Pennsylvania Department of Health
 OAKWOOD HEIGHTS VILLAGE
Patient Care Inspection Results

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OAKWOOD HEIGHTS VILLAGE
Inspection Results For:

There are  91 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.
OAKWOOD HEIGHTS VILLAGE - 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 Compliance Survey completed on February 6, 2026, it was determined that Oakwood Heights Village 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(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on resident interviews, review of facility policy and resident council minutes, and resident and staff interviews, it was determined that the facility failed to respond to resident concerns identified during resident council minutes for three of three months reviewed (November 2025, December 2025, and January 2026).

Findings include:

Review of a facility policy entitled, "Resident Council" dated 1/28/26, indicated that a Resident Council Response Form will be utilized to track issues and their resolution and the facility department related to any issues will be responsible for addressing the item(s) of concern.

During an interview on 2/04/26, at 10:45 a.m. Resident Council Members (Residents R5, R56, R58, R67, R79, and R86) confirmed they do not receive responses to previous Resident Council concerns and do not believe Resident Council concerns are resolved in a timely manner due to the number of ongoing concerns voiced by the group.

Review of November 2025, Resident Council Meeting Minutes revealed: new business included a leaking faucet, broken call bell, and missing clothing; ongoing business included residents upset with dirty floors and bathrooms, windows needed cleaning, and staff wearing name tags; resolved business included a beautician was hired. There was no evidence that the facility utilized a Resident Council Response Form to track issues and their resolution, and that the department related to any issues addressed the item(s) of concern.

Review of December 2025, Resident Council Meeting Minutes revealed: new business included the same broken call bell, requests of a Nurse Aid to help in the dining room, the beautician leaving; ongoing business included residents upset with dirty floors and bathrooms, the leaking faucet, and staff still not wearing name tags. There was no evidence resident concerns from the previous month's meeting were resolved and/or discussed, and there was no evidence that the facility utilized a Resident Council Response Form to track issues and their resolution, and that the department related to any issues addressed the item(s) of concern.

Review of January 2026, Resident Council Meeting Minutes revealed: new business included poor floor care, wrinkled clothing, call bell response times, staffing, missing clothing, activities, room temperatures, and Administrator participation in the meetings. There was no evidence resident concerns from the previous month's meeting were resolved and/or discussed, and there was no evidence that the facility utilized a Resident Council Response Form to track issues and their resolution, and that the department related to any issues addressed the item(s) of concern.

Review of facility Concern, Comment, Procedure Forms revealed:

On 8/23/25, a concern was submitted that Room 317 and the bathroom needed a deep clean and the floors were sticky, and that the resident needed help with eating. Facility findings included, the floor scrubber was broken. Corrective action included, Environmental Services Director and Administrator were notified and that the room would be cleaned.

On 9/02/25, a concern was submitted that Room 209's bathroom floor was dirty and that family cleaned it. The corrective action included, Environmental Services Director would handle this with his/her team.

During an interview on 2/04/26, at 1:15 p.m. the Nursing Home Administrator confirmed that there was lack of evidence that the repeated concerns from Resident Council and/or Concern, Comment, Procedure Forms were resolved, and there was a lack of evidence that the Resident Council was informed of the concern outcomes and was satisfied with the outcomes by the facility.

28 Pa. Code 201.14(a) Responsibility of Licensee

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

28 Pa. Code 201.18(e)(1)(4) Management





 Plan of Correction - To be completed: 04/03/2026

Prior to survey facility had done a sweep and reminder for all staff on the importance of wearing name badges and provided free name badges.

Maintenance did a house wide training / refresher on using the TELS work order system for tracking repairs. Facility did not appropriately share these efforts with resident council. A refresher of this January training will be completed as part of the current plan of correction

Administrator will meet with Resident Council and review the addition and importance of noting follow up responses in "Old Business" in the Resident Council Minutes and address to request administrator or any team member to resident council.

Resident Council will be inserviced by administrator on their right to request the attendance of the NHA or any member of the facility team to discuss any concerns or ideas to improve.

Department Managers will review the minutes once completed in next AM meeting and discuss any items that will require follow-up.
Specifically, any item requiring repairs will be placed in TELS – the facility monitoring and work order system which will acknowledge the completion of the issue. The staff will be reeducated on how to place items in TELS as they arise.

Concerns not involving repairs and maintenance brought forth in Resident Council will be placed on the facility concern and grievance form and given to Social Services Director to properly track the identification – and resolution – of these items. The staff, residents and families will be reeducated on the locations and how to fill out a facility concern and grievance form. New grievances are reviewed as part of the AM meeting process and assigned to the appropriate person(s) for follow up by the Social Services Director.

Incomplete TELS workorders and unresolve concerns and grievances will be reviewed daily as part of the AM meeting process.

The TELS work order summary, monthly grievance log and resident council minutes – with specific review of reported resolutions or repeating issues will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee as part of the monthly ongoing agenda.

483.30(b)(1)-(3) REQUIREMENT Physician Visits - Review Care/Notes/Order: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.
§483.30(b) Physician Visits
The physician must-

§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;

§483.30(b)(2) Write, sign, and date progress notes at each visit; and

§483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
Observations:

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician signed and dated all orders during visits for nine of 21 residents reviewed (Residents R4, R7, R10, R18, R19, R22, R23, R58, and R67).


Findings include:

Review of facility policy entitled "Physician Visits and Physician Delegation" dated 1/28/26, revealed "The physician should: See resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law ... Sign and date all orders ..."

Review of resident R4's clinical record revealed an admission date of 11/26/18, with diagnoses that included Alzheimer's disease (a progressive disorder that affects memory, thinking skills, and ability to perform simple tasks), diabetes (a chronic disease where the body does not produce enough insulin or cannot use it efficiently), and muscle weakness.

Review of Resident R4's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days.


Review of Resident R7's clinical record revealed an admission date of 1/7/25, with diagnoses that included asthma (a long term lung disease that causes the airways to narrow and make it difficult to breath), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure).

Review of Resident R7's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days.


Review of Resident R10's clinical record revealed an admission date of 5/30/25, with diagnoses that included hypertension, hyperlipidemia (high cholesterol) and muscle weakness.

Review of Resident R10's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days.


Review of Resident R18's clinical record revealed an admission date of 12/1/24, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), diabetes, and chronic kidney disease.

Review of Resident R18's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days.


Review of Resident R19's clinical record revealed an admission date of 2/25/25, with diagnoses that included chronic obstructive pulmonary disease, heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), and hyperlipidemia.

Review of Resident R19's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days.


Resident R22's clinical record revealed an admission date of 9/04/19, with diagnoses including heart disease/failure, COPD, and Type 2 Diabetes (condition that happens when the body cannot use insulin correctly and sugar builds up in the blood).

Review of Resident R22's clinical record revealed that his/her physician orders were signed on 9/12/25, and not again until 1/26/26, which was beyond the required 60 days.


Review of Resident R23's clinical record revealed an admission date of 10/25/24 with diagnoses that included heart failure, hypertension, and atrial fibrillation (irregular heartbeat).

Review of Resident R23's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days.


Review of Resident R58's clinical record revealed an admission date of 4/8/22, with diagnoses that included hypertension, gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and hyperlipidemia.

Review of Resident R58's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days.


Review of Resident R67's clinical record revealed an admission date of 10/19/25, with diagnoses that included hypertension, chronic kidney disease, and muscle weakness.

Review of Resident R67's clinical record revealed that his/her physician orders were signed until 1/26/26, which was beyond the required 60 days.

During an interview on 2/5/26, at 2:06 p.m. the Director of Nursing confirmed that physician orders for Residents R4, R7, R10, R18, R19, R22, R23, R58, and R67 were not reviewed and signed by the physician in the required 60 days and confirmed that physician orders should be reviewed and signed with every physician visit on admission then every 30 days for the first 90 days then every 60 days.

Refer to F841

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.5(f)(i) Medical records






 Plan of Correction - To be completed: 04/03/2026

The facility has secured a new Medical Director effective 2-27-26.

New Medical Director will be provided a list of all residents currently being required to be seen.

New Medical Director is experienced with skilled nursing facilities.

During onboarding physician will be educated on requirements and expectations of facility. These will include, but not be limited to express language in Medical Director Agreement, current state and federal regulations as it relates to physician visits

Facility has two other attending physicians - one is compliant, one will be addressed by new medical director as part of the required responsibilities and both will receive copy of required regulations

Facility Medical Records Manager or Director of Nursing will audit compliance by utilizing the Orders Pending for Signature report and Physicians Visits Survelience in Point Click Care both which highlight signatures and visits required

This will be done weekly

Results will be provided to the Quality Assurance Performance Improvement committee for the next 3 months

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

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to maintain proper care of respiratory equipment and failed to provide oxygen according to physician's orders for seven residents reviewed for respiratory care (Residents R12, R19, R22, R25, R56, R50, and R29).

Findings include:

Review of facility policy entitled "Oxygen Administration" dated 1/28/26, indicated "Oxygen is administered under orders of a physician ..., and Keep delivery devices covered in plastic bag when not in use."

Review of Resident R12's clinical record revealed an admission date of 10/9/24, with diagnoses that include chronic respiratory failure (a condition where your lungs don't exchange air properly), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues).

Review of Resident R12's physician orders revealed an order for Oxygen at two liters/minute via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) every shift dated 11/18/25.

Observations on 2/3/26, at 9:30 a.m., and again at 10:45 a.m. revealed Resident R12 lying in his/her bed with supplemental oxygen in place and the oxygen concentrator (machine used to deliver concentrated oxygen to patients) flow rate set at three liters/minute.


Review of Resident R19's clinical record revealed an admission date of 2/25/25, with diagnoses that include chronic obstructive pulmonary disease (COPD-- when your lungs do not have adequate air flow) heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), and hyperlipidemia (high cholesterol).

Observations on 2/3/26, at 10:00 a.m. and again at 12:22 p.m. revealed Resident R19's nasal cannula was connected to the oxygen concentrator and the prongs that go into Resident R19's nostrils were lying on the floor.


Resident R22's clinical record revealed an admission date of 9/04/19, with diagnoses including heart disease/failure, COPD, and Type 2 Diabetes (condition when the body cannot use insulin correctly and sugar builds up in the blood). The clinical record revealed a physician's order dated 7/12/24, to use two liters/minute of supplemental oxygen via nasal cannula at night.

Observations on 2/03/26 between 10:50 a.m. and 12:15 p.m. revealed Resident R22's oxygen tubing and nasal cannula hanging over the top of the oxygen concentrator and not in a plastic bag.


Resident R25's clinical record revealed an admission date of 1/16/26, with diagnoses that included COPD, Type 2 Diabetes, communication deficit, and seizures. The clinical record also revealed a physician's order dated 1/21/26, for oxygen at four liters/minute every shift.

Observations on 2/03/26 between 10:50 a.m. and 12:15 p.m. revealed Resident R25's oxygen tubing and nasal cannula laying on the floor and not in a plastic bag.


Resident R29's clinical record revealed an admission date of 1/13/26, with diagnoses including Type 2 Diabetes, heart failure, difficulty swallowing, and long-term kidney disease, a physician's note dated 1/13/26, for oxygen at two liters/minute via nasal cannula as needed.

Observations on 2/03/26 between 10:50 a.m. and 12:15 p.m. revealed Resident R29's oxygen tubing and nasal cannula hanging over the top of the oxygen concentrator and not in a plastic bag.


Resident R50's clinical record revealed an admission date of 8/07/24, with diagnoses that included sudden and ongoing respiratory failure, COPD, irregular heartbeat, and heart failure. The clinical record also revealed a physician's order dated 2/14/25, for oxygen at two liters/minutes via nasal cannula as needed.

Observations on 2/03/26, between 10:50 a.m. and 12:15 p.m. revealed Resident R50's oxygen tubing and nasal cannula laying on the floor and not in a plastic bag.


Resident R56's clinical record revealed an admission date of 9/08/21, with diagnoses that included COPD, Alzheimer's Disease (brain disorder that slowly destroys a person's memory and thinking skills), asthma, and irregular heartbeat,. The clinical record also revealed a physician's order dated 7/01/25, for oxygen at two liters/minute via nasal cannula every night.

Observations on 2/03/26 between 10:50 a.m. and 12:15 p.m. revealed Resident R56's oxygen tubing and nasal cannula hanging over the top of the bed rail and not in a plastic bag.


During an interview on 2/3/26 at 12:55 p.m. Registered Nurse Employee E6 confirmed that Resident R12's oxygen flow rate was set at three liters per min and that Resident R19's nasal cannula was lying on the floor. He/she also confirmed that Resident R12's oxygen flow rate was not per physician orders and that Resident R19's nasal cannula should not be on the floor.

During an interview on 2/03/26, at 12:45 p.m. Licensed Practical Nurse Employee E4 confirmed that Resident's R22, R25, R29, R50, and R56's oxygen tubing and nasal cannulas were lying on the floor and hanging over equipment and that the tubing and cannulas should be in plastic bags when not in use.

During an interview on 2/03/26, at 12:47 p.m. the Director of Nursing confirmed that oxygen tubing and cannulas are to be stored in a plastic bag when not in use.


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

28 Pa. Code 211.10(c) Resident care policies



 Plan of Correction - To be completed: 04/03/2026

All oxygen administration checked the day O2 tubing observed on the floor and checked for accuracy of administration. All Oxygen bags in place on concentrators and oxygen tank and all tubing dated appropriately.

Nursing staff educated on policy and procedures with Oxygen administration.

Director of Nursing/Designee to check all oxygen administration of accuracy, dates of tubing changed and that bags on concentrators/E-tanks dated appropriately and flow rate are correct
per physician orde. This will be completed two times weekly X 2 weeks, then weekly X 2 weeks, then monthly X 2 months to ensure compliance with policy and procedures.

Results of the audit will be provided to the Quality Assurance Performance Improvement committee

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
Observations:

Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital, for four of four residents reviewed (Residents R11, R12, R76, and R90).

Findings include:

Review of facility policy entitled "Transfer and Discharge" dated 1-28-26, indicated "Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated." And "For a transfer to another provider, for any reason, the following information must be provided to the receiving provider:"

Contact information of the practitioner who was responsible for the care of the residentResident representative information, including contact informationAdvance directive informationAll other information necessary to meet the resident's needs ...All special instructions and/or precautions for ongoing care ...The residents' comprehensive care plan goalsAll other information necessary to meet the residents' needs which includes, but may not be limited to:Resident status ...Diagnosis and allergiesMedicationsMost relevant labs ...

Review of Resident R11's clinical record revealed an admission date of 2/13/24, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs), and hypertension (high blood pressure).

Review of Resident R11's progress notes revealed notes dated 9/3/25, and 9/20/25, indicating transfer to the hospital,the clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 9/20/25.


Review of Resident R12's clinical record revealed an admission date of 10/9/24, with diagnoses that included chronic respiratory failure (a condition where your lungs don't exchange air properly), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues).

Review of Resident R12's progress notes revealed notes dated 4/8/25, 9/6/25, 10/14/25, and 10/21/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 9/6/25, and 10/14/25.


Review of Resident R76's clinical record revealed an admission date of 12/17/21, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypertension (high blood pressure), and gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat).

Review of Resident R76's progress notes revealed notes dated 12/26/25, and 1/31/26, indicating transfer to the hospital,. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 12/26/25.


Review of Resident R90's clinical record revealed an admission date of 9/13/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and diabetes (a health condition that is caused by the body's inability to produce enough insulin).

Review of Resident R90's progress notes revealed a note dated 11/18/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.

During an interview on 2/5/26, at 3:00 p.m. the Director of Nursing confirmed that Resident's R11, R12, R76 and R90's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer. He/she confirmed that Resident's R11, R12, and R76's clinical records lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer. He/she also confirmed when the transfers occurred clinical information should have been provided to the receiving healthcare provider and bed hold policy should be provided to the resident/representative upon transfer.


28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(c.3)(2) Resident rights



 Plan of Correction - To be completed: 04/03/2026

Director of Nursing educated Licensed Nursing staff on discharge process and bed hold information for all future discharges. Past discharged are not able to be addressed.

Transfer checklist created to ensure proper documentation sent with any discharge out to the hospital.

All discharges and bed hold information to be reviewed by DON /Designees for accuracy of the reason for the discharge documented, sent forms, MD, Responsible party notifications and nursing documentation regarding the discharge.

DON/Designee will review every discharge for 2 months.

Results of the review will be provided to the Quality Assurance Performance Improvement committee

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 observations, review of facility policies and documents, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment for multiple resident rooms on the first floor (101, 102, 103, 104, 105, 107, 108, 109, 111, and 113) and multiple resident rooms on the third floor (303, 304, 305, 309, 316 and 317).

Findings include:

Review of facility policy entitled "Homelike Environment" dated 1/28/26, indicated residents are provided with a safe, clean, comfortable and homelike environment.

Review of the facility Admission Agreement page 10 revealed that the facility will provide clean lodging.
A facility document entitled, "Room Cleaning Process" revealed that daily housekeeper tasks included remove trash, sweep/mop floor, clean bathroom surfaces then toilet, and sweep/mop bathroom.

Observations on 2/03/26, between 10:50 a.m. and 1:15 p.m. and on 2/04/26, between 8:45 a.m. and 9:30 a.m. revealed resident Rooms 101, 102, 103, 104, 105, 107, 108, 109, 111, and 113 to have a removable build-up of a black substance covering much of the bedroom and bathroom floors.

During an interview on 2/04/26, at 9:30 a.m. the Environmental Services Manager confirmed the presence of black substance and that it was removeable with minor effort.

Observations on 2/3/26, between 10:00 a.m. and 12:45 p.m. and again on 2/4/26, between 8:30 a.m. and 9:17 a.m. revealed resident bathrooms in rooms 303, 304, 305, 309, 316 and 317 had large areas of a dry black substance on the bedroom and bathroom floors.

During an interview on 2/4/26, at 9:17 a.m. Licensed Practical Nurse Employee E3 confirmed the black substance on the bedroom and bathroom floors and confirmed that it was removable with minimal effort.


28 Pa. Code 201.14(a) Responsibility of Licensee

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

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




 Plan of Correction - To be completed: 04/03/2026

Housekeeping and general environmental services staff will be inserviced on completing the established room cleaning checklist and its importance to maintaining a clean environement

The facility has initiated a facility wide deep clean and stripping and waxing program with 2 resident rooms and bathrooms being done each week until completion by the floor care technician a position separate from the regular housekeeping staff

Regular housekeeping staff addressed the condition of the bathroom floors.

Following this effort a preventive maintenance rotation will be maintained

Environmental Services Director (EVS) will conduct daily audits of 10 rooms per day for 2 weeks and 5 rooms per day for 1 week by completing the established Room Ready Checklist. 2 room ready checklists will be completed monthly there after as part of ongoing quality assurance

The results of the Room Ready checklist audits will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee.




483.10(f)(10(i)(ii) REQUIREMENT Protection/Management of Personal Funds: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(f)(10) The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds.
(i) The facility must not require residents to deposit their personal funds with the facility. If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section.
(ii) Deposit of Funds.
(A) In general: Except as set out in paragraph (f)( l0)(ii)(B) of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund.
(B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interest-bearing account, or petty cash fund.
Observations:

Based on review of facility documents, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents access to petty cash on an ongoing basis, and to ensure have access to their funds from the resident's petty cash fund the same day for amounts less than $100.00 ($50.00 for Medicaid residents) and on weekends for all 89 of 89 residents in the facility.


Findings include:

Review of the facility Admissions Agreement Section 18 (iv) page 22 revealed "the facility shall provide cash, if requested within one day of the request or a check, if requested within three days of the request."

During interviews on 2/04/26, at 10:45 a.m. Residents R5, R56, R58, R67, R79 and R86 confirmed that they cannot access petty cash on the same day during the week and not at all on weekends. Residents stated that they must give at least 24-hour notice of cash requests to allow the Nursing Home Administrator (NHA) time to go to the bank.

During an interview on 2/04/26, 1:15 p.m. the NHA confirmed the cash box contains $400 and is kept in the Business Office. Residents sign a receipt for the amount of money they wish, and the Business Office Manager (BOM) issues a check to the NHA to cash and reimburse the petty cash box, and there is no one in the building on weekends to access the petty cash to fulfill resident requests for money.

Observation and confirmation from the BOM on 2/05/26, at 8:46 a.m. of the petty cash box revealed there was a $5 bill, a few $1 bills and change, receipts and resident checks dated in December.

During an interview at that time the NHA confirmed that he/she has had the check to take to the bank since last week and that he/she hasn't gotten the chance to cash it.

Review of facility Checking Account Statement printed 2/05/26, revealed that a check was issued to the NHA on 1/23/26, for $400.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(2)(3) Management

28 Pa. Code 201.18(e)(1) Management.

28 Pa. Code 201.29(a) Resident rights




 Plan of Correction - To be completed: 04/03/2026

The facility has added an additional cash box ($200) that will be maintained in the RN Supervisor's office for weekend requests.

The RN Supervisors will receive training from the Business Office Manager (BOM) on how to verify available balance and properly receipt and distribute funds to requesting residents.

The main cash box will continue to be located in the business office and contain sufficient funds assuring residents may access cash as needed and on the same day.

The residents and families will be notified of the change in process to make petty cash available on weekends.

The facility BOM has been instructed to initiate a cash replenishment when the new collective cash balance ($600) drops below $300 which will allow ample time for check distribution and cashing.

BOM will print a Petty Cash Reconciliation Report from the Resident Fund Management Software System (RFMS) following each replenishment to audit the replenishment of the petty cash
boxes.

Administrator will verify that residents are able to receive money in the appropriate and timely fashion by attending resident council (March)

The results of the RFMS Reconciliation Audit will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(h)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide resident privacy on one of five medication carts (Third floor 100 hall medication cart).

Findings include:

Review of facility policy entitled "Confidentiality of Information and Personal Privacy" dated 1/28/26, revealed "Ensure computer screens are in privacy mode or hidden when administering medications ..."

Observations on 2/3/26, between 12:30 p.m. and 12:50 p.m. of the Third floor 100 hall medication cart revealed the medication cart sitting in the hallway against the wall with an open computer on top of the medication cart and resident health information visibly facing into the hallway. Continued observations revealed Licensed Practical Nurse (LPN) Employee E2 returned and walked away from the medication cart several times leaving resident health information visible while several visitors, residents and staff walked past the viewable health record.

During an interview on 2/3/26, at 12:50 p.m. LPN Employee E2 confirmed that he/she left the medication cart with the computer open and did not cover resident health information. He/she also confirmed that resident information should be covered when not within view.


28 Pa. Code 201.14(a) Responsibility of licensee

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



 Plan of Correction - To be completed: 04/03/2026

Plan of Correction:

Director of Nursing educated the nursing staff on confidentiality of resident PHI (Personal Health Information) Medication Administration records being visible to whomever walks by the medication carts and how to lock the screen to protect the PHI.

Random cart, medication pass audits to occur twice weekly to ensure compliance for 2 weeks, once weekly for 2 weeks, and then once weekly for 1 month.

Results of the Audits will be reviewed in Monthly Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(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 facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in the main kitchen and failed to maintain sanitary conditions in one of three pantry refrigerators (First Floor).

Findings include:

Review of a facility policy entitled, "Dietary-Food Receiving and Storage" dated 1/28/26, revealed that "All foods stored in the refrigerator or freezer will be covered, labeled and dated. The policy also indicated that dining services, of other designated staff, will maintain clean food storage areas at all times.

Observation on 2/03/26, at 9:30 a.m. in the main kitchen walk in cooler revealed two 48-ounce bottles of salsa, three 16 ounce jars of parmesan grated cheese and one bottle of sweet relish, all with no open dates.

During an interview on 2/03/26, at 9:45 a.m. the Dietary Manager confirmed that the above food items should have been dated when opened.

Observation on 2/03/26, 10:45 a.m. of the pantry refrigerator on First Floor revealed it had brown/tan dried liquid on the bottom floor of the main compartment and on the bottom shelf of the door.

During an interview on 2/03/26, at 10:51 a.m. Housekeeping Employee E1 confirmed the above listed conditions in the First-Floor pantry refrigerator.

28 Pa. Code 201.14(a) Responsibility of licensee

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



 Plan of Correction - To be completed: 04/03/2026

The Dietary staff will be inserviced on proper labeling and dating by Certified Dietary Manager - there were no negative affects to the resident and the items were discarded that were found to be not labeled with surveyor present.

Dietary Manager or designee will conduct daily audits for all refrigerators in pantry areas (4) for labeled food and cleanliness and walk in main cooler in dietary department. Dietary Manager will follow up on any noted deficiencies with labeling to assure proper labeling or disposal if needed.

The 1st floor pantry was immediately cleaned.

Dietary Manager will review the position cleaning sheets (1-12) which includes refrigerators in all pantries to assure staff is completing all area required which will cover all refrigerators in pantry areas.

This is completed weekly and Dietary Manager is validating the audits.

Results of both ongoing reviews will
Be provided to the Quality Assurance Performance Improvement committee monthly in the food safety and sanitation section.




483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for two of three medication carts reviewed (First floor rehab and Second floor medication carts) and failed to prevent the opportunity for potential unauthorized access of medications on one of five medication carts observed (Third floor 100 hall medication cart).

Findings include:

Review of facility policy entitled "Administering Medications" date 1/28/26, revealed "When opening a multi-dose container, the date opened is recorded on the container." and "During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse ... and The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by."

Review of facility policy entitled "Labeling of Medications and Biologicals" dated 1/28/26, revealed "Labels for multi-dose vials must include: The date the vial was initially opened or accessed."

Review of manufacturer's guidelines revealed that an open vial of Aspart Insulin must be used within 28 days after opening or be discarded.

Manufacturer's guidelines for Trelegy Ellipta (medication used to treat Chronic Obstructive Pulmonary Disease [COPD a condition that prevents airflow to the lungs resulting in difficulty breathing] and Asthma [a long-term inflammatory disease of the airways that cause the airways to narrow and swell causing symptoms such as wheezing, coughing, chest tightness, and shortness of breath], indicated that Trelegy should be discarded six weeks after opening the foil tray or when the counter read "0", whichever comes first.

Observation of drug storage on 2/3/26, at 10:53 a.m. of the First-floor rehab medication cart revealed a Trelegy Ellipta Diskus out of the foil package, in use and lacking an open date.

During an interview on 2/3/26, at the time of observations, Licensed Practical Nurse (LPN) Employee E4 confirmed that the Trelegy Ellipta Diskus in use lacked an open date, and staff were unable to determine the discard date. He/she she also confirmed that theTrelegy Ellipta Diskus should have been discarded.

Observations of drug storage on 2/3/26, at 11:22 a.m. of the Second-floor medication cart revealed an open vial of Aspart insulin lacking an open date. Further observations revealed in the second and third drawers of the medication cart were several loose random pills.

During an interview on 2/3/26, at the time of observations, LPN Employee E5 confirmed that the open vial of Aspart insulin lacked an open date, and staff were unable to determine the discard date and there were several loose random pills in the second and third drawers. He/she also confirmed that the vial of Aspart insulin and the random loose pills should have been discarded.

Observations on 2/3/26, between 12:30 p.m. and 12:50 p.m. revealed LPN Employee E2 preparing medications from the Third floor 100 hall medication cart parked in the hall against the wall with the drawers facing into the hallway. Continued observations revealed PLN Employee E2 walked away from the medication cart entering resident rooms, and the pantry several times. LPN Employee E2 did not securely lock the Third floor 100 hall medication cart. LPN Employee E2 was unable to view medication cart from resident rooms and the pantry.

During an interview on 2/3/26, at 12:50 p.m. LPN Employee E2 confirmed that he/she left the medication cart unlocked which was out of view while in resident rooms and the pantry. LPN employee E2 also confirmed that the medication cart should be locked when out of view.


28. Pa. Code 201.18(b)(1) Management

28. Pa. Code 211.9(a)(1) Pharmacy services

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





 Plan of Correction - To be completed: 04/03/2026

All carts were immediately reviewed for loose pills and that meds were all dated

All staff was educated immediately on carts be locked when unattended

The opened and undated vials/inhaler were destroyed, and a fresh bottle/inhaler was opened, dated and put in service.

An audit was immediately performed of all medication carts by a staff Registered Nurse Supervisor to insure that the opened vials of insulin and/or other multi-use medication vials were appropriately dated and that any/all vials that were not compliant were removed from the medication carts and destroyed.

Nursing staff were educated by the Director of Nursing (DON) as to the proper labeling and dating of insulin and/or other multi-use medication vials/inhalers in the medication carts. This training included proper storage and disposal of the vials as well.
Medication carts will be inspected by the DON or a designee to insure that the opened vials of insulin and/or other multi-use medication vials were appropriately dated and that any/all vials that were not compliant were removed from the medication carts and destroyed, that there are no loose pills and that the unattended carts are locked weekly for three weeks, then monthly for three months in order to insure adherence to policy.

Results will be presented to the Quality Assurance Performance Improvement committee.

483.30(c)(1)-(4) REQUIREMENT Physician Visits-Frequency/Timeliness/Alt NPP: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.
§483.30(c) Frequency of physician visits
§483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.

§483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

§483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.

§483.30(c)(4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with paragraph (e) of this section.
Observations:

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure the resident's initial visit was conducted by the physician and that the physician alternate required resident visits with the nurse practitioner or physician's assistant for two of 21 residents reviewed (Residents R22 and R29).

Findings include:

Facility policy entitled, "Physician Visits and Physician Delegation" dated, 1/28/26, revealed that the physician should: see the resident within 30 days of initial admission to the facility; date, write, and sign a progress note for each visit; at the option of the physician, required visits in skilled nursing facilities, after the initial visit, may alternate between personal visits by the physician and visit by a physician assistant, nurse practitioner, or clinical nurse specialist.

Resident R29's clinical record revealed an admission date of 1/13/26, with diagnoses including Type 2 Diabetes (condition when the body cannot use insulin correctly and sugar builds up in the blood), heart failure, difficulty swallowing, and muscle weakness.

Further review of Resident R29's clinical record revealed that on 1/25/26, a progress note indicated that the nurse practitioner conducted the initial assessment on Resident R29, and not the physician.


Resident R22's clinical record revealed an admission date of 9/04/19, with diagnoses including heart disease/heart failure, Type 2 Diabetes, and chronic obstructive pulmonary disease, (group of lung disease that cause airflow blockage and breathing-related problems).

Further review of Resident R22's clinical record lacked evidence that the resident had been seen by the physician since 1/31/25. Provider progress notes were completed and signed by the nurse practitioner on 3/18/25, 5/20/25, 6/17/25, and 8/26/25.

During an interview on 2/06/26, at 9:00 a.m. the Director of Nursing confirmed that he/she could not determine the most recent date Resident R22 received a visit from the physician, and that Resident R29's initial visit at the facility was conducted by the nurse practitioner.

Refer to F841

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.5(f)(ii)(vii) Medical records








 Plan of Correction - To be completed: 04/03/2026

The facility has secured a new Medical Director effective 2-27-26.

New Medical Director experienced with skilled nursing facilities.

Resident R22 and R29 will be seen by new Medical Director

During onboarding physician will be educated on requirements and expectations of facility. These will include, but not be limited to express language in Medical Director Agreement, current state and federal regulations as it relates to physician visits

Facility Medical Records Manager or Director of Nursing will audit compliance by utilizing the Orders Pending for Signature report and Physicians Visits Survelience in Point Click Care - both reports will detail signatures due and visits due for the whole house.

Facility has conducted a whole house audit to assure all residents are seen as required by new Medical Director

This will be done weekly and provided to the Medical Director as part of the regular scheduling as well as the two other attending physicians.

The DON, ADON, RN Supervisors and Medical Records Manager will all be educated on physician visit requirements

Results will be provided to the Quality Assurance Performance Improvement committee for the next 3 months

483.10(e)(1), 483.12(a)(2), 483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

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

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

§483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of 21 residents reviewed (Resident R4).

Findings include:

Review of facility policy entitled "Psychotropic Medication Use" dated 1/28/26, revealed that "non-pharmacological approaches are used to minimize the need for medications, permit lowest possible dose, and allow for discontinuation of medications when possible."

Review of Resident R4's clinical record revealed an admission date of 11/26/18, with diagnoses that included Alzheimer's disease (a progressive disorder that affects memory, thinking skills, and ability to perform simple tasks), diabetes (a chronic disease where the body does not produce enough insulin or cannot use it efficiently), and muscle weakness. The clinical record revealed that on 12/2/25, Resident R4's physician ordered Lorazepam (a medication ordered to treat anxiety) 0.5 milligrams (mg) every 4 hours PRN for anxiety.

Review of Resident R4's December 2025 Medication Administration Record (MAR) and January 2026 MAR revealed that the PRN Lorazepam was used on 12/8/25,12/16/25,12/21/25,1/2/26, 1/14/26, 1/15/26, 1/17/26, and 1/22/26. Resident R4's clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the eight administrations in December 2025 and January 2026.

During an interview on 2/5/26, at 10:56 a.m. the Director of Nursing confirmed that Resident R4's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for the dates listed above and that non-pharmacological interventions should be attempted and documented in the clinical record.

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




 Plan of Correction - To be completed: 04/03/2026

The Ativan order for affected resident (R4) was reviewed by the physician, and it was renewed with non pharmaceutical interventions and stop date. The issue cannot be corrected retroactively.

A review of all psychotropic medication for non pharmaceutical interventions was performed for all residents within the facility at the time it was discovered. PRN is an abbreviation that is commonly used in the health care industry for the Latin term "Pro Re Nata," which means that a medication is dispensed on an "as needed" basis. Non-Pharmaceutical interventions prior to administering the PRN medication was ensured written on all of the PRN Psychoactive medication orders.

The review of initial PRN orders for psychotropic medications will be initiated for all residents with an order for psychoactive medications by the Director of Nursing (DON) or designee upon admission. All existing PRN orders for psychoactive medications will be reviewed bi-weekly for two weeks, weekly for two weeks and monthly for two months to insure that they are in adherence to this practice.

All licensed staff will be educated by the DON or a designee regarding the PRN psychoactive medication policy and non-pharmaceutical interventions both in the order and being completed along with the documentation prior to administration of the medication.

This review will be performed for two months. Results will be provided to the Quality Assurance Performance Improvement committee.

483.70(g)(1)(2) REQUIREMENT Responsibilities of Medical Director:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.70(g) Medical director.
§483.70(g)(1) The facility must designate a physician to serve as medical director.

§483.70(g)(2) The medical director is responsible for-
(i) Implementation of resident care policies; and
(ii) The coordination of medical care in the facility.
Observations:

Based on review of the Medical Director agreement, facility records, and staff interview, it was determined that the facility failed to ensure that the Medical Director fulfilled his/her responsibilities to develop, review, and improve resident care policies.

Findings include:

Review of the Medical Director agreement revealed he/she is expected to guide, approve, and help oversee the development, implementation, and monitoring/evaluation of the facility's resident care policies and procedures in several areas.

Review of facility's annual policy reviews dated 1/28/26, revealed no signature by the Medical Director.

Interview with the Nursing Home Administrator on 2/6/26, at approximately 12:12 p.m. revealed that the Medical Director was not present at the facility throughout the year to fulfill his/her responsibility in the development, review, and improvement of resident care policies and the Medical Director was not a part of the annual policy review.

Refer to F711, F712, and F868

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

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







 Plan of Correction - To be completed: 04/03/2026

The facility has secured a new Medical Director effective 2-27-26. Previous lack of visits cannot be corrected

Medical Director is experienced with skilled nursing facilities.

During onboarding physician will be educated on requirements and expectations of facility. These will include, but not be limited to express language in Medical Director Agreement, current state and federal regulations as it relates to review of facility care policies.

Weekly monitoring thru Point Click Care will ensure continued compliance

New physician will sign off on current facility care policies. NHA will confirm this review and sign off and bring documentation to the March Quality Assurance and Improvement Committee.


483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
Observations:

Based on review of facility policy, facility records, and staff interview, it was determined that the facility failed to ensure the required attendance of the Medical Director or his/her designee to Quality Assurance and Performance Improvement (QAPI) Committee meetings for four of four quarterly QAPI Committee meetings reviewed.

Findings include:

Review of facility policy entitled "Quality Assurance and Performance Improvement" dated 1/28/26, revealed "The QAA Committee shall be interdisciplinary and shall consist at a minimum of ... The Medical Director or his/her designee ..."

Review of the QAPI Committee Attendance Records from March 2025, through December 2025, revealed no evidence on the attendance sign-in sheets for all required QAPI meetings that included the Medical Director or his/her designee was in attendance.

During an interview on 2/06/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed the facility lacked evidence that the Medical Director or his/her designee attended the Quarterly QAPI Committee meetings as required.

Refer to F841

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




 Plan of Correction - To be completed: 04/03/2026

Plan of Correction:

Facility cannot go back and correct past meetings

The facility has secured a new Medical Director effective 2-27-26.

Local physician experienced with skilled nursing facilities.

During onboarding the physician will be educated on requirements and expectations of facility by the Admininstraor.
These will include, but not be limited to express language in Medical Director Agreement, current state and federal regulations as it relates to participation in facility quality assurance process.

New physician will attend the quality assurance meeting and designate so by signing in as required by other members of the Quality Assurance and Improvement team.

Administrator will ensure the Medical Director attends by placing the required dates on his outlook calendar as well as the office managers calendar and notify both office manager and physician if they miss a required meeting in writing

Results of the Physician Attendance will be reviewed as part of the Quality Assurance Committee for compliance




483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

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

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

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

Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) and failed to ensure that the MDS assessment accurately reflected the status for three of 21 residents reviewed (Residents R11, R23, and R90).

Findings include:

Review of Resident R11's clinical record revealed an admission date of 2/13/24, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs), and hypertension (high blood pressure).

Review of Resident R11's physician orders revealed an order for hospice with a start date of 12/30/25.

Review of Resident R11's MDS dated 11/18/25, section O special treatments, procedures, and programs under O0110 hospice revealed Resident R11 was inaccurately coded "yes."


Review of Resident R23's clinical record revealed an admission date of 10/25/24, with diagnoses that included heart failure, hypertension, and atrial fibrillation (irregular heartbeat).

Review of Resident R23's physician orders revealed an order for hospice with a start date of 10/25/24.

Review of Resident R23's MDS dated 11/4/25, section O special treatments, procedures, and programs under O0110 hospice revealed Resident R11 was inaccurately coded "no."


Review of Resident R90's clinical record revealed an admission date of 9/13/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and diabetes.

Review of Resident R90's discharge recapitulation of stay dated 12/15/25, under nursing services indicated that resident R90 was admitted to another facility.

Review of Resident R90's MDS submissions revealed an MDS for a discharge return anticipated dated 11/18/25, MDS submissions lacked evidence that an MDS for return not anticipated was completed.

During an interview on 2/5/26, at 10:47 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that Residents R11 and R23's MDS's were coded inaccurately for hospice services.

During an interview on 2/6/26, at 10:47 a.m. the RNAC confirmed that Resident R90's discharge MDS was coded inaccurately.

28 Pa. Code 211.5(f) Medical records

28 Pa. Code 201.14 (a) Responsibility of Licensee



 Plan of Correction - To be completed: 04/03/2026

The inaccurate Minimum Data Set assessments identified during review have been corrected and resident records were reviewed to assure that all supporting documentation aligns with the corrected MDS entries.

MDS Coordinator and interdisciplinary team members will review in-service training on RAI manual with emphasis on sections where errors were identified by regional MDS consultant.

Weekly random audits of 10% of submitted MDS assessments will be performed for three weeks and then monthly for 3 months for accuracy in coding and accuracy in total MDS. These audits will be done by regional MDS consultant

A whole house audit will be done to assure accurate coding by the facility MDS Consultant.

Audit results will be reviewed in the Quality Assurance and Performance Committee

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on review of facility infection control records and staff interview, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1).

Findings include:

Review of Infection Prevention and Control meeting minutes revealed lack of attendance sign-in sheets for all quarterly infection control meetings.


MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:

(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:

(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient-safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

1303.405(a)- Patient Safety Authority Jurisdiction states:

(a)The occurrence of a healthcare-associated infection is deemed a serious event. Written notification to the resident of the serious event should be documented.

A review of the facility Infection Control Program on 2/6/26, revealed that the facility failed to have evidence of laboratory and pharmacy representatives on the attendance sign-in sheets for all quarterly infection control meetings.

During an interview on 2/6/26, at approximately 10:00 a.m. the Director of Nursing confirmed that the facility lacked evidence of laboratory and pharmacy representatives on the attendance sign in sheets for all quarterly infection control meetings.




 Plan of Correction - To be completed: 04/03/2026

Assistant Director of nursing educated on requirements of Infection Control Committee reviews that Pharmacy, Lab and MD to attend these meetings quarterly. Administrator will be responsible for notifying Pharmacy and Lab of the required date and times for the meeting to be attended as an education

Pharmacy and Lab representatives will be notified in writing of the time and dates of the required meeting and Director of Nursing will audit attendance

Results of Infection Control Meeting attendance will be reviewed at Monthly Quality Assurance and Improvement Meetings


§ 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 facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 15 residents on the overnight shift for four of 21 days reviewed for staffing (1/23/26,1/29/26, 1/30/26, and 2/03/26).

Findings include:

Review of facility nursing staffing documents for the time periods of 1/15/26 through 1/21/26, 1/22/26 through 1/28/26, and 1/29/26 through 2/04/26, revealed following NA shortages for the overnight shift:

1/23/26 facility census of 91 residents 5.46 NAs worked and 6.07 were required.
1/29/26 facility census of 91 residents 5.53 NAs worked and 6.07 were required.
1/30/26 facility census of 91 residents 5.86 NAs worked and 6.07 were required.
1/23/26 facility census of 89 residents 4.60 NAs worked and 5.93 were required.

During an interview on 2/05/26, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility was unable to provide all required staffing information requested during the survey and failed to meet the minimum NA ratio requirements on the above shifts and dates.



 Plan of Correction - To be completed: 04/03/2026

Plan of Correction:

The facility admits that it did not meet the prescribed ratios on the dates given.

There are no known negative outcomes on the dates ratios were not met
The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval.
Education has been provided to the DON, Scheduler and Nursing Supervisors to insure that they know how staffing ratios are met in creating schedules and deal with call offs

Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime in the event that ratios will not be met.
The Administrator and DON performs a daily audit of schedules versus actual hours of care to track adherence to regulations.
This occurs during a daily staffing meeting to insure that staffing ratios are within prescribed parameters. If it is determined that staffing ratios or PPD are not projected to be attained, Overtime, staff bonuses or agency will be utilized to meet standard.

The results of the audits will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings


§ 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 facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 40 residents on the overnight shift for one of 21 days reviewed for staffing (1/29/26).

Findings include:

Review of facility nursing staffing documents for the time periods of 1/15/26 through 1/21/26, 1/22/26 through 1/28/26, and 1/29/26 through 2/04/26, revealed following LPN shortages for the overnight shift:

1/29/26 facility census of 91 residents 2.13 LPNs worked and 2.28 were required.

During an interview on 2/05/26, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility was unable to provide all required staffing information requested during the survey and failed to meet the minimum LPN ratio requirements on the above shift.



 Plan of Correction - To be completed: 04/03/2026

Plan of Correction:

The facility admits that it did not meet the prescribed ratios on the dates given.

There were no known negative outcomes on the rations were not met
The upcoming schedules are created by the scheduler and reviewed with the
Director of Nursing (DON) and Administrator for approval.
Education has been provided to the DON, Scheduler and Nursing Supervisors to insure that they know how to achieve LPN Ratios in creating schedules and deal with call offs.

Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime in the event that ratios will not be met.
The Administrator and DON performs a daily audit of schedules versus actual hours of care to track adherence to regulations.
A daily staffing meeting occurs to insure that staffing ratios are within prescribed parameters. If it is determined that staffing ratios or PPD are not projected to be attained, Overtime, staff bonuses or agency will be utilized to meet standard.

The results of the audits will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings.


§ 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 facility nursing staffing documents and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a twenty-four-hour period for three of 21 days reviewed (1/23/26, 1/30/26, and 2/01/26).

Findings include:

Review of facility nursing staffing documents for the time periods of 1/15/26 through 1/21/26, 1/22/26 through 1/28/26, and 1/29/26 through 2/04/26, revealed that the hours of direct resident care were below 3.2 minimum per patient per day (PPD) on the following dates:

1/23/26 3.13 PPD
1/30/26 3.08 PPD
2/04/26 3.15 PPD

During an interview on 2/05/26, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility was unable to provide all required staffing information requested during the survey to calculate PPD accurately for all days and did not meet the 3.2 minimum hours of direct resident care on above dates.



 Plan of Correction - To be completed: 04/03/2026

The facility admits that it did not meet the prescribed total hours on the dates given.

There were no known negative outcomes on the days the facility did not meet ppd
The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval.
Education has been provided to the DON, Scheduler and Nursing Supervisors to insure that they know how to achieve a 3.2 hours PPD in creating schedules and deal with call offs.

Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime in the event that PPD will not be met
The Administrator and DON performs a daily audit of schedules versus actual hours of care to track adherence to regulations.

A daily staffing meeting occurs to insure that staffing ratios are within prescribed parameters. If it is determined that staffing ratios or PPD are not projected to be attained, Overtime, staff bonuses or agency will be utilized to meet standard.

The results of the audits will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings.


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