Pennsylvania Department of Health
CAMP HILL SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CAMP HILL SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 214 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.


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

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights survey completed on February 26, 2026, it was determined that Camp Hill Skilled Nursing and Rehabilitation 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.

Plan of Correction:

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

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(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 facility policy review, observations, and staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in one of three nursing units observed.

Findings include:

Review of facility policy, titled "Safe and Homelike Environment" last reviewed January 5, 2026, read, in part, "The resident/patient has the right to a safe, clean, comfortable, and homelike environment that de-emphasizes the institutional character of the setting. The center must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior."

Observations in Resident 22's room on February 24, 2026, at 10:30 AM and at 2:12 PM, revealed the wall was damaged in a corner of the room, the baseboard was coming away from the wall, four of the ceiling tiles in her room had brown stains on them, and there were holes in the wall above her bed.

Observation in Resident 22's room on February 25, 2026, at 9:51 AM, revealed the wall was damaged in a corner of the room, the baseboard was coming away from the wall, four of the ceiling tiles in her room had brown stains on them, and there were holes in the wall above her bed, consistent as the day before.

Observations in Resident 26's room on February 24, 2026, at 10:30 AM and at 2:11 PM, revealed her tray table was dirty with a spilled liquid, and the floor around her bed was dirty.

Observation in Resident 26's room on February 25, 2026, at 9:50 AM, revealed her tray table was dirty with a spilled liquid, and the floor around her bed was dirty, consistent as the day before.

Observations in Resident 30's room on February 24, 2026, at 10:25 AM and at 2:11 PM, revealed the table on the side of her bed was dirty with several rings from beverage cups, and the floor underneath the table was dirty.

Observation in Resident 30's room on February 25, 2026, at 9:49 AM, revealed the table on the side of her bed was dirty with several rings from beverage cups, and the floor underneath the table was dirty, consistent as the day before.

Observations in Resident 84's room on February 24, 2026, at 12:27 PM and at 2:13 PM, revealed the baseboard was coming away from the wall and the wall was damaged.

Observation in Resident 84's room on February 25, 2026, at 9:52 AM, revealed the baseboard was coming away from the wall and the wall was damaged, consistent as the day before.

During an interview with the Nursing Home Administrator (NHA) on February 25, 2026, at 2:04 PM, the surveyor communicated the environmental concerns in Resident 22's, 26's, 30's, and 84's rooms, the NHA revealed the concerns would be addressed immediately, and he would expect the facility to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and home-like environment.

28 Pa. Code 201.18(e)(2.1) Management

Plan of Correction - To be completed: 04/21/2026

1.) Residents #22, #26, #30, and #84's identified room areas of concern were repaired immediately upon notification during survey.

2.) A house wide audit of resident rooms and common areas will be conducted to identify/repair any outstanding issues that require immediate attention.

3.) The Director of Maintenance/designee will re-educate the maintenance department on OPS200 Safe and Homelike Environment policy.

4.) The Nursing Home Administrator/designee will conduct weekly audits of five resident rooms and common area for four weeks and then monthly for three months to identify and then notify the maintenance team utilizing the facility work order system for identified necessary repairs to achieve compliance. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§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.

Plan of Correction - To be completed: 04/21/2026

1.) The identified food that was not correctly dated and/or expired was discarded at the time of the survey. Freezer One's temperature was decreased and monitored, and freezer Three was thoroughly cleaned to ensure compliance. The scoops were removed and stored appropriately.

2.) A storage/cleanliness audit will be conducted by the Food Service Director/designee to identify any further storage/cleanliness issues that need to be addressed. Corrections will be made as necessary.

3.) The Food Service Director/designee will re-educate the food service staff on the facility's policies Food Storage: Cold Food and Food Storage: Dry Goods, including kitchen temperature log completion and kitchen cleanliness.

4.) The Food Service Director/designee will complete a storage/cleanliness audit weekly for four weeks and then monthly for two months. The Food Storage Director/designee will audit dishwasher temperature logs weekly for four weeks then monthly for two months. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

483.60(e)(1)(2) REQUIREMENT Therapeutic Diet Prescribed by Physician:

§483.60(e) Therapeutic Diets
§483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.

§483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.

Observations:

Based on facility policy review, review of facility diet extension sheets, review of nutrition facts label, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician for six of 36 residents reviewed on a consistent carbohydrate diet (Residents 5, 8, 15, 52, 68, and 106).

Findings include:

Review of facility policy, titled "Consistency Alterations and Therapeutic Menus" last reviewed January 5, 2026, read, in part, "The menu is written for a regular/liberalized diet and is extended for a number of therapeutic diets. Purpose: to provide diets as ordered by the physician/advance practice provider (APP). The menu is extended for the following therapeutic diets [including] Consistent Carbohydrate."

Review of facility diet extension sheet for the lunch meal on February 25, 2026, revealed the regular/liberalized diet should be served a slice of angel food cake, and the consistent carbohydrate diet should be provided a slice of diet angel food cake.

Observations during tray line meal service on February 25, 2026, between 12:07 PM and 12:41 PM, revealed Residents 5, 8, 15, 52, 68, and 106 were served a piece of angel food cake on their trays.

Review of physician orders for Resident 5, 8, 15, 52, 68, and 106 revealed they were ordered a consistent carbohydrate diet for diabetes.

Review of physician orders for Resident 4, 6, 7, 9, 10, 16, 20, 24, 31, 35, 49, 50, 59, 64, 67, 69, 75, 77, 78, 85, 87, 88, 89, 96, 99, 104, 109, 110, 123, 124, and 126, revealed they were also ordered a consistent carbohydrate diet for diabetes.

During an interview with Employee 4 (Dietary Manager) on February 25, 2026, at 12:46 PM, he revealed the angel food cake served at lunch today was the same angel food cake served across all diet orders.

Review of the nutrition facts and ingredients label for "Angel Food Bundt Cake" served at the lunch meal on February 25, 2026, revealed the cake contained 28 grams of total carbohydrates and 20 grams of sugar. Further review of the ingredients revealed the number one ingredient of the cake was sugar, and there were no sugar substitutes present in the ingredients.

Interview with the Nursing Home Administrator on February 25, 2026, at 2:06 PM, revealed he would expect therapeutic diets to be provided as ordered and extension sheets to be followed for therapeutic diet alterations.

28 Pa Code 201.18(b)(1)Management

Plan of Correction - To be completed: 04/21/2026

1.) Residents #5, #8, #15, #52, #68, and #106 had no negative effect from being served angel food bundt cake and not diet angel food bundt cake.

2.) The Food Services Director/designee will complete an audit of the current facility residents' diet orders, meal tickets and extension sheets to ensure they are being followed for therapeutic diet alterations. Corrections will be made as necessary.

3.) The Food Services Director will re-educate the kitchen staff regarding the requirement to provide diets as ordered by the physician/advanced practice provider.

4.) The Food Services Director/designee will complete an audit of the ten random facility resident meal trays, meal tickets and extension sheets weekly for four weeks, then monthly for three months to ensure they are being followed for therapeutic diet alterations. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

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

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

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

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

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

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

Observations:

Based on facility policy, staff interview, and clinical record review, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medications use and obtain consent prior to administering psychotropic medications for one of five residents reviewed for psychotropic medication use (Resident 4).

Findings included:

Review of facility provided policy, titled NSG206 Behaviors; Management of Symptoms, revised September 25, 2025, revealed, "When medication is ordered for behavioral symptoms: Obtain consent."

Review of Resident 4's clinical record revealed diagnoses that included major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) and dementia (a general term for severe mental function loss).

Review of Resident 4's physician orders revealed an order for Zoloft (medication used to treat depression) 25 mg, given by mouth at bedtime for depression, starting on January 29, 2026. Further review revealed an order for Olanzapine (antipsychotic medication) 5 mg at bedtime for psychotic behaviors, starting on December 21, 2025.

Review of Resident 9's Care plan revealed a focus of: Resident 4 is at risk for complications related to the use of psychotropic drugs, created on December 22, 2025.

Review of Resident 9's medical record failed to reveal an explanation for the risks and benefits of psychotropic medications and consent for use of those medications by Resident 4 or their Representative.

Interview with the Director of Nursing on February 25, 2026, at 1:45 PM, revealed that Resident 4 did not have the appropriate notifications made prior to starting psychotropic medications.

211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/21/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1.) Psychotropic medication consent obtained from Resident #4's representative on February 25, 2026.

2.) Audit of current facility residents with orders for psychotropic medications will be completed by the Director of Nursing\designee and consents obtained from the residents or their representatives as necessary.

3.) Facility Licensed Nurses will be educated on policy NSG206 Behaviors Management of Symptoms with a focus on obtaining consent for psychotropic medications.

4.) The Director of Nursing\designee will conduct weekly audits for four weeks of newly admitted residents with psychotropic medication orders to ensure informed consent has been obtained, then monthly for three months. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Plan of Correction - To be completed: 04/21/2026

1.) Residents #120, #121, and #122 have been discharged from the facility.

2.) The Social Services Director/designee will complete an audit of current facility residents to ensure provision of a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF-ABN) notice was issued as applicable. Corrections will be made as necessary.

3.) Employees within the Social Services department, MDS Coordinators and department managers will receive re-education on when to provide a SNF-ABN to facility residents.

4.) The Social Services Director/designee will audit three random resident SNF-ABN weekly for four weeks, then monthly for three months to ensure they were issued as applicable. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

483.25 REQUIREMENT Quality of Care:

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

Observations:

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice for one of the 24 residents reviewed (Resident 5).

Findings Include:

Review of the facility's policy, titled "Person-Centered Care Plan," recently reviewed January 5, 2026,defined professional standards of Quality as "care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting."

Review of Resident 5's clinical record revealed diagnoses that included cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged), chronic kidney disease (a long-term, progressive condition where the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), and dementia (a loss of thinking, remembering, and reasoning skills).

Review of Resident 5's census information revealed multiple hospital transfers and included a hospital transfer date of October 26, 2025, with a return and readmission to the facility on November 2, 2025.

Review of the facility's document titled "Consultant Pharmacist's Progress Note," dated November 4, 2025, revealed the following documented as "Transcription Errors":

"Hospital d/c [discharge order] Lactulose 10 gm/15 m/-Give 30 ml TID [three times per day]. ... Current order: Lactulose 10 gm/15ml-Give 30 ml QD [once per day]."

Upon review by the Certified Registered Nurse Practitioner (CRNP) (Employee 2), it was revealed that an agreement to change the lactulose order to the recommended dosage made on the hospital discharge summary.

Review of the pharmacist's progress notes also revealed "Hospital d/c order-Tamsulosin 0.4 QD. ... Current order - Tamsulosin 0.4 mg-Give 2 capsules (0.8mg)."

Upon review by Employee 2, an agreement was documented to change to "0.4 mg 1 cap at HS [hour of sleep- bedtime]."

Review of the pharmacist's progress notes revealed "Hospital d/c order-Bumetanide 1 mg BID [twice per day]. ... Current order- Bumetanide 0.5 mg BID."

Upon review by Employee 2, an agreement was documented to change the medication order "to Bumetanide 1 mg BID."

Continued review of Resident 5's monthly consultant pharmacy recommendation for the Resident's physician to address, dated November 20, 2025, read "Per DC [discharge summary] resident was ordered levothyroxine 37.5 mg po [by mouth] ONCE DAILY. ... On 11/3/2025, it was ordered twice daily; this med [medication] typically dosed once daily."

Upon review of the pharmacy recommendation, Employee 2 agreed with the recommendation and documented "Please change to 37.5 mcg ONCE daily."

An interview with the Director of Nursing on February 26, 2026, at 10:15 AM, revealed that the Registered Nurse (Employee 1) did not have possession of Resident 5's hospital discharge record and used the prior medication list to review with the physician at Resident 5's readmission to the facility. The interview revealed that Employee 1 should have used the hospital discharge medication order recommendations to review with the physician and add to Resident 5's clinical record instead of Resident 5's medications listed before the hospitalization.

28 PA. Code 211.12 (d) (1) (2) (5) Nursing services

Plan of Correction - To be completed: 04/21/2026

1.) Orders for Resident #5 have been reviewed and are correct.

2.) An audit of current facility residents that admitted in the past 14 days will be conducted by the Director of Nursing\designee to ensure that hospital discharge instructions are present in the medical record and that medication orders have been transcribed using the hospital discharge orders. Corrections will be made as necessary.

3.) Facility Licensed Nurses will be educated on policy OPS424 Medication Reconciliation with a focus on obtaining the hospital discharge orders prior to transcribing the orders and on utilizing an admission medication reconciliation checklist that will require a second nurse to verify that the orders have been transcribed correctly.

4.) An audit of admissions\readmissions will be conducted weekly for four weeks then monthly for three months by the Director of Nursing\designee to ensure that hospital discharge instructions are present in the medical record and that medication orders have been transcribed using the hospital discharge orders. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§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 clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure 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 for one of two residents reviewed (Resident 8).

Findings include:

Review of Resident 8's clinical record revealed diagnoses that included polyneuropathy (a nerve disease caused by damage to many nerves) and hypertension (high blood pressure).

Observation conducted of Resident 8 on February 24, 2026, at 10:13 AM, revealed the Resident was lying in bed, not wearing a float heel, and did not have any pillows placed under their foot.

Interview conducted with Resident 8 on February 25, 2026, at 11:58 AM, revealed that he hardly ever wears a right heel boot as staff do not place it on him. Resident 8 revealed his heel boot was in his closet.

Observation conducted of Resident 8 on February 25, 2026, at 11:59 AM, revealed the Resident lying in bed, not wearing a float heel, and did not have any pillows placed under their foot.

Observation conducted of Resident 8 on February 25, 2026, at 12:36 PM, revealed the Resident lying in bed, without a float heel on.

Review of Resident 8's care plan revealed a focus area that the Resident is at risk for skin breakdown related to pressure ulcer to right heel, revised on January 23, 2026; with an intervention to wear a prevalon boot to right foot when in bed.

Review of Resident 8's clinical record revealed the Resident had a wound assessment completed on January 15, 2026, for a pressure ulcer on their right heel, with a nutrition recommendation for a dietitian consultation, as well as a recommendation to place heel-float boots to bilateral feet while in bed to offload the heels.

The facility was unable to provide documentation that a dietary consultation has been made or conducted per the wound assessment recommendation above for Resident 8.

Review of Resident 8's clinical record revealed their most recent dietary consult was conducted on September 29, 2025.

Review of Resident 8's clinical record revealed the Resident had a wound assessment completed on January 22, 2026, with the following treatment recommendations: primary dressing: 1. Santyl ointment; secondary dressing: 1. Vashe moistened gauze 2. Foam; this treatment will be done daily and as needed until discontinued.

Review of Resident 8's January 2026 TAR (Treatment administration record) revealed an order for: Santyl External Ointment 250 unit/gram (Collagenase); apply to right heel topically every day shift for pressure ulcer, with a start date of January 23, 2026, and a discontinue date of January 31, 2026. The order failed to include the secondary dressing in the recommendation from the wound assessment above on January 22, 2026.

Review of Resident 8's February 2026 TAR revealed an order for: Right heel boots on all the time except for care every shift for pressure ulcer prevention, with a start date of October 23, 2025. Further review of the TAR revealed that on February 24 and 25, 2026, during every shift, it was documented that Resident 8 was wearing a right heel boot.

During an interview with the Nursing Home Administrator and Director of Nursing on February 26, 2026, at 10:05 AM, revealed they would expect Resident 8 to be wearing their heel boot as ordered and documented, would expect wound assessment recommendations to be completed, and for wound orders to be put in correctly.

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

Plan of Correction - To be completed: 04/21/2026

1.) Resident # 8 was assessed by the licensed nurse and heel offloading boot applied per physician order during the survey. Resident #8's wound care treatment order was reviewed and corrected to accurately reflect the current treatment recommendations during the survey. Consultation by registered dietitian was completed 2/17/2026 with no new recommendations.

2.) The facility's Skin Health Team Lead nurse/designee will conduct an audit of current facility residents with physician orders for heel offloading devices, active wound care treatments, and wound care recommendations requiring dietary consults to verify that ordered interventions are in place, physician orders are accurately entered, and dietary consults have been completed as recommended. Corrections will be made as necessary.

3.) The facility Nursing staff will be re-educated on ensuring heel boots are in place. The facility Licensed Nursing staff will be re-educated on ensuring accurate transcription and entry of wound treatment orders and initiating dietary consults when recommended by the wound care provider.

4.) The facility's Skin Health Team Lead nurse/designee will conduct ongoing audits of all residents with active orders for heel boots to ensure that they are applied as ordered. The Skin health team lead nurse/designee will audit all new wound treatment orders to ensure they are transcribed accurately. The skin health team lead nurse/designee will audit all weekly wound provider recommendations to ensure dietary consults have been completed as recommended. All audits will be completed weekly for four weeks, then monthly for three months. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on clinical record review, observation, policy review, and staff interview, it was determined that the facility failed to provide respiratory services in accordance with professional standards of practice for one of 26 residents (Resident 97) reviewed for respiratory care.

Findings include:

Review of facility provided policy, titled Oxygen: Concentrator, revised August 7, 2023, revealed when implementing supplemental oxygen for a resident, step 1. Verify order.

Review of Resident 97's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive, incurable, but treatable lung disease) and obstructive sleep apnea (serious, common sleep disorder where throat muscles relax excessively, causing repeated airway collapse and breathing pauses [apnea] during sleep).

Observation of Resident 97 on February 24, 2026, at 10:24 AM, revealed Resident 97 lying in bed. Resident 97 was wearing a nasal canula (oxygen delivery device) and receiving supplemental oxygen at 2 liters per minute.

Review of Resident 97's care plan revealed a care plan of: Resident exhibits or is at risk for respiratory complications related to recent hospitalization, COPD, created on October 23, 2025.

Review of current physician orders for Resident 97 failed to reveal a physician's order for supplemental oxygen.

Interview with the Director of Nursing on February 26, 2026, at 10:15 AM, revealed that Resident 97 had an order for supplemental oxygen previously, but the order had not been renewed.

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

Plan of Correction - To be completed: 04/21/2026

1.) The physician was notified of the need for oxygen, and an order was obtained and entered into the medical record for Resident #97 during the survey.

2.) The Director of Nursing/designee will audit current facility residents requiring supplemental oxygen to ensure that the physician's order is present in the medical record. Corrections will be made as necessary.

3.) The facility Licensed Nurses will be re-educated on the requirement that all treatments, including oxygen therapy, must have a current physician order before administration. Licensed Nurses will be re-educated on ensuring oxygen therapy orders are present during monthly order reviews.

4.) The Director of Nursing/designee will audit current facility residents requiring supplemental oxygen to ensure that the physician's order is present in the medical record weekly for four weeks, then monthly for three months, to ensure physician orders are present. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Plan of Correction - To be completed: 04/21/2026

1.) Resident #86 no longer resides in the facility.

2.) The Director of Nursing/designee will conduct an audit of current facility residents with orders for topical pain medications, including Lidocaine patches, to ensure the physician orders include an application site. Corrections will be made as necessary.

3.) The facility licensed nurses will be re-educated on Policy OPS410 Physician/Advanced Practice Provider (APP) Orders and ensuring that physician orders for topical medications specify application sites, and clarifying incomplete orders.

4.) The Director of Nursing/designee will conduct an audit of current facility residents with new orders for topical pain medications, including Lidocaine patches, to ensure the physician orders include an application site weekly for four weeks then monthly for three months. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents reviewed (Resident 7).

Findings Include:

Review of facility policy, titled "Trauma Informed Care and Culturally Competent Care," effective May 1, 2024, revealed, "Process: 6. The Center will identify triggers which may re-traumatize patients with a history of trauma. Trigger specific interventions will identify ways to decrease the patient's exposure to triggers which re-traumatize the patient, as well as identify ways to mitigate or decrease the effect of the trigger on the patient and will be added to the patient's care plan."

Review of Resident 7's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma, accompanied by intense emotional and physical reactions) and major depressive disorder (ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).

Review of Resident 7's clinical record revealed the Resident was seen by a psychiatry on December 31, 2025, and January 20, 2026, with documentation of the visit to include the Resident had trauma history with being abused as a child by stepfathers and prefers not to have male caregivers.

Review of Resident 7's care plan on February 24 and 25, 2026, revealed a care plan for Resident 7 being at risk for distressed/fluctuating mood symptoms related to anxiety and PTSD, initiated and created on December 1, 2025. Further review of Resident 7's care plan failed to reveal an intervention that the Resident prefers not to have male caregivers, or any triggers identified.

Review of Resident 7's clinical record revealed the Resident had a trauma assessment completed on February 25, 2026, at 12:52 PM, and scored a 4, which indicated a positive screen for trauma.

Interview conducted with the Nursing Home Administrator on February 26, 2026, at 10:04 AM, revealed he would have expected Resident 7's trigger of male caregivers to have been added to her care plan prior to this date and have been in place.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management
28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Plan of Correction - To be completed: 04/21/2026

1.) A Trauma Informed Care Screening was completed for Resident #57 by the Regional Social Services Director during the survey.

2.) The Social Services Director/designee will complete an audit of current facility residents to ensure a Trauma Informed Care Screening was completed and his\her care plan updated. Corrections will be made as necessary.

3.) The Regional Social Services Director or Designee will provide re-education to the Social Services Department on the policy OPS219 Trauma Informed Care and the importance of care planning interventions and preferences.

4.) The Social Services Director/designee will complete an audit of all newly admitted\readmitted facility residents to ensure a Trauma Informed Care Screening was completed and his\her care plan updated as needed. Audits will be completed weekly for four weeks then monthly for three months. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Observations:

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure Medication Regimen Reviews were responded to by the attending physician or prescriber for one of five residents reviewed (Resident 4).

Findings include:

Review of facility policy, titled Medication Regimen Review and Reporting, revised January 2024, revealed, "For recommendations that do not require physician intervention, the director of nursing or licensed designee will address the recommendations."

Review of Resident 4's clinical record revealed diagnoses that included major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) and dementia (a general term for severe mental function loss).

Review of Resident 's medical record revealed a recommendation made on September 9, 2025, by the consultant pharmacist to add an parameters for Resident 4's PRN (as needed) pain medication. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity.

Review of Resident 's medical record revealed a recommendation made on December 29, 2025, by the consultant pharmacist, to add an appropriate dose for Resident 4's pain medication. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity.

Interview with the Director of Nursing on February 26, 2026, at 10:45 AM, revealed that they would expect the regulation to be followed and that the physician would review the irregularities, document what, if any, action has been taken to address it, and document his or her rationale in the resident's medical record.

28 Pa. Code 211.10(c) Resident care policies.

Plan of Correction - To be completed: 04/21/2026

1.) A Drug Regimen Review (DRR) for Resident #4 with a date of 12/29/25 was reviewed by the provider, and the order will remain at 2 grams four times daily/QID.

2.) The Director of Nursing/designee will complete an audit of DRRs for the last two months to ensure that the provider has reviewed and responded to the recommendation(s). Corrections will be made as necessary.

3.) The facility Director of Nursing and Unit Managers will be re-educated on the policy "Medication Regimen Review".

4.) The Director of Nursing/designee will complete an audit of ten random DRRs monthly for four months to ensure that the DRR recommendation(s) were reviewed with the provider and were responded to. Corrections will be made as necessary. Audit results will be reviewed with the Quality Assurance Performance Improvement committee to ensure compliance.

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