Pennsylvania Department of Health
ATHENS NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ATHENS NURSING AND REHABILITATION CENTER
Inspection Results For:

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ATHENS NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a Complaint Investigation completed on October 30, 2025, it was determined that Athens Nursing and Rehabilitation Center 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§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 observation and resident and staff interview, it was determined that the facility failed to provide sufficient housekeeping services for one of two nursing units (Sage nursing unit, Resident 3).

Findings include:

Interview with Resident 3 on October 30, 2025, at 2:16 PM revealed that her bathroom was cleaned, "a couple days ago." Resident 3 stated that it is cleaned once or twice a week and believed it was dirty. Resident 3 encouraged the surveyor to observe the condition of her bathroom, including her toilet. Observation of Resident 3's bathroom confirmed that the toilet was soiled with a large amount of brown spattering over almost the entire inside surface of the toilet.

Interview with Employee 4 (maintenance assistant director) and Employee 5 (maintenance director) on October 30, 2025, at 2:30 PM confirmed that both staff supervise the housekeeping staff under the environmental services department. Employees 4 and 5 confirmed that Resident 3 did not receive sufficient housekeeping services to maintain a clean bathroom.

Observation of the Sage nursing unit pantry on October 30, 2025, at 2:30 PM with Employee 6 (licensed practical nurse) revealed several chairs stored in the center of the pantry that would prevent effective cleaning of the floor. Debris that included plastic spoons, plastic straws, discarded straw packaging, paper towels, food crumbs, brown spillage, and sticky substances were noted on the visible surfaces of the floor. Interview with Employee 6 on the date and time of the interview revealed that she was unsure why the chairs were stored in the pantry and confirmed that the floor did not appear to have had effective housekeeping services.

Observation of the Sage nursing unit pantry on October 30, 2025, at 2:45 PM with Employee 7 (licensed practical nurse) revealed that she was unsure why the chairs were stored in the pantry; however, confirmed that the floor did not appear to have had effective housekeeping services.

Interview with Employee 8 (housekeeper) on October 30, 2025, at 3:00 PM revealed that no staff were assigned to the hallway on the Sage nursing unit that included the pantry and Resident 3's room since the staff that normally services that hallway was assigned to the laundry department to cover that person's scheduled day off. Employee 8 confirmed that no housekeeping services were provided on that hallway of the Sage nursing unit during the onsite visit and her shift was to have already ended. Employee 8 confirmed that she was aware that several chairs were stored in the Sage nursing unit pantry; however, she did not know why. Employee 8 stated that those chairs have been in that room for a week.

The surveyor reviewed the above housekeeping concerns during an interview with the Nursing Home Administrator on October 30, 2025, at 3:45 PM.

483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment
Previously cited deficiency 7/3/2025

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(3)(e)(1)(2.1) Management

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

Plan of Correction - To be completed: 12/01/2025

1. Resident 3's bathroom was cleaned the day of the survey. Chairs were removed from Sage Pantry, and area was cleaned the day of the survey.

2. Administrator and Housekeeping Director will conduct an audit of general cleanliness standards of resident bathrooms to ensure no other cleanliness issues are present.
Administrator will conduct an audit of all pantry areas to ensure no other cleanliness issues are present.

3. Housekeeping Director and housekeeping staff will be educated on general cleanliness standards of resident bathrooms.
Housekeeping, Dietary Staff, and Nursing will be educated on cleanliness of the pantry's.
Daily cleaning checklist will be implemented for Pantry's and signed off once verified by Department Head.

4. Nursing home administrator/designee will conduct random audits of 5 resident bathrooms daily x4 days a week for two weeks and then weekly times two months.
Administrator or designee will conduct random audits 3x a week for 4 weeks, and then weekly for 2 months. Results will be reviewed during the monthly QAPI meeting to ensure ongoing compliance.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Plan of Correction - To be completed: 12/01/2025

1. Unable to retroactively correct deficiencies cited. Resident 8's tray ticket was updated to state "THICKENED Mighty Shake (Nectar)". Residents 5,6,7,8 will remain on puree diet consistency and given the proper portion at each meal.

2. Administrator/Designee will conduct an audit of all scoops used for puree in Recipe Book to ensure all scoop sizes are available.

3. All cooks will be educated on following recipes in recipe book, including utilizing the proper size scoops.
All cooks will be educated with demonstration of "Fork-Drip-Test" and "Spoon-Tilt-Test".
All staff will be educated that Mighty Shakes must be thickened for nectar diets.
All residents on Nectar consistent liquids will have tray ticket updated to reflect the same.

4. Nursing home administrator/designee will conduct audits of residents on puree diet daily x4 days a week for two weeks and then weekly times two months to ensure proper portion is given per recipe book.

Administrator or designee will conduct random audits 5x a week for 4 weeks, and then weekly x2 weeks on residents on nectar thick liquids who receive mighty shake to ensure proper consistency. Results will be reviewed during the monthly QAPI meeting to ensure ongoing compliance.

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

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

Plan of Correction - To be completed: 01/02/2026

1. Facility is unable to correct past deficiency.

2. The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies and contracts with Staffing Agencies.

3. Staff Scheduler and DON will be educated on the importance of meeting C.N.A ratios, and that the facility is actively recruiting C.N.As and/or per diem staff.
Agency will be utilized for open shifts as needed and available. Bonus are offered when needed.
Calculation of daily shift ratios will be completed and reviewed daily during Daily Labor Meeting for accuracy by the scheduler and DON. All efforts will be made to meet the staffing ratio. 
If call offs occur, all efforts will be made to attempt to fill that position with C.N.A's that are working in ancillary departments.
Census will be capped at a number that ratio can be met with current staff.

4.The DON or designee will conduct an audit of the C.N.A ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.

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

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

Plan of Correction - To be completed: 01/02/2026

1. Facility is unable to correct past deficiency.

2. The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies and contract with Staffing Agencies.
Facility has also initiated relationship with staff recruiters to fill vacant LPN positions.
Facility is actively recruiting LPNs and onboarding is continuing.

3. Staff Scheduler and DON will be educated on the importance of meeting LPN ratios, and that the facility is actively recruiting LPNs.
Agency will be utilized for open shifts as needed and available. Bonus are offered when needed.
Education will be given to LPN's on punching out early for shifts.
Calculation of daily shift ratios will be completed and reviewed daily during Daily Labor Meeting for accuracy by the scheduler and DON. All efforts will be made to meet the staffing ratio. 
If call offs occur, all efforts will be made to attempt to fill that position with LPN's that are working in ancillary departments.
Census will be capped at a number that ratio can be met with current staff.

4.The DON or designee will conduct an audit of the LPN ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.

§ 211.12(i)(2) LICENSURE Nursing services.:

(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 staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, for 17 of the 21 days reviewed.

Findings include:

A review of nursing care hours provided by the facility from July 5 through 11, 2025; August 30 through September 5, 2025; and October 23 through 29, 2025, revealed that the facility failed to meet the minimum hours per patient day for the following days:

July 5, 2025, 2.97 hours PPD
July 6, 2025, 2.80 hours PPD
July 9, 2025, 3.19 hours PPD
July 10, 2025, 3.09 hours PPD
July 11, 2025, 3.12 hours PPD

August 31, 2025, 2.99 hours PPD

September 1, 2025, 3.19 hours PPD
September 2, 2025, 2.87 hours PPD
September 3, 2025, 2.89 hours PPD
September 4, 2025, 2.75 hours PPD
September 5, 2025, 2.77 hours PPD

October 23, 2025, 3.09 hours PPD
October 24, 2025, 3.08 hours PPD
October 25, 2025, 2.90 hours PPD
October 26, 2025, 2.89 hours PPD
October 28, 2025, 3.18 hours PPD
October 29, 2025, 2.92 hours PPD

Interview with the Nursing Home Administrator on October 30, 2025, at 3:45 PM confirmed that the facility did not meet regulatory PPD hours as evidenced above.

Plan of Correction - To be completed: 01/02/2026

1. The facility is unable to retroactively provide a minimum PPD hours for cited dates.

2.A facility wide audit was completed to ensure PPD was met. A review of projected ppd for the week was completed and implement staffing plans accordingly.
The facility has actively been hiring licensed staff, with an increased focus on LPN and CNA's new hires in the last month.

3.The DON and Scheduler will be re-educated on ensuring that the nursing care ratios are provided. A daily staffing meeting with DON and NHA has been on-going to review census and staffing to ensure we are meeting required PPD for nursing.

4.The DON or designee will conduct an audit of the nursing PPD to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.

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