Pennsylvania Department of Health
 HILLTOP HEIGHTS HEALTH & REHAB CENTER
Patient Care Inspection Results

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HILLTOP HEIGHTS HEALTH & REHAB CENTER
Inspection Results For:

There are  198 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
HILLTOP HEIGHTS HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on March 4, 2026, it was determined that Hilltop Heights Health and Rehab Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
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 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency 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.
§483.60(i) Food safety requirements.
The facility must -

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

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


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain the sanitation of the kitchen regarding thermal coffee mugs.

Findings include:

The facility's policy for kitchen sanitation and cleaning, dated August 18, 2025, revealed that the food and nutrition services staff would maintain the sanitation of the kitchen.

Observations in the main kitchen on March 4, 2026, at 09:16 a.m. revealed that 25 out of 39 maroon and/or black thermal coffee mugs observed had a moderate to large blackish brown removable substance inside. These mugs were on a rack beside the entrance door to the kitchen and beside the exit of the dishwasher.

Interview with the Dietary Aide 1 on March 4, 2026 at 9:19 a.m., who was running the dishwasher at the time, confirmed that the thermal coffee mugs observed were washed and in circulation and ready to be used for the residents. He also confirmed that they had a brownish black removable build up inside the cup. He was surprised and indicated that they should not be dirty since they were washed.

Interview with the Dietician (the Dietary Manager was not in the facility at the time) on March 4, 2026, at 9:23 a.m. confirmed that the maroon and/or black thermal coffee mugs had a blackish brown removable substance inside. She confirmed that coffee mugs observed were in circulation and ready to be used for the residents.

Interview with the Infection Preventionist on March 4, 2026 at 1:30 p.m. confirmed that all items used for serving food should be clean.

Interview with the Nursing Home Administrator on March 4, 2026 at 14:02 p.m. confirmed that the 25 maroon and/or black thermal coffee mugs observed should be clean inside, and they were not.

28 Pa. Code 211.6(f) Dietary Services.











 Plan of Correction - To be completed: 03/24/2026

1. Prior to the survey exit, dietary director immediately scrubbed the coffee cups with a visible film to ensure clean cups were served to residents.
2. On 3/5/26 dietary director hand cleaned all coffee mugs in facility to ensure cleanliness before use. To guarantee continued compliance dietary department will soak coffee cups in cleaner weekly and dietary director will audit/validate weekly.
3. Education provided to dietary staff by dietary director/designee on the dish wash process and need to validate cleanliness.
4. Dietary director/designee to audit coffee cups for cleanliness daily x1 week, weekly x3 weeks, and monthly x1 month. Results will be reviewed at the monthly quality assurance and improvement committee.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that recommendations from a wound consultant were reviewed with the attending physician for two of 12 residents reviewed (Resident 1 and Resident 11).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

Review of a facility policy for skin and wound best care practices dated August 18, 2025, indicated that communities may engage the services of a consulting wound care provider after consultation with the resident's medical provider and receipt of an order.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 13, 2025, indicated that the resident was cognitively intact, had impairment to her range of motion to her lower extremity on one side, was dependent for lower body dressing and toileting hygiene, was dependent for rolling left to right in bed, refused to get out of bed, was always incontinent of bowel and bladder, had no pressure ulcers, received ointments/medications other than to her feet, had a pressure relieving device to her bed and chair, and had diagnoses that included morbid obesity and diabetes.

A wound consultant note for Resident 1, dated February 11, 2026, revealed that the resident had gluteal dermatitis and recommended changing the treatment due to difficulty keeping the regions dry due to incontinence and the resident refusing side lying positions. The wound consultant recommended to discontinue the silver sulfadiazine (SSD-a topical antibiotic cream) and change the treatment to the gluteal regions to include distal folds related to Incontinence Associated Dermatitis (IAD-moisture associated skin damage). Staff were to cleanse the area with soap and water, pat dry, apply Nystatin Topical Powder (an antifungal powder used to treat infections in moist areas) to the base of the wound, and secure with a pad with nonwoven dry gauze sheet twice daily and as needed.

A review of Resident 1's Treatment Administration Record (TAR), dated February 2026, revealed that the resident's recommended treatment to her gluteal dermatitis was not initiated until February 13, 2026. There was no documented evidence that the physician reviewed that above wound consultant recommendations until February 13, 2026.

Interview with the Director of Nursing, Nursing Home Administrator and the facility's Consultant on February 4, 2026, at 4:25 p.m. confirmed that wound care recommendations are made by the wound nurse practitioner and the physician is to review the recommendations and accept or decline the recommendation. They confirmed that the wound recommendations are received from the wound consultant the same day the recommendations are made; however, they often do not review the recommendations with the physician until he comes into the facility for his weekly rounds. The Director of Nursing confirmed that the wound care recommendations for Resident 1's treatment change to her gluteal regions to include distal folds related to IAD, recommended on February 11, 2026, were not reviewed with the attending physician until February 13, 2026, resulting in wound care not being completed as recommended by the wound consultant.

A quarterly MDS assessment for Resident 11, dated January 9, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, required substantial assistance with bed mobility, was frequently incontinent of bowel and bladder, had a wound infection, had a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin), and had diagnosis that included dementia.

A wound consultant note for Resident 11, dated January 7, 2026, revealed that the resident had a left hip abscess (a build-up of pus caused by an infection) and recommended to change the treatment. Staff were to cleanse the area with wound cleanser, apply Bacitracin (a topical antibiotic) ointment to the base of the wound, and secure with dry dressing daily and as needed. A wound consultant note, dated January 14, 2026, revealed that the wound consultant recommended to continue the treatment to the left hip abscess as recommended on January 7, 2026. There was no documented evidence that the physician reviewed that above wound consultant notes to agree or disagree with the recommendations, resulting in wound care not being completed as recommended by the wound consultant.

A review of Resident 11's Treatment Administration Record (TAR), dated January 2026, revealed that there was no documented evidence that the treatment to the resident's left hip abscess was completed according to the wound care consultant's recommendations.

Interview with the Director of Nursing on March 4, 2026, at 3:39 p.m. confirmed that the wound care recommendations for Resident 11's treatment to her left hip abscess, recommended on January 7 and 14, 2026, were not reviewed with the attending physician, resulting in wound care not being completed as recommended by the wound consultant.

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





 Plan of Correction - To be completed: 03/24/2026

Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

1. The wound care orders for R 1 have been reviewed with the physician and orders received and R 11 the area on left hip is healed.

2. Wound care notes for the previous 2 weeks completed by the wound care practitioner have been reviewed to ensure that no other recommendations were made and needed to be approved by the physician.

3. Education provided to the nurse that rounds with the wound practitioner as well as the Director of Nursing by the Administrator on wound care recommendations being discussed with the physician in a timely manner.

4. Audits on wound care recommendations will be completed by the Director of Nursing/Designee weekly X4 weeks then monthly X2 months. Results of the audits will be reported to the Quality Assurance and Performance Improvement Committee.
483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations: Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice, by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician for one of 12 residents reviewed (Resident 9) who had pressure ulcers, and by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician and initiated timely for a resident with a worsening pressure ulcer (Resident 11). Findings include: Review of a facility policy for skin and wound best care practices dated August 18, 2025, indicated that pressure injuries will be treated with evidence-based interventions as ordered by the provider. Communities may engage the services of a consulting wound care provider after consultation with the resident's medical provider and receipt of an order. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated January 19, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnosis that included traumatic ischemia of muscle (condition where there is inadequate blood supply to the muscle tissue, caused specifically by a traumatic event or injury), and had pressure ulcers (skin breakdown caused by pressure). Physician's orders for Resident 9 dated January 15, 2026, included for the resident to have his Right buttocks and right sacrum (area on the lower back near the base of the spine), right lateral (right side of the body positioned away from the midline), and right proximal (the right side of the body that is situated closer to the center) cleansed with wound cleanser, pat dry, apply hydrogel (advanced wound care products designed to create a moist, soothing environment that promotes faster healing, pain relief, and autolytic debridement (removal of dead, damaged, or infected tissue)) to base of wound, and secure with dry dressing. Change daily and as needed once a day. Physician's orders for Resident 9 dated January 22, 2026, included for the resident to have his left sacrum pressure ulcer/injury cleansed with wound cleanser, apply Bacitracin (an antibiotic) ointment to base of the wound, and secure with dry dressing. Change daily and as needed. A wound consultant note for Resident 9, dated February 4, 2026, revealed that the resident's pressure ulcer on his right sacrum was resolved and to discontinue the treatment. A wound consultant note dated February 11, 2026, revealed that the pressure ulcer to the resident's left sacrum was resolved and to discontinue the treatment. There was no documented evidence that the physician reviewed that above wound consultant notes to agree or disagree with the recommendations. A review of Resident 9's Treatment Administration Record (TAR) dated February 2026 revealed that the resident continued to receive hydrogel to his right sacrum and Bacitracin to his left sacrum through March 3, 2026. Interview with the Nursing Home Administer and the Director of Nursing on March 4, 2026, at 4:26 p.m. confirmed that wound care recommendations are made by the wound nurse practitioner and the physician is to review the recommendations and accept or decline the recommendation. Staff get verbal orders from the physician to accept or decline the recommendations. There was no documented evidence that the physician reviewed the wound care notes or recommendations for Resident 9 on the above-mentioned dates. A quarterly MDS assessment for Resident 11, dated January 9, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, required substantial assistance with bed mobility, was frequently incontinent of bowel and bladder, had a wound infection, had a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin), and had a diagnosis of dementia. A wound consultant note for Resident 11, dated January 7, 2026, revealed that the resident had an unstageable pressure ulcer (full-thickness pressure injury in which the base is obscured by slough and/or eschar) to her left sacrum (last bone in the spine located above the tailbone) that was rapidly progressing, larger and presented with eschar (dead tissue that prevents healing) and slight induration.Recommendations were made to change the treatment to the left sacrum and staff were to cleanse the wound with wound cleanser, apply skin prep to the surrounding tissue or peri wound, apply Bacitracin ointment to base of the wound, secure with bordered dressing daily and as needed. A review of Resident 11's Treatment Administration Record (TAR), dated January 2026, revealed that the resident's recommended treatment to her left sacrum was not initiated until January 11, 2026. There was no documented evidence that the physician reviewed the wound care recommendations until January 11, 2026. Interview with the Director of Nursing, Nursing Home Administrator and the facility's Consultant on February 4, 2026, at 4:25 p.m. confirmed that wound care recommendations are made by the wound nurse practitioner and the physician is to review the recommendations and accept or decline the recommendation. They confirmed that the wound recommendations are received from the wound consultant the same day the recommendations are made; however, they often do not review the recommendations with the physician until he comes into the facility for his weekly rounds. They indicated that the delay was acceptable and did not feel it was necessary to call the physician for every recommendation, especially if the wound was stable and not worsening. They confirmed that there was no documented evidence the wound treatment recommendations made on January 7, 2026, to Resident 11's worsening left sacrum was reviewed by the physician and initiated until January 11, 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. -
 Plan of Correction - To be completed: 03/24/2026

1. The wound care orders for R 9 and R 11have been reviewed with the physician and orders received.

2. Wound care notes for the previous 2 weeks completed by the wound care practitioner have been reviewed to ensure that no other recommendations were made and needed to be approved by the physician.

3. Education provided to the nurse that rounds with the wound practitioner as well as the Director of Nursing by the Administrator on wound care recommendations being discussed with the physician in a timely manner.

4. Audits on wound care recommendations will be completed by the Director of Nursing/Designee weekly X4 weeks then monthly X2 months. Results of the audits will be reported to the Quality Assurance and Performance Improvement Committee.
§ 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 schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for twelve of 21 days, failed to ensure a minimum of one nurse aide per 11 residents on the evening shift for 16 of 21 days, and failed to ensure a minimum of one nurse aide per 15 residents on the overnight shifts, for 5 of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on January 26, 2026, the facility census was 91, which required 9.10 (91 residents divided by 10) nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 8.13 NAs provided care on the day shift on January 26, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 26, 2026, the facility census was 91, which required 8.27 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 6.00 NAs provided care on the evening shift on January 26, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 26, 2026, the facility census was 91, which required 6.07 nurse aides (NAs) during the night shift. Review of the nursing time schedules revealed 5.90 NAs provided care on the night shift on January 26, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 29, 2026, the facility census was 89, which required 8.09 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 7.03 NAs provided care on the evening shift on January 29, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 30, 2026, the facility census was 94, which required 8.55 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 7.94 NAs provided care on the evening shift on January 30, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 31, 2026, the facility census was 90, which required 8.18 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 7.29 NAs provided care on the evening shift on January 31, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 8, 2026, the facility census was 94, which required 9.40 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 6.27 NAs provided care on the day shift on February 8, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 8, 2026, the facility census was 94, which required 8.55 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 4.53 NAs provided care on the evening shift on February 8, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 9, 2026, the facility census was 94, which required 8.55 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 6.80 NAs provided care on the evening shift on February 9, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 10, 2026, the facility census was 94, which required 8.55 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 8.07 NAs provided care on the evening shift on February 10, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2026, the facility census was 96, which required 8.73 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 8.60 NAs provided care on the day shift on February 11, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2026, the facility census was 96, which required 3.20 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 3.13 NAs provided care on the evening shift on February 11, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 12, 2026, the facility census was 97, which required 9.70 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 9.27 NAs provided care on the day shift on February 12, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 12, 2026, the facility census was 97, which required 8.82 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 7.60 NAs provided care on the evening shift on February 12, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 13, 2026, the facility census was 99, which required 9.00 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 8.53 NAs provided care on the evening shift on February 13, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 14, 2026, the facility census was 98, which required 9.80 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 7.27 NAs provided care on the day shift on February 14, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 14, 2026, the facility census was 98, which required 8.91 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 7.03 NAs provided care on the evening shift on February 14, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 14, 2026, the facility census was 98, which required 6.53 nurse aides (NAs) during the night shift. Review of the nursing time schedules revealed 5.90 NAs provided care on the night shift on February 14, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 25, 2026, the facility census was 100, which required 10.00 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 8.13 NAs provided care on the day shift on February 25, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 25, 2026, the facility census was 100, which required 9.09 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 7.19 NAs provided care on the evening shift on February 25, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 25, 2026, the facility census was 100, which required 6.67 nurse aides (NAs) during the night shift. Review of the nursing time schedules revealed 6.38 NAs provided care on the night shift on February 25, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 26, 2026, the facility census was 100, which required 10.00 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 9.77 NAs provided care on the day shift on February 26, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 26, 2026, the facility census was 100, which required 9.09 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 7.53 NAs provided care on the evening shift on February 26, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 27, 2026, the facility census was 98, which required 9.80 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 9.22 NAs provided care on the day shift on February 27, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 27, 2026, the facility census was 98, which required 8.91 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 5.81 NAs provided care on the evening shift on February 27, 2026. No additional excess higher-level staff were available to compensate this deficiency

Review of facility census data indicated that on February 27, 2026, the facility census was 98, which required 6.53 nurse aides (NAs) during the night shift. Review of the nursing time schedules revealed 4.84 NAs provided care on the night shift on February 27, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 28, 2026, the facility census was 98, which required 9.80 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 9.09 NAs provided care on the day shift on February 28, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 28, 2026, the facility census was 98, which required 8.91 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 5.84 NAs provided care on the evening shift on February 28, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 28, 2026, the facility census was 98, which required 6.53 nurse aides (NAs) during the night shift. Review of the nursing time schedules revealed 5.94 NAs provided care on the night shift on February 28, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 1, 2026, the facility census was 98, which required 9.80 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 7.66 NAs provided care on the day shift on March 1, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 1, 2026, the facility census was 98, which required 8.91 nurse aides (NAs) during the evening shift. Review of the nursing time schedules revealed 5.81 NAs provided care on the evening shift on March 1, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 2, 2026, the facility census was 96, which required 8.73 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 5.13 NAs provided care on the day shift on March 2, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 3, 2026, the facility census was 96, which required 8.73 nurse aides (NAs) during the day shift. Review of the nursing time schedules revealed 8.19 NAs provided care on the day shift on March 3, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on March 4, 2026, at 4:30 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.







 Plan of Correction - To be completed: 03/24/2026

1) The facility cannot retroactively correct the nurse aide (NA) ratios.
2) Moving forward, the facility will continue to schedule NA's to meet the required ratios. The facility will make every effort to use internal and external resources to meet staffing ratios. The facility offers bonuses for staff to pick up and will also utilize agency staff when necessary.

3)The regional vice president of operations has re-educated the nursing home administrator, director of nursing, and scheduler on the staffing ratios for NAs. The staffing is reviewed each day for the subsequent day by the NHA and/or DON to ensure adequate NA staff to meet the required ratios.

4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility NA staffing meets the required ratios each shift. Audits will be done 5x/week for 4 weeks and 3x/week for 4 weeks. The results of the audits will be forwarded to the facility Quality Assurance and performance improvement committee for further review and recommendations.
§ 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 schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for three of 21 days, failed to ensure a minimum of one licensed practical nurse (LPN) per 30 residents during the evening shift for five of 21 days.

Findings Include:

Review of facility census data indicated that on January 26, 2026, the facility census was 91, which required 3.64 Licensed Practical Nurses (LPN) during the day shift. Review of the nursing time schedules revealed 3.52 LPNs worked on the day shift on January 26, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 8, 2026, the facility census was 94, which required 3.13 Licensed Practical Nurses (LPN) during the evening shift. Review of the nursing time schedules revealed 3.06 LPNs worked on the evening shift on February 8, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2026, the facility census was 96, which required 3.20 Licensed Practical Nurses (LPN) during the evening shift. Review of the nursing time schedules revealed 3.13 LPNs worked on the evening shift on February 11, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 12, 2026, the facility census was 97, which required 3.23 Licensed Practical Nurses (LPN) during the evening shift. Review of the nursing time schedules revealed 2.94 LPNs worked on the evening shift on February 12, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 13, 2026, the facility census was 99, which required 3.30 Licensed Practical Nurses (LPN) during the evening shift. Review of the nursing time schedules revealed 2.94 LPNs worked on the evening shift on February 13, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 26, 2026, the facility census was 100, which required 4.00 Licensed Practical Nurses (LPN) during the day shift. Review of the nursing time schedules revealed 3.97 LPNs worked on the day shift on February 26, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 28, 2026, the facility census was 98, which required 3.27 Licensed Practical Nurses (LPN) during the evening shift. Review of the nursing time schedules revealed 3.03 LPNs worked on the evening shift on February 28, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 1, 2026, the facility census was 98, which required 3.92 Licensed Practical Nurses (LPN) during the day shift. Review of the nursing time schedules revealed 3.09 LPNs worked on the day shift on March 1, 2026. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on March 4, 2026, at 4:30 p.m. confirmed that the facility did not meet the required Licensed Practical Nurse-to-resident staffing ratios for the days listed above.





 Plan of Correction - To be completed: 03/24/2026

1) The facility cannot retroactively correct the licensed practical nurse (LPN) ratios.
2) Moving forward, the facility will continue to schedule LPN's to meet the required ratios. The facility will make every effort to use internal and external resources to meet staffing ratios. The facility offers bonuses for staff to pick up and will also utilize agency staff when necessary.

3)The regional vice president of operations has re-educated the nursing home administrator, director of nursing, and scheduler on the staffing ratios for LPNs. The staffing is reviewed each day for the subsequent day by the NHA and/or DON to ensure adequate LPN staff to meet the required ratios.

4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility LPN staffing meets the required ratios each shift. Audits will be done 5x/week for 4 weeks and 3x/week for 4 weeks. The results of the audits will be forwarded to the facility Quality Assurance and performance improvement committee for further review and recommendations.
§ 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 schedules and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for 10 of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of January 25 through January 31, 2026, and February 1 through February 14, 2026, revealed that the facility provided only 2.79 hours of direct care for each resident on January 26, 2026; 3.13 hours of direct care for each resident on January 30, 2026; 2.51 hours of direct care for each resident on February 8, 2026; 2.97 hours of direct care for each resident on February 12, 2026; 2.64 hours of direct care for each resident on February 14, 2026; 2.97 hours of direct care for each resident on February 25, 2026; 3.14 hours of direct care for each resident on February 26, 2026; 2.88 hours of direct care for each resident on February 27, 2026; 2.77 hours of direct care for each resident on February 28, 2026; and 2.69 hours of direct care for each resident on March 1, 2026.
Interview with the Nursing Home Administrator on March 4, 2026, at 4:30 p.m. confirmed that the facility did not meet the required daily PPD on the days listed above.






 Plan of Correction - To be completed: 03/24/2026

1) The facility cannot retroactively correct nursing hours per patient day (PPD)
2) Moving forward, the facility will continue to schedule to meet the required PPD. The facility will make every effort to use internal and external resources to meet staffing PPD of 3.20.

3)The regional vice president of operations has re-educated the nursing home administrator, director of nursing, and scheduler on the requirement to provide 3.20 hours of direct care per resident. The staffing is reviewed each day for the subsequent day by the NHA and/or DON to ensure adequate staffing to meet the required 3.20 PPD.

4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets the required PPD each day. Audits will be done 5x/week for 4 weeks and 3x/week for 4 weeks. The results of the audits will be forwarded to the facility Quality Assurance and performance improvement committee for further review and recommendations.

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