the resident's room. Feeding Assistant Employee E18 was standing over her and the bedside table feeding the resident her lunch. No chair was present in the room.

Interview with Director of Nursing on 8/18/26, at 10:00 a.m. indicated the facility could not produce the State approved training that was provided to Feeding Assistant Employee E18.

28 Pa. Code 211.10(a)(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.






 Plan of Correction - To be completed: 10/05/2026

F0948 – The facility shall provide appropriate training for paid feeding assistant use. Employee 18 was immediately removed from paid feeding assistant duties. The facility suspended use of paid feeding assistants during the survey, until an approved plan of correction could be ascertained.
The facility Administrator, Director of Nursing and Dietary Manager shall review the current paid feeding assistant training program to ensure all areas of the required training of paid feeding assistants is included in the facility paid feeding assistant training. The facility Administrator, or designee, shall review the list of staff paid feeding assistants to ensure paid feeding assistant training was provided. Any staff identified to need the training will be trained prior to being used as an approved paid feeding assistant.
Education will be provided to the facility paid feeding assistants by the facility Director of Nursing, or designee, on providing for a dignified and complaint meal experience. Paid feeding assistants must demonstrate competency prior to being utilized as a paid feeding assistant. Education will be provided to the facility Director of Nursing by the facility Administrator on ensuring that approved paid feeding assistant training was provided to staff prior to being utilized as a paid feeding assistant.
The facility Director of Nursing, or designee, shall audit weekly for four weeks, a random sample of resident meals to ensure only trained, and facility approved, paid feeding assistant(s) assist appropriate residents with proper feeding techniques in a dignified manner. Results of the audits will be reviewed at the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
§ 201.18(b)(2) LICENSURE Management.:State only Deficiency.
(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.
Observations:

Based on review of facility policy, clinical closed record review and staff interview, it was determined that the facility failed to document return of personal items upon discharge or death for one of three residents sampled (Closed Resident Record (CR) 158).

Findings include:

Review of facility policy "Care of Resident's Belongings" dated 4/16/26, it was indicated to complete inventory of Personal Effects when the resident is admitted to the care community, transferred, or discharged. To be completed by nursing staff with assistance of the resident or family. Sign form and have resident or family member co-sign. If unable to do so, have another employee sign. Submit completed form to Licensed Nurse. License Nurse will review the form for completion and places it in the chart.

Review of the clinical record indicated Closed Resident Record CR158 was admitted to the facility on 6/4/26, and discharged to another facility on 6/12/26.

There was no documented evidence in the resident's clinical record that included an inventory list of the resident's personal items returned after the resident's discharge on 6/12/26.

During an interview on 8/19/26, at 1:22 p.m. Medical Records Employee E5 confirmed that the facility failed to document return of personal items upon death or discharge for Closed Resident Record CR158.






 Plan of Correction - To be completed: 10/05/2026

1210 - The facility shall protect resident personal property rights during and after discharge. Resident 158 was discharged, and the facility is unable to correct deficient practice.
An audit of the personal inventory records for the last 15 discharges will be completed by the facility Medical Records Coordinator.
Education will be provided to the facility Medical Records Coordinator and nursing staff on the importance of documentation of return of personal items upon death or discharge by the facility Director of Nursing, or designee.
Each discharge will be audited by the facility Medical Records Coordinator to ensure documentation is present, if it is not present both the facility Director of Nursing and facility Administrator will be notified for assistance in obtaining this documentation.
Results of audits will be reviewed in the facility monthly Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes. The facility Administrator shall ensure compliance.
§ 201.19(6) LICENSURE Personnel policies and procedures.:State only Deficiency.
(6) Documentation of the employee's orientation to the facility and the employee's assigned position prior to or within 1 week of the employee's start date.

Observations:

Based on a review personnel record, punch detail documentation and a staff interview, it was determined that the facility failed to provide an employee orientation to the facility for one of five sampled personnel records (Certified Nurse aide Employee E11).

Findings include:

Review of Certified Nurse aide (NA) Employee E11's personnel record indicated she was hired on 8/2/26. Further review of her personnel record did not include evidence of an employee orientation to the facility.

Review of Certified Nurse aide (NA) Employee E11's punch detail report (a report showing how many days and hours staff worked) dated 8/19/26, indicated the Certified NA Employee E11 worked the following days: 8/4/26, 8/7/26, 8/12/26, 8/14/26, 8/15/26, 8/16/26, and 8/17/26.

During an interview on 8/19/26, at 11:09 a.m. Regional Human Resource Director Employee E6 confirmed that the facility failed to provide Certified Nurse aide (NA) Employee E11 and employee orientation to the facility as required.









 Plan of Correction - To be completed: 10/05/2026

1490 - The facility shall document an employee's orientation to the facility and their position. The facility Administrator, or designee, shall review all current facility staff records to ensure an orientation record of the facility and position is included. All new staff hired from 9/4/2026 the facility Human Resources Director shall ensure the appropriate documented orientation is present.
Education will be provided to both the HR director, labor manager and department managers that the orientation packet is given on the first day the new employee begins on the floor. Education to be provided by the director of nursing, or designee. The director of nursing will be responsible to ensure that orientation packet is complete at the end of the new hires orientation and that it is given to HR director for the employees file
An audit will be completed weekly for four weeks of all facility newly hired employees by the Human Resources Director, or designee, to ensure completed and recorded within one week of hire.
Results of audits will be reviewed in the facility monthly Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes.
§ 201.20(a)(2) LICENSURE Staff development.:State only Deficiency.
(2) Restorative nursing techniques.
Observations:

Based on review of facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Restorative Nursing for two of five staff members (Licensed Practical Nurse (LPN) Employee E7 and Registered Nurse (RN) Employee E8).

Findings include:

Review of LPN Employee E7's personnel file indicated a date of hire on 1/24/23. Review of LPN Employee E7's personnel file did not include annual in-service training on Restorative Nursing from 1/1/25 through 12/31/25.

Review of RN Employee E8's personnel file indicated a date of hire on 10/20/06. Review of RN Employee E8's personnel file did not include annual in-service training on Restorative Nursing from 1/1/25 through 12/31/25.

During an interview on 8/19/26, at 1:29 p.m. Human Resources Employee E6 confirmed that the facility failed to provide training on Restorative Nursing for two of five staff members (LPN Employee E7 and RN Employee E8).






 Plan of Correction - To be completed: 10/05/2026

1560 - The facility shall provide Restorative Nursing training to appropriate staff. An inhouse audit of licensed nursing staff will be completed to ensure all licensed staff have restorative nursing as a learning course. The course will be added to their annual Relias learning plan as needed.
Facility nursing staff shall receive Restorative nursing education by the facility Director of Nursing, or designee, to ensure restorative nursing education has been completed while adding this course to the annual Relias plan.
For the next 30 days, each newly hired licensed nurse record will be audited by the facility Director of Nursing, or designee, to ensure restorative nursing has been assigned in their annual training plan. Results of audits will be reviewed in the facility monthly Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes.
§ 201.22(b) LICENSURE Prevention, control and surveillance of tuber:State only Deficiency.
(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:

Based on review of facility policy, personnel records, punch detail records, and staff interview, it was determined that the facility failed to complete pre-employment tuberculin skin testing (TB skin test- a two-step test that determines if someone has tuberculosis, a contagious respiratory disease) prior to working on the nursing unit with residents for one of five sampled personnel records (Certified Nurse aide Employee E16).

Findings include:

During a review of facility "Mantoux testing" policy last reviewed on 4/16/26, indicated that employee TB testing will be at the time of hire and annually thereafter. The intradermal tuberculin 2-step skin test shall be administered to new employees unless there is documentation of a previous positive test.

Review of Certified Nurse aide (NA) Employee E16's personnel record indicated she was hired on 8/6/26.

Review of Certified Nurse aide (NA) Employee E16's TB skin test dated 8/4/26, indicated the first-step TB test was administered, and TB skin reading was completed with a negative finding.

Review of Certified Nurse aide (NA) Employee E16's medical information did not include a second TB skin reading as required.

Review of Certified Nurse aide (NA) Employee E16's punch detail report (a report showing how many days and hours staff worked) dated 8/19/26, indicated the Certified NA Employee E16 worked the following days and hours:
8/6/265 hours
8/7/2612.13 hours
8/11/2612.62 hours

During an interview on 8/19/26, at 11:09 a.m. Regional Human Resource Director Employee E6 confirmed that the facility failed to complete pre-employment tuberculin skin testing for Certified Nurse aide (NA) Employee E16 prior to working on the nursing unit with residents as required.








 Plan of Correction - To be completed: 10/05/2026

1700 – The facility will follow the CDC recommendations for TB screening, testing, and surveillance. All newly hired employees shall have received a 2-step TB test. Those who have not, will not be able to begin employment until their second TB test has been administered and read.
The facility Administrator, or designee, will educate the Human Resources Director of requirement for 2- step TB test before starting employment.
Facility Administrator, or designee, will audit all new hires weekly for four weeks to ensure they have received their 2-step TB test and have appropriate documentation to support such.
Results of audits will be reviewed in the facility monthly Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes.
§ 204.2(a) LICENSURE Building Plans.:State only Deficiency.
(a) A licensee or prospective licensee shall submit its plans for construction, alteration or renovation to the Department. The Department will post instructions for submissions on its public website.

Observations:

Based on observations and staff interview, it was determined that the facility failed to notify the department of renovations made to one of three nursing units (Angel Wing Room 111).

Findings include:

Observations on 8/17/26, at 10:30 a.m. on Angel Wing, Room 111 was noted to have a bed with no mattress, no furniture, screws, drills, scrapers, box shower base materials, no commode, exposed pipes and wires and pain on the floor. The door was not secured.

During an interview on 8/17/26, at 10:35 a.m. with Licensed Practical Nurse (LPN) Employee E20 confirmed the appearance of the room and that it was not secured.

During an interview on 8/1726, at 10:40 a.m. the Nursing Home Administrator confirmed that the facility failed to notify the department of renovations to the Angel Wing Room 111 prior to starting the renovations.








 Plan of Correction - To be completed: 10/05/2026

2590 – The facility shall notify the Department of any construction, alteration or renovation to the facility. Room 111 was immediately secured. The facility Administrator, or designee, shall notify the Department of the plans for renovation to Room 111. The facility Administrator shall review the entire facility for any other unreported construction, alterations, or renovations and report to the Department as needed.
The facility Administrator and Director of Maintenance shall be educated by the corporate Facilities Manager of Department notification requirements related to building construction, alteration or renovation.
The facility Administrator, or designee, shall audit the facility building weekly for four weeks for any construction, alteration, or renovation projects to ensure notification requirements have been met. The facility Administrator shall ensure compliance.

§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 (NA) per 10 residents during the day shift for 11 of 21 days (8/7/26, 8/8/26, 8/9/26, 8/10/26, 8/11/26, 8/12/26, 8/13/26, 8/14/26, 8/15/26, 8/16/26, and 8/17/26), one nurse aide per 11 residents on evening shift for five of 21 days (8/9/26, 8/10/26, 8/13/26, 8/14/26, and 8/16/26), and one nurse aide per 15 residents on night shift, on ten of 21 days (8/7/26, 8/8/26, 8/9/26, 8/10/26, 8/11/26, 8/12/26, 8/13/26, 8/14/26, 8/15/26, and 8/16/26).

Findings include:

Review of facility census data and nursing time schedules from 7/30/26 through 8/19/26, revealed the following NA staffing shortages.

Day Shift:
8/7/26, Census 143, 13.12 Full-Time Equivalents (FTEs) present, 14.30 FTEs required.
8/8/26, Census 143, 14.02 FTEs present, 14.30 FTEs required.
8/9/26, Census 144, 13.96 FTEs present, 14.40 FTEs required.
8/10/26, Census 147, 11.27 FTEs present, 14.70 FTEs required.
8/11/26, Census 146, 12.02 FTEs present, 14.60 FTEs required.
8/12/26, Census 147, 14.19 FTEs present, 14.70 FTEs required.
8/13/26, Census 145, 13.92 FTEs present, 14.50 FTEs required.
8/14/26, Census 147 13.24 FTEs present, 14.70 FTEs required.
8/15/26, Census 145, 13.02 FTEs present, 14.50 FTEs required.
8/16/26, Census 147, 13.13 FTEs present, 14.70 FTEs required.
8/17/26, Census 148, 13.06 FTEs present, 14.80 FTEs required.

Evening Shift:
8/9/26, Census 144, 13.02 FTEs present, 13.09 FTEs required.
8/10/26, Census 147, 13.15 FTEs present, 13.36 FTEs required.
8/13/26, Census 145, 13.05 FTEs present, 13.18 FTEs required.
8/14/26, Census 147, 13.06 FTES present, 13.36 FTEs required.
8/16/26, Census 147, 12.61 FTEs present, 13.36 FTEs required.

Night Shift:
8/7/26, Census 143, 7.23 FTEs present, 9.53 FTEs required.
8/8/26, Census 143, 7.98 FTEs present, 9.53 FTEs required.
8/9/26, Census 144, 8.08 FTEs present, 9.60 FTEs required.
8/10/26, Census 147, 8.20 FTEs present, 9.80 FTEs required.
8/11/26, Census 146, 8.30 FTEs present, 9.73 FTEs required.
8/12/26, Census 147, 8.60 FTEs present, 9.80 FTEs required.
8/13/26, Census 145, 6.06 FTEs present, 9.67 FTEs required.
8/14/26, Census 147, 7.22 FTEs present, 9.80 FTEs required.
8/15/26, Census 145, 8.16 FTEs present, 9.67 FTEs required.
8/16/26, Census 147, 7.05 FTEs present, 9.80 FTEs required.

During an interview on 8/21/26, at 10:34 a.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, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift as required with no additional excess higher-level staff to compensate this deficiency.






 Plan of Correction - To be completed: 10/05/2026

5520 - The facility was unable to make corrective action for the nurse aide ratio for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. Facility Director of Nursing, or designee, will re-educate the labor manager and the RN supervisors on the 7/1/2024 requirements. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. Administrator, Director of Nursing, and Labor manager will conduct daily staffing meetings Monday – Friday to review nurse aide ratio throughout the day, the following day, and the weekend. In the event of vacancies the facility will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. Director of Nursing, or designee, will audit daily staffing ratios and PPD along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly facility Quality Assurance and Performance Improvement Committee meeting.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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 three of 21 days (8/9/26, 8/15/26, and 8/16/26).

Findings include:

Review of facility census data and nursing time schedules from 7/30/26, through 8/19/26, revealed the following LPN staffing shortages.

Day Shift:
8/9/26, Census 144, 5.11 Full-Time Equivalents (FTEs) present, 5.76 FTEs required.
8/15/26, Census 145, 4.90 FTEs present, 5.80 FTEs required.
8/16/26, Census 147, 5.86 FTEs present, 5.88 FTEs required.

During an interview on 8/21/26, at 10:34 a.m. the Nursing Home Administrator confirmed the staffing shortages and that the facility failed to provide one LPN per 25 residents during the day shift as required with no additional excess higher-level staff to compensate this deficiency.







 Plan of Correction - To be completed: 10/05/2026

5530 - The facility was unable to make corrective action for the licensed nurse ratio's for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. Director of nursing, or designee, will re-educate the labor manager and the RN supervisors on the 7/1/2023 requirements. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. Admin, DON, and Labor manager will conduct daily staffing meetings Monday – Friday to review ratios throughout the day, the following day, and the weekend. In the event of vacancies, the facility will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. Director of nursing or designee will audit daily staffing ratios and ppd along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly Quality assurance process improvement meeting.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on ten of 21 days (8/7/26, 8/8/26, 8/9/26, 8/10/26, 8/11/26, 8/12/26, 8/13/26, 8/14/26, 8/15/26, and 8/17/26).

Findings include:

Review of facility census data and nursing time schedules 7/30/26 through 8/19/26, revealed that the facility failed to maintain 3.20 hours of general nursing care (PPD) to each resident in a 24-hour period on the following dates:
8/7/26, Census 143, PPD 3.13
8/8/26, Census 143, PPD 3.05
8/9/26, Census 144, PPD 3.03
8/10/26, Census 147, PPD 2.97
8/11/26, Census 146, PPD 3.01
8/12/26, Census 147, PPD 3.16
8/13/26, Census 145, PPD 2.97
8/14/26, Census 147, PPD 3.02
8/15/26, Census 145, PPD 3.00
8/16/26, Census 147, PPD 2.86

During an interview on 8/21/26, at 10:34 a.m. the Nursing Home Administrator confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on ten of 21 days as required.






 Plan of Correction - To be completed: 10/05/2026

5640 - The facility was unable to make corrective action for minimum per patient day hours for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. Director of nursing or designee will re-educate the labor manager and the RN supervisors on the 7/1/2024 requirements. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. Admin, DON, and Labor manager will conduct daily staffing meetings Monday – Friday to review the minimum per patient day hours throughout the day, the following day, and the weekend. In the event of vacancies, the facility will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. Director of nursing or designee will audit daily staffing ratios and PPD along with all steps taken to fill vacancies five days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly facility Quality Assurance and Performance Improvement Committee meeting for tracking and trending purposes.

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