Pennsylvania Department of Health
LAUREL RIDGE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LAUREL RIDGE CENTER
Inspection Results For:

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LAUREL RIDGE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to three complaints, completed on July 9, 2026, it was determined that Laurel Ridge Center was in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, the facility was not in compliance with the 28. Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.аа

Plan of Correction:

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.

з483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in з483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

з483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

з483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

з483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

з483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

з483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications. This failure resulted in an Immediate Jeopardy situation for four of 25 residents (Residents R1, R2, R3, and R4).

Findings include:

Review of the "Facility Assessment" for 2026, Quarter 1, indicated the facility will provide intravenous medications and treatment for infections. Under the Acuity Care Requirements section indicated, "We also admit residents with IV medications."

Review of the clinical record indicated Resident R1 was admitted to the facility on 6/18/26.

Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/21/26, included diagnoses of Diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), Peripheral Vascular Disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and Osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Review of Section O: Special Treatments, Procedures, and Programs indicated Resident R1 had been receiving intravenous therapy at the time of admission.

Review of hospital discharge paperwork dated 6/18/26, included a note from the infectious disease physician that indicated Resident R1 was ordered ceftaroline ("Teflaro," broad-spectrum cephalosporin antibiotic administered intravenously for treating complicated skin and soft tissue infections). "I am going to recommend IV antibiotics for several weeks along with clinical follow up. I do want to cover more broadly than just anaerobes. So, in addition to the Flagyl (antibiotic and antiprotozoal medication) I would like to have some aerobic Gram-negative and Gram-positive coverage with ceftaroline."

Review of Resident R1's plan of care initiated 6/19/26, revealed "Patient has osteomyelitis and is receiving IV antibiotics" indicated the facility will, "Administer antibiotics as ordered."

Review of Resident R1'sphysician's order dated 6/18/26: Ceftaroline Fosamil Intravenous Solution Reconstituted Use 300 mg intravenously two times a day for sepsis (life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs).

Review of Resident R1's June 2026 medication administration record (MAR) revealed Resident R1 did not receive ceftaroline, from admission (6/18/26) through 6/24/26, when he was hospitalized to allow him to receive the missed antibiotic medication.

Review of Resident R1's electronic MAR progress notes for the scheduled ceftaroline doses were documented as follows:
-Medication not available / on back order from pharmacy, or
-Not received from pharmacy pending insurance coverage, or
-Pending pharmacy, or
-Awaiting pharmacy.

Review of Resident R1's progress notes failed to address the medication not being provided until note written by Registered Nurse (RN) Employee E3 dated 6/23/26, at 4:48 p.m. revealed, "LM (left message) for [infectious disease physician] about antibiotic changes."

Review of Resident R1's progress note dated 6/24/26, at 10:19 a.m. revealed infectious disease physician wanted Resident R1 to remain on the originally ordered antibiotic.

Review of a progress note dated 6/24/26, at 11:23 a.m. revealed Resident R1 was transferred to the hospital to receive medication.

Interviews conducted with staff on 7/7/25, revealed all notifications to provider will be through "Care Communications" (the electronic communication platform) or if by telephone, a progress note will be entered into the electronic medical records system.

Review of Resident R1's progress notes dated 6/18/26, through 6/24/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R1 not receiving his ceftaroline.

Review of Care Communications revealed one entry related to Resident R1 not receiving his IV antibiotic, written by RN Employee E2, dated 6/22/26, at 11:47 p.m., "Spoke with pharmacy regarding resident's iv ax (IV antibiotics) that was supposed to be stared on 6/18 for SEPSIS. They said that they left a message on Friday regarding a co-pay of $1,324.00 that would need approved. That is a Corporation issue he was accepted on that antibiotic and needs to be on it!! Has he been getting it???? If he hasn't, there WILL be big problems!!! SOMEONE SHOULD BE FIRED. I don't know why pharmacy has such a problem getting antibiotics for our residents."

Review of an electronic communication written by Resident R1's attending physician dated 6/26/26, at 7:14 p.m. indicated, "Is anyone at the pharmacy going to be held accountable for this debacle? Totally unacceptable what happened because of them in my opinion. There was notification to me via the communication board 6 days after the patient was there that they didn't send an IV antibiotic. And the reason they gave, was because of COST!!! Good luck defending that in court when we agreed to accept him and treat him. But beyond that and much more important is that the fact that this gentleman did not receive proper treatment because of them. I do not know anybody who would be willing to accept this as a valid reason if it were one of their family members. I'm really not sure what it is about this pharmacy and delivering medications that are ordered. They delay controlled substances being delivered even though they have valid prescriptions confirmed electronically. Maybe I am mistaken, but I thought the main job of having this pharmacy was to deliver us medications that we order. If there is a problem, contact me immediately. I have NEVER had an issue with someone reaching out to me especially if it has to do with an antibiotic or medication not being covered. I get called for much less relevant issues and I am fine with that."

Review of emergency room documentation dated 6/24/26, revealed Resident R1, "Presents secondary to his nursing facility being unable to secure the ceftaroline. I spoke with the staff at [facility] and they advised that the patient has not yet received a dose of this antibiotic despite being at the facility since Thursday (6/18/26). They contacted the pharmacy and the pharmacy does not have an ETA for the antibiotic. They then spoke with [Infectious disease] office who spoke who advised that there were no alternatives. Patiently was subsequently sent here for admission for his IV antibiotics."

Review of the hospital discharge summary dated 6/26/26, revealed Resident R1, "presented due to inability to receive IV antibiotics at SNF."

Review of the clinical record indicated Resident R2 was admitted to the facility on 4/22/26.

Review of the MDS 4/29/26, dated included diagnoses of Hepatic Encephalopathy (decline in brain function caused by severe liver disease), Heart Failure (progressive heart disease that affects pumping action of the heart muscles), and End Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood). Review of Section N: Medications indicated Resident R2 received antibiotic medication.

Review of Resident R2's plan of care initiated 4/23/26, failed to include a care plan developed for the use of a gastrointestinal antibiotic.

Review of Resident R2's physician's order dated 4/23/26, revealed Resident R2 was to receive Rifaximin (antibiotic that stays in gastrointestinal tract) 550 mg two times a day for hepatic encephalopathy.

Review of June 2026 MAR and progress notes revealed Resident R2 did not receive rifaximin for 14 of 60 scheduled doses, on:
6/1/26, PM dose: documented to see nurse's note on MAR. No nurse's note in EMR (electronic medical record).
6/2/26, PM dose: "Not available. On order."
6/3/26, PM dose: "Pending pharmacy."
6/5/26, AM dose: "Unable to find and resident has an appointment."
6/9/26, AM dose: "Unable to find, not in Pyxis."
6/10/26, AM dose: "On order."
6/24/26, PM dose: "Pending pharmacy."
6/25/26, PM dose: "Med on order."
6/26/26, PM dose: "Pending pharmacy."
6/27/26, PM dose: "Pending pharmacy."
6/28/26, AM dose: "On back order."
6/28/26, PM dose: "Pending pharmacy."
6/29/26, AM dose: "On back order."
6/29/26, PM dose: "Pending pharmacy."

Review of Resident R2's progress notes dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R2's not receiving his Rifaximin on the above dates.

Review of Care Communications dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R2's not receiving his Rifaximin.

During an interview on 7/9/26, at 12:49 p.m. the attending physician confirmed that he had not been made aware by facility staff that Resident R2 had not received his ordered antibiotics.

Review of the clinical record indicated Resident R3 was admitted to the facility on 6/4/26.

Review of the MDS dated 6/10/26, included diagnoses of cancer, bacteremia (presence of bacteria in the bloodstream), and Klebsiella pneumoniae (a bacterium that can cause pneumonia, urinary tract infections, bloodstream infections, and other serious illnesses, often exhibiting antibiotic resistance).

Review of hospital discharge paperwork dated 6/3/26, indicated Resident R3 was to receive intravenous ceftriaxone (Rocephin, antibiotic medication) and intravenous Linezolid (Zyvox, an antibiotic used to treat various bacterial infections, including pneumonia and skin infections).

Review of the Clinical Admission Assessment completed on 6/4/26, under the "Care Planning" section indicated "Administer antibiotic therapy as prescribed" was documented as "not active."

Review of the plan of care initiated 6/5/26, for "Patient is receiving PO (by mouth) antibiotics related to abdominal wound infection" indicated to "Administer antibiotic as ordered." Further review of the plan of care failed to reveal goals and interventions developed for the use of intravenous antibiotic medications.

Review of physician's orders dated 6/5/26, 6/6/26, 6/13/26, and 6/23/26, indicated Resident R3 was to receive ceftriaxone, two grams intravenously one time a day.

Review of June 2026 MAR and progress notes indicated that Resident R3 did not receive Ceftriaxone on:
6/05/26: "Unable to complete/ on back order from pharmacy."
6/11/26: Documented as held. Resident at CT scan, returned at approx. 1:30 p.m., no request to provider to see if it should be provided.
6/14/26: "Medication not available/ on back order from pharmacy."
6/15/26: "Unavailable."
6/24/26: Documented to see nurse's note on MAR. No nurse's note in EMR.

Review of physician's orders dated 6/4/26, 6/5/26, 6/6/26, and 6/10/26, indicated Resident R3 was to receive linezolid, 600 mg intravenously two times a day.

Review of physician's orders dated 6/22/26 and 6/23/26, indicated Resident R3 was to receive linezolid, 300 mg intravenously two times a day.

Review of June 2026 MAR and progress notes indicated that Resident R3 did not receive linezolid IV infusions on:
6/5/26, PM dose: Documented to see nurse's note on MAR. No nurse's note in emr.
6/6/26, AM dose: "awaiting from pharmacy."
6/07/26, AM dose: "not available."
6/07/26, PM dose: Documented to see nurse's note on MAR. No nurse's note in emr.
6/08/26, AM dose: Documented to see nurse's note on MAR. No nurse's note in emr.
6/08/26, PM dose: "med not available."
6/09/26, AM dose: "called pharmacy about IV ATB Linezolid" "Resident has not received this ATB since admission 6/6 reported to MD."
6/09/26, PM dose: "On order."
6/10/26, PM dose: No documentation.
6/11/26, AM dose: Documented as held. Resident at CT scan, returned at approx. 1:30 p.m., no request to provider to see if it should be provided.
6/16/26, PM dose: Documented as held. No note stating reason.
Review of Resident R3's progress notes did not include a reason for the omissions.

Review of Resident R3's progress notes dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R3's not receiving her ceftriaxone or linezolid on the above dates.

Review of Care Communications dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R3's not receiving her ceftriaxone or linezolid.

During an interview on 7/9/26, at 12:49 p.m. the attending physician confirmed that he had not been made aware by facility staff that Resident R3 had not received her ordered antibiotics.

Review of the clinical record indicated Resident R4 was admitted to the facility on 11/5/25.

Review of the MDS dated 6/18/26, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), osteoarthritis (degeneration of the joint causing pain and stiffness), and history of cancer.

Review of the plan of care initiated 5/23/25, for "Patient has a suspected/actual infection, UTI (urinary tract infection) and is at risk for sepsis" failed to include any updates after 10/14/25,
Review of a physician's order dated 6/6/26, at 7:40 a.m. indicated Resident R4 was to receive meropenem (broad-spectrum intravenous antibiotic used to treat serious bacterial infections) one gram intravenously three times per day. The medication was scheduled to be received at 6:00 a.m., 2:00 p.m., and 10:00 p.m., with the first dose to be given on 6/6/26, at 2:00 p.m.

Review of Resident R4's MAR and progress notes indicated that Resident R4 did not receive meropenem IV infusions on:
6/6/26, 2:00 p.m. dose: "med not available"
6/6/26, 10:00 p.m. dose: No documentation.
6/7/26, 6:00 a.m. dose: "unable to get IV access, med not delivered."
6/7/26, 2:00 p.m. dose: "awaiting on medication from pharmacy; Supervisor aware."
6/7/26, 10:00 p.m. dose: "pending pharmacy."
6/8/26, 6:00 a.m. dose: "no IV site to administer medication."

Review of Resident R4's progress notes dated 6/5/26, through 6/10/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R4's not receiving her meropenem on the above dates.

Review of Care Communications dated 6/5/26, through 6/10/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R4's not receiving her meropenem.

On 7/8/26, at 9:20 a.m. the Nursing Home Administrator (NHA) and the Interim Director of Nursing (DON) were made aware that an Immediate Jeopardy situation existed and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time.

On 7/8/26, at 3:20 p.m. an acceptable Corrective Action Plan was reviewed which included the following interventions:

R1 has been discharged from the facility. Upon identification that the resident did not receive the prescribed antibiotic for six days due to unavailability, the resident was immediately assessed by licensed nursing staff and founder of no adverse reaction. The provider was notified of the delaying antibiotic therapy period out of concern for further delay and potential for worsening infection, the patient was transferred to the hospital for evaluation with received prescribed antibiotic.
R2 for the month of June, the patient was found to have missed 14 out of 60 doses of Rifaximin. Upon identification, the patient was immediately assessed with no adverse reaction to the patient. The patient is now receiving the medication as prescribed by the provider.
R3 has been discharged from the facility The resident was found to have missed several doses of their prescribed antibiotic. Upon identification, the patient was immediately assessed with no adverse reaction. The patient's antibiotic stop date was extended to ensure that the patient received the required doses prescribed by the provider.
An initial audit of the current residents will be conducted by the Director of Nursing or designee for the past seven days to verify medications were available from the pharmacy and administered as per MD (Doctor of Medicine) orders. Any residents identified with unavailable meds will have the provider notified and mediation will be adjusted if indicated as per provider. Will be completed by 7/8/26.
The DON/designee conducted mandatory re-inservicing for facility licensed nurses and licensed agency nurses prior to the start of their next shift on the Medication Shortage, with the focus on notification to the provider and pharmacy for missing medications, medication administration, ordering of medications, and medication error policies. Education will include the process for obtaining medications from RxNow (medication dispensing machine) cabinet and notifying physician, or medication change if indicated.
The DON/designee will review new admissions on the following day to verify medications were delivered and administered as per the MD orders. Pharmacy and provider will be notified of any identified unavailable medications.
Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting Completed 7/7/26.
NHA/DON/designee sched a meeting on 7/8/26, with the pharmacy consultant to review concerns with medication availability and will schedule weekly x4 meetings, then monthly x2, to review any identified trends.
The Admissions Director will review scheduled admissions prior to arrival to verify medication availability from the pharmacy. If medication is not available, the Admissions Director will notify the hospital for a medication adjustment prior to discharge from the hospital.
DON or designee to conduct weekly x4, then monthly x2 audits of five residents on each medication cart to verify medications were available from the pharmacy and administered as per MD orders. Results of the audits to be presented at the QAPI meetings for review and recommendations.
Review of resident clinical records and facility provided audit on 7/9/26, confirmed that all residents were reviewed for missed medications and the attending physician was notified.

Review of facility-provided sign-in sheets, dated 7/8/26, and 7/9/26, confirmed reeducation was provided to all licensed nurses provider notification, actions to take if medications are not available, ordering medications, and documentation.

During interviews conducted on 7/9/26, confirmed two of two registered nurses and two of two licensed practical nurses received reeducation on provider notification, actions to take if medications are not available, ordering medications, and documentation.

Review of facility documents confirmed a meeting was completed with the NHA, DON, and the pharmacy consultant on 7/8/26, in which the process for reordering medications, pharmacy communication, procedure for missed medications, incomplete and/or inaccurate prescriptions, and the use of the RxNow dispensing unit were reviewed.

The Immediate Jeopardy was lifted on 7/9/26, at 11:30 a.m. when the action plan implementation was verified.

During an interview on 7/9/26, at approximately 12:15 p.m. the Nursing Home Administrator and the Interim Director of Nursing confirmed that the facility failed to implement procedures to ensure availability of prescribed medications. This failure resulted in an Immediate Jeopardy situation for four of 25 residents

28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 211.9(a)(1) Pharmacy Services
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: 07/29/2026

Residents R1 and R3 have been discharged from the facility. Resident R2 and R4 antibiotic therapy have completed their antibiotic therapy.
Current residents with orders for antibiotics will be reviewed for the past 7 days to ensure antibiotic medication is available, and to ensure the medical provider has been notified of inability to provide antibiotic medication if applicable, and care plan has been updated.
The DON/designee conducted mandatory re-in servicing for facility licensed nurses and licensed agency nurses prior to the start of their next shift on the Medication Shortage, with the focus on notification to the provider and pharmacy for missing medications, Med Administration, Ordering of medications and Med Error policies. Education will include the process for obtaining medications from Rx now cabinet and notifying pharmacy to send unavailable medication stat, or obtain a hold order from the physician, or medication change if indicated.
The Admissions Director was re-in serviced by the Clinical Lead on reviewing scheduled admissions prior to arrival to verify medication availability from the pharmacy. If medication is unavailable, the Admissions Director will notify the hospital for medication adjustment prior to discharge from the hospital to ensure nursing care and physical needs can be provided by the staff and facility.
The Pharmacy staff was re-inserviced on the process for new orders of antibiotics and medications to ensure they are made available to the facility as prescribed by the provider. The pharmacy was re-inserviced on the responsibility of triaging and notifying the back up pharmacy in order to ensure availability of new antibiotic medications as needed.
Licensed nurses will be provided Direct In-Service training by Lewis Litigation Support & Clinical Consulting LLC on 7/23/26 in service will include presentations on F755 Pharmacy Services. The presentation will also be recorded for staff unable to participate for the live training.
The DON/designee will conduct weekly audits of 5 residents with orders for antibiotics to verify availability, care plan is updated and to ensure the medical provider has been notified of inability to provide antibiotic medication if applicable.

The Audits will be conducted weekly x 4, then monthly x 2 audits

Results of the audits will be presented at the QAPi meetings for review and/or recommendations.

Compliance date: 07/29/2026

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

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.

з483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in з483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in з483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in з483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

з483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in з483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under з483.15(c)(9).

Observations: Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to notify the medical provider of the inability to provide ordered antibiotic medications for four of 25 residents (Residents R1, R2, R3, and R4). Findings include: Review of the facility policy, "Physician / Advanced Practice Provider (APP) Notification" dated 5/15/26, indicated an effective process for next day notification must be in place and communicated to all physicians/APPs and licensed nurses. During staff interviews completed on 7/7/25, indicated all notifications to provider will be through "Care Communications" (the electronic communication platform) or if by telephone, a progress note will be entered into the electronic medical records system. Review of a physician's order for Resident R1 dated 6/18/26: Ceftaroline Fosamil Intravenous Solution Reconstituted Use 300 mg intravenously two times a day for sepsis (life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs). Review of Resident R1's June 2026 medication administration record (MAR) indicated that Resident R1 did not receive ceftaroline, from admission (6/18/26) through 6/24/26, when he was hospitalized to allow him to receive the missed antibiotic medication. Review of Resident R1's progress notes dated 6/18/26, through 6/24/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R1 not receiving his ceftaroline. Review of Care Communications revealed one entry related to Resident R1 not receiving his IV antibiotic, written by RN Employee E2, dated 6/22/26, at 11:47 p.m., "Spoke with pharmacy regarding resident's iv ax (IV antibiotics) that was supposed to be stared on 6/18 for SEPSIS. They said that they left a message on Friday regarding a co-pay of $1,324.00 that would need approved. That is a Corporation issue he was accepted on that antibiotic and needs to be on it!! Has he been getting it???? If he hasn't, there WILL be big problems!!! SOMEONE SHOULD BE FIRED. I don't know why pharmacy has such a problem getting antibiotics for our residents." Review of an electronic communication written by Resident R1's attending physician dated 6/26/26, at 7:14 p.m. indicated, "There was notification to me via the communication board 6 days after the patient was there that they didn't send an IV antibiotic." "If there is a problem, contact me immediately. I have NEVER had an issue with someone reaching out to me especially if it has to do with an antibiotic or medication not being covered. I get called for much less relevant issues and I am fine with that." Review of Resident R2's physician's order dated 4/23/26, indicated Resident R2 was to receive Rifaximin (antibiotic that stays in gastrointestinal tract) 550 mg two times a day for hepatic encephalopathy. Review of June 2026 MAR and progress notes indicated that Resident R2 did not receive rifaximin for 14 of 60 scheduled doses, on 6/1/26, 6/2/26, 6/3/26, 6/5/26, 6/9/26, 6/10/26, 6/24/26, 6/25/26, 6/26/26, 6/27/26, 6/28/26 x 2 doses, and 6/29/26 x 2 doses. Review of Resident R2's progress notes and the Care Communications log dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R2's not receiving his Rifaximin on the above dates. During an interview on 7/9/26, at 12:49 p.m. the attending physician confirmed that he had not been made aware by facility staff that Resident R2 had not received his ordered antibiotics. Review of Resident R3's physician's orders dated 6/5/26, 6/6/26, 6/13/26, and 6/23/26, indicated Resident R3 was to receive ceftriaxone, two grams intravenously one time a day. Review of June 2026 MAR and progress notes indicated that Resident R3 did not receive Ceftriaxone on 6/5/26, 6/11/26, 6/14/26, 6/15/26, and 6/24/26. Review of physician's orders dated 6/4/26, 6/5/26, 6/6/26, and 6/10/26, indicated Resident R3 was to receive linezolid, 600 mg intravenously two times a day. Review of physician's orders dated 6/22/26 and 6/23/26, indicated Resident R3 was to receive linezolid, 300 mg intravenously two times a day. Review of June 2026 MAR and progress notes indicated that Resident R3 did not receive linezolid IV infusions on 6/5/26. 6/6/26, 6/7/26 x2 doses, 6/8/26 x2 doses, 6/9/26 x 2 doses, 6/10/26, 6/11/26, and 6/16/26. Review of Resident R3's progress notes and the Care Communications log dated 6/1/26, through 6/30/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R3's not receiving her ceftriaxone or linezolid on the above dates. During an interview on 7/9/26, at 12:49 p.m. the attending physician confirmed that he had not been made aware by facility staff that Resident R3 had not received her ordered antibiotics. Review of a physician's order dated 6/6/26, at 7:40 a.m. indicated Resident R4 was to receive meropenem (broad-spectrum intravenous antibiotic used to treat serious bacterial infections) one gram intravenously three times per day. The medication was scheduled to be received at 6:00 a.m., 2:00 p.m., and 10:00 p.m., with the first dose to be given on 6/6/26, at 2:00 p.m. Review of Resident R4's MAR and progress notes indicated that Resident R4 did not receive meropenem IV infusions on 6/6/26, 2:00 p.m. 6/6/26, 10:00 p.m., 6/7/26, 6:00 a.m., 6/7/26, 2:00 p.m., 6/7/26, 10:00 p.m., and 6/8/26, 6:00 a.m. Review of Resident R4's progress notes and the Care Communications log dated 6/6/26, through 6/9/26, failed to reveal notification to the nurse practitioner or to the physician related to Resident R4's not receiving her meropenem on the above dates. During an interview on 7/9/26, at approximately 12:15 p.m. the Nursing Home Administrator and the Interim Director of Nursing confirmed that the failed to notify the medical provider of the inability to provide ordered antibiotic medications for four of 25 residents. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.9(a)(1) Pharmacy Services 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: 07/29/2026

F580
Residents R1and R3 have been discharged from the facility. Resident R2 and R4 antibiotic therapy have completed their antibiotic therapy.

An initial audit of current residents with orders for antibiotics was conducted by the DON/designee for the past 7 days to verify antibiotics were provided and administered as ordered. The medical provider was immediately notified of any identified concerns.

The DON/designee will re-inservice licensed nurses on the Medication Shortage policy, Medication Ordering policy and Provider Notification.

The DON/designee will conduct weekly x 4, then monthly x 2 audits of documentation of medication administration to verify antibiotic medication was available, and to ensure the medical provider has been notified of inability to provide antibiotic medication if applicable.
Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Compliance date: 07/29/2026

з483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

з483.35 Nursing Services

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at з483.71.

з483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

з483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

з483.35(c) Proficiency of nurse aides.

The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Plan of Correction - To be completed: 07/29/2026

The facility can not retroactively correct the deficient practice for residents R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, and R19. Employees E4, E5, E6, E7, E8, E9, E10, E11, E12 and E13 have been re-inserviced on Medication Administration policy, Medication shortage policy, and medication availability via medication dispensing machine.

An initial audit of current residents will be conducted for the past 7 days to verify medications were available as per the providers orders. The medical provider will immediately be notified of any identified concerns. Access has been provided to licensed nurses, including agency nurses to the RxNow dispensing machine.

The DON/designee will re-inservice licensed nurses on Medication Administration policy, Medication shortage policy, and medication availability via medication dispensing machine.

The DON/designee will conduct weekly x 4, then monthly x 2 audits of documentation of 5 residents on each medication cart to verify medication was available as per the providers orders, and to ensure the medical provider has been notified of inability to provide medication if applicable. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Compliance date: 07/29/2026

483.70 REQUIREMENT Administration:

з483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Observations: Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the former Director of Nursing (DON) failed to implement procedures to ensure availability of prescribed medications. This failure resulted in a resident who was ordered intravenous antibiotic medication to be rehospitalized to receive the ordered medication (Resident R1). This failure created an Immediate Jeopardy situation for four of 25 residents who failed to receive medications (Resident R1, R2, R3, and R4). Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, "Create an environment where staff members are highly engaged and are focused on providing the highest level of clinical care and compassion to patients, residents and families. Responsible for assuring that the center operates in full compliance with Federal and State regulations while "Doing the Right Things", which will result in high levels of performance in each of the [Corporation] Strategic Focus Areas. The Administrator is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents." Review of the facility-provided Director of Nursing (DON) job description indicated, "The Director of Nursing leads the Center clinical team to fulfill the organization's mission, vision and values. This position has overall accountability for providing leadership, direction, and administration of day-to-day operations associated with direct patient care activities, nursing practice, and clinical education and development, including continuous improvement of nursing services and staff to meet patients/residents and their families' needs and expectations. The DON communicates a shared vision for clinical excellence and ensures the realization of high quality and cost-effective health care services that are consistent with [Corporation] evidence-based practices and policies, regulatory and other legal requirements, and philosophies. This position is responsible for driving, supporting and modeling a service-oriented culture focused on top of license practice, interprofessional collaboration, employee engagement, quality, patient safety, service excellence, fiscal responsibility, and the overall patient/resident experience. The DON collaborates with the Administrator and Center Leadership Team to drive business excellence, including strategic planning, budget preparation, and effective oversight of resource utilization." Based on findings identified in this report, the facility failed to prevent the failed to implement procedures to ensure availability of prescribed medications. The NHA and the previously employed DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 7/9/26, at approximately 12:15 p.m. the NHA and current DON confirmed that facility administration failed to implement procedures to ensure availability of prescribed medications. This failure resulted in a resident who was ordered intravenous antibiotic medication to be rehospitalized to receive the ordered medication (Resident R1). This failure created an Immediate Jeopardy situation for four of 25 residents who failed to receive medications. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 07/29/2026

Residents R1and R3 have been discharged from the facility. Resident R2 and R4 antibiotic therapy have completed their antibiotic therapy.

An initial audit of current residents with orders for antibiotics was conducted by the DON/designee for the past 7 days to verify antibiotics were provided and administered as ordered. The medical provider was immediately notified of any identified concerns.

The Market Operations Advisor/designee will re-educate the Nursing Home Administrator and Director of Nursing on their job descriptions and fulfill their essential job duties to ensure the federal and state guidelines and regulations are followed, to include overseeing staff following procedures to ensure availability of prescribed medications.
The NHA/DON/designee will complete random audits weekly x 4, then monthly x 2 of two medication carts to verify antibiotic medications are available as ordered. The NHA/DON/designee will conduct random interviews of 5 nurses weekly x 4, then monthly x 2 to verify ongoing knowledge of the medication availability process.

The Market Operations Advisor or designee will monitor the Director of Nursing and the Administrators job performance monthly x 3 to ensure they are fulfilling their essential job duties to include overseeing staff following procedures to ensure availability of prescribed medications Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Compliance date: 07/29/2026

з 201.24(c) LICENSURE Admission policy.:

(c) A facility shall admit only residents whose nursing care and physical needs can be provided by the staff and facility.

Observations: Based on a review of facility documents, clinical record review, and staff interviews it was determined that the facility failed to admit only residents whose nursing care and physical needs can be provided by the staff and facility. for one out of four residents (Resident R1). Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on 6/18/26. Review of the hospital referral documents sent to the facility, included the following information from the Infectious Disease physician: - Resident R1 required long-term antibiotic therapy. - "I am going to recommend IV antibiotics for several weeks along with clinical follow up. I do want to cover more broadly than just anaerobes. So, in addition to the Flagyl (antibiotic and antiprotozoal medication) I would like to have some aerobic Gram-negative and Gram-positive coverage with ceftaroline ("Teflaro," broad-spectrum cephalosporin antibiotic administered intravenously for treating complicated skin and soft tissue infections). During an interview on 7/7/26, at 12:34 p.m. Admissions Employee E1 confirmed that he processed the referral for Resident R1. Admissions Employee E1 stated that referrals usually include demographic information, insurance information, a medical history and physical, psychiatric history information, and that he is able to review information from the hospital charting system. When asked, Admissions Employee E1 confirmed that he does not have a clinical background, and confirmed that he uses facility provided guidelines and medication pricing guidelines. Review of the facility-provided, "High Cost List" indicated Teflaro to have an average cost per dispensed day of $500-$999. During a follow-up interview on 7/8/26, at 9:05 a.m. Admissions Employee E1 stated that he did not know that the brand name of ceftaroline was Teflaro, and thought the medication would be similar to other cephalosporin antibiotics (cefepime, ceftazidime, ceftriaxone) that average less than $25 per dispensed day. Admissions Employee E1 confirmed that when he did not recognize the medication, he should have consulted clinical staff or further investigated the medication to ensure that the facility could provide the medication. Review of an entry in the facility "Care Communications' (electronic communication platform) revealed an entry written by Registered Nurse Employee E2 on 6/22/26, at 11:47 p.m., "Spoke with pharmacy regarding resident's iv ax (IV antibiotics) that was supposed to be stared on 6/18 for SEPSIS (life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs). They said that they left a message on Friday regarding a co-pay of 1,324.00 that would need approved. That is a Corporation issue he was accepted on that antibiotic and needs to be on it!! Has he been getting it???? If he hasn't, there WILL be big problems!!! SOMEONE SHOULD BE FIRED. I don't know why pharmacy has such a problem getting antibiotics for our residents." During an interview on 7/9/24, at approximately 12:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that facility failed to admit only residents whose nursing care and physical needs can be provided by the staff and facility for one of four residents.

Plan of Correction - To be completed: 07/29/2026

Resident R1 has been discharged from the facility.
Current scheduled admissions will be reviewed by the Admissions Director or designee prior to arrival to verify medication availability from the pharmacy. If medication is unavailable, the Admissions Director will notify the hospital for medication adjustment prior to discharge from the hospital. The Admissions DIrector will consult with the DON/designee if unfamiliar with a medication to ensure nursing care and physical needs can be provided by the staff and facility.
The Admissions Director was re-inserviced by the Clinical Lead on reviewing scheduled admissions prior to arrival to verify medication availability from the pharmacy. If medication is unavailable, the Admissions Director will notify the hospital for medication adjustment prior to discharge from the hospital to ensure nursing care and physical needs can be provided by the staff and facility.

The Admissions Director/designee will conduct weekly x 4, then monthly x 2 audits of scheduled admissions to verify medication availability from the pharmacy, and If medication is unavailable, notification to the hospital for medication adjustment prior to discharge was completed. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Compliance date: 07/29/2026

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