Pennsylvania Department of Health
 ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are  181 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.
ST. JOHN NEUMANN CENTER FOR REHABILITATION & HEALTHCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to one complaint, completed on September 4, 2025, it was determined that St. John Neuman Center for Rehabilitation and Healthcare, was not in compliance with the 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 related to the health portion of the survey process.



 Plan of Correction:


483.20(e)(1)(2) REQUIREMENT Coordination of PASARR and Assessments: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.
§483.20(e) Coordination.
A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes:

§483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

§483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.
Observations:
Based on clinical record review, and staff interview it was determined that the PASARR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for four of eight residents reviewed (Residents R12, R169, R18, R135).

Findings include:

The PASRR (Preadmission Screening Resident Review), created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA), has three goals: to identify individuals with mental illness and/or intellectual disability; to ensure they are placed appropriately, whether in the community or in a nursing facility; and to ensure they receive the services they require for their mental illness or intellectual disability.

A Level I PASRR must be completed for all persons considering admission to a Medicaidz zcertified nursing facility. A Level II PASRR evaluation must be completed if the Level I PASRR determines that the person is a targeted individual with mental illness or an intellectual disability. The Level II PASRR determines whether placement or continued stay in the requested or current nursing facility is appropriate.

Review of Resident R169's clinical record revealed an admission date of November 7, 2023, with diagnoses of anxiety disorder (intense, excessive, persistent worry or fear), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), and bipolar disorder (extreme swings in mood and thought). Resident R169 does not have any diagnosis of neurocognitive disorder listed (group of conditions characterized by cognitive impairments that affect memory, thinking, and reasoning, often leading to significant challenges in daily functioning)



Review of Resident R169's PASRR, dated November 1, 2023, revealed that the assessment did not include the resident's diagnoses of anxiety disorder, depression, and bipolar disorder. Additionally, the PASRR assessment indicated that Resident R169 has a diagnosis of neurocognitive disorder; however, there was no documentation in the clinical record to support this diagnosis.


Review of Resident R18's clinical record revealed an admission date of April 12, 2019, with diagnoses of anxiety disorder, major depressive disorder, schizoaffective disorder (chronic mental health condition characterized by hallucinations or delusions).



Review of Resident R18's PASRR, dated August 8, 2018, revealed that the assessment did not include the resident's diagnoses of anxiety disorder, major depressive disorder, schizoaffective disorder.

Review of Resident 135's clinical record revealed an admission date of September 12, 2025, with diagnoses of schizophrenia, anxiety disorder unspecified, and unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with agitation.

Review of Resident 135's PASRR, dated June 12, 2025, revealed that the assessment did not include the resident's diagnoses of anxiety disorder unspecified, and unspecified dementia with agitation.

During an interview on September 3, 2026, at 10:04 a.m., Employee E7, Social Worker, confirmed that the PASRR assessments for Residents R18, R169, and R135 were not accurately completed according to their respective resident assessments. Employee E7 stated that she/he was hired within the past year and was not aware that PASRR assessments must be updated when new diagnoses are obtained.

During an interview on September 3, 2026, at approximately 2:15 p.m., Employee E1, Administrator, confirmed that the facility does not have a PASRR policy in place and that the facility follows only the standard procedure for completing the PASRR form.


Review of Resident R12's clinical record revealed the resident was admitted to the facility on August 9, 2022, with diagnoses including schizoaffective disorder, bipolar disorder, and anxiety disorder.

Review of Resident R12's Level 1 PASARR, dated August 8, 2023, revealed that the assessment did not include the resident's diagnosis of bipolar disorder.

Interview on September 3, 2026, at 9:40 a.m., Employee E7, Social Worker, confirmed that Resident R12's PASARR assessment was not updated to include the resident's diagnosis of bipolar disorder.


28 Pa. Code 201.14(a) Responsibility of licensee.

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

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








 Plan of Correction - To be completed: 09/18/2026

- The PASRR for R169, R18, R135, and R12 have been updated with appropriate diagnosis.
- An audit was completed for current residents to ensure that PASRR's were updated with appropriate diagnosis
- The Administrator educated the SS Department regarding the necessity of updating PASRR's with appropriate diagnosis as diagnosis are added to the medical record
- The SSD/Designee will conduct random audits (10 PASRRs) weekly x 4 weeks then monthly x 2 months to assure that diagnosis on PASRR's is updated as appropriate. Findings of the audits will be reported to QA monthly x3.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:
Based on observations, resident and staff interviews the facility failed to ensure that required state hotline information and grievance postings were consistently displayed, readable, and accessible to all residents throughout the facility on 6 of 6 units observed (Front Lobby, and Nursing Unit 300, 400, 500, 600, and 700).

Findings Include:

On September 2, 2026, at 10:00 a.m. 09/02/2026, a tour with the Social Worker Director (E7) tour was conducted on all units, and the following observations were made:

In the hallway before entering the 300 unit, the resident bulletin board did not have the state phone number posted. Unit 300 had no state posting available and no grievance forms accessible.

Unit 400 did not have the state number posted and had no information about the grievance officer.

Units 600 and 500, the state number was posted; however, the font was not readable, and it was not placed at a wheelchair-accessible height.

700 had no state number posted. According to the Social Worker (E7), this unit serves short term residents admitted for rehabilitation services.

The front lobby did not have any phone numbers posted.

On September 2, 2026, at 10:30 a.m., a resident council meeting was held with six alert and oriented residents (Residents R71, R116, R175, R189, R197, and R214). The residents reported that they were not aware of the location of the state phone number posting. Resident R214 requested that the phone number be provided to him/her due to not knowing where the state number was posted.

28 Pa. Code 201.14 (a) Responsibility of licensee.





 Plan of Correction - To be completed: 09/18/2026

- The State hotline's information and facility's grievances postings were placed and made accessible to residents on all nursing units and at the front desk.
- An audit was completed to assure the state hotline and grievance posting information was posted and accessible to residents on nursing units and at the front desk.
- The Regional Administrator educated the Administrator on the requirements of posting the state hotline and grievance information at a accessible level to residents.
- The SSD/or designee will audit the nursing units and front desk area weekly x4, then monthly x2 to ensure the state hotline and facility's grievance posting is displayed and accessible to residents. Findings of the audits will be reported to QA monthly x3.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on clinical record review, observations and interviews with staff, the facility did not ensure house supplements were administered per physician order for two out of two people reviewed (Resident R95 and R28).

Findings:

A review of Resident R95's record revealed that the resident was admitted to the facility on September 10, 2020, with the diagnosis of muscle wasting and atrophy (wasting) not elsewhere classified left upper arm, muscle weakness, and difficulty in walking.

A review of the Medication Administration Record (MAR) for September 2026 revealed a house supplement ordered once daily, 4 ounces (oz) by mouth at 10:00 a.m. This order was initiated on February 26, 2026. The MAR indicated that the house supplement was administered, as evidenced by Employee E6, Licensed Nurse, signing off at 10:00 a.m. on September 2, 2026.

A review of Resident R28's record revealed that the resident was admitted to the facility on March 16, 2024, with the diagnosis of Alzheimer's (a progressive disease that destroys memory and other important mental functions), Type 2 diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), and muscle disorder.

A review of the Medication Administration Record (MAR) for September 2026 revealed a house supplement ordered twice daily: a diabetic complete Neutrino shake, 8 oz by mouth at 10:00 a.m. This order was initiated on March 20, 2024. The MAR indicated that the house supplement was administered, as evidenced by Employee E6, Licensed Nurse, signing off at 10:00 a.m. on September 2, 2026.

However, on September 2, 2026, at 2:14 p.m., an observation of the pantry refrigerator on the 300-nursing unit revealed a tray containing 13 labeled supplements/snacks that had not been given to 13 residents at 10:00 a.m. Employee E6 confirmed that the house supplements had been signed off as administered at 10:00 a.m. for Residents R28 and R95, yet the supplements remained in the refrigerator and had not been provided to the residents.

On September 3, 2026, at 11:00 a.m., an interview was conducted with the regional dietitian, Employee E5, who confirmed that the supplements had been assigned to Residents R28 and R95 and should have been administered at 10:00 a.m. on September 2, 2026, as prescribed in the physician's order.

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





 Plan of Correction - To be completed: 09/18/2026

- R95 and R28 receive their house supplements per physician order.
- An audit was completed to ensure the necessary residents have a physician order for house supplements
- Education was completed with licensed nurses on the requirements of administering house supplements per the physician's order
- The DON/Designee will conduct random (10 residents) interviews to confirm residents are being offered their house supplements per their physician order. Audits will be conducted weekly x4 then monthly x2, findings of the audits will be reported to QAPI.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:
Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to ensure the resident was assessed after a significant weight loss for one of two residents reviewed for weight loss (Resident R31).


Findings Include:

Review of facility policy " Weight Assessment, Management and Intervention Procedure " , no date, revealed " Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Dietitian. The Dietitian will respond timely with receipt of notification. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: Initially: a. 1 month 5% weight loss is significant; greater than 10% is severe. 6 months 10% weight loss is significant; greater than 10% is severe " .


Clinical record review revealed Resident R31 was admitted to the facility on December 2, 2025, with a diagnosis of cerebral infarction (stroke - brain damage), muscle wasting and atrophy (wasting), and hyperlipidemia.

Further review of Resident R138 ' s clinical record revealed the following notable weights documented:

- 1/6/26: 380.0 pounds (lbs)

- 2/18/26: 307.6 lbs

- 3/13/26: 302.5 lbs

Review of Resident R31 ' s clinical record revealed dietician progress note, dated February 25, 2026, that revealed the following:

" Brief weight change review: Resident (Rt) triggers for a possible significant weight loss:
Current Weight: 307.8#
Previous Weight: 380#
Weight Change: -19.0% , -72.2 Lbs
Unplanned
Possible Etiology: weight outlier, scale malfunction
Interventions: rt is eating 50-100% of meals and is accepting HS (nighttime) snacks. BMI (body mass index) remains in obese range, to prevent further weight loss CBW (current body weight) should be confirmed, adding 10am/2pm snacks for adequate intake and to promote more gradual weight loss towards BMI < (less than) 30
Plan: Re-weight requested to confirm weight change. IDT and MD notified " .

Further review of Resident R31's clinical record revealed a re-weigh was not completed until March 13, 2026. .

Interview on September 9, 2026, at 10:15 a.m. with Employee E5, Dietitian, confirmed Resident R31 was not assessed timely after a significant weight loss was noted and a re-weigh was not completed in a timely manner.

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





 Plan of Correction - To be completed: 09/18/2026

- R31 has been assessed for weight loss and is within desired limits.
- A 30-day look back audit was completed for current residents to ensure that any residents who have experienced significant weight loss are reweighed and interventions are in place.
- The Administrator educated the dieticians to assure that residents are assessed timely and a interventions is put into place after a significant weight loss occurs.
- The DON/Designee will audit residents with significant weight loss weekly x 4 weeks then monthly x 2 months to assure that residents with significant weight loss are assessed timely and interventions are implemented. Findings of the audits will be reported to QAPI.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(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 observation, record review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of 35 residents reviewed (Residents R152).


Findings include:

Review of facility policy "Oxygen Therapy" revised July 2025, revealed that to use oxygen with a resident, check the mask, cannula, tank or concentrator to make sure that they are in good working order.

Review of Resident 152's clinical record revealed diagnoses including chronic respiratory failure with hypoxia (occurs when the lungs cannot adequately oxygenate the blood, leading to low oxygen levels (hypoxemia)). Further review revealed a physician order dated March 23, 2023, for oxygen at 2 liters per minute via nasal canula (tubing to deliver oxygen through the nose).

Observations in Resident R152's room on September 1, 2026, at 11:05 a.m. revealed Resident 152 was wearing his/her oxygen and the filter on the concentrator contained a lot of grey fuzz. Interview with Resident R152 revealed that he/she did not feel the oxygen coming through the tubing.

Interview with Licensed Nurse, Employee E18, on September 1, 2026, at 11:09 a.m. confirmed the buildup of dust on the oxygen concentrator filter. Employee R18 also asked the resident about the oxygen and felt the nasal canula and then checked the tubing connection at the concentrator and said that it was disconnected, and that is why Resident R152 was not feeling the oxygen.


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

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






 Plan of Correction - To be completed: 09/18/2026

- R152's Oxygen concentrators filter was immediately cleaned and properly connected to ensure proper functioning.
- An audit was completed for current residents using concentrators to assure that filter is free of dust and that the oxygen tubing was connected correctly
- Education was completed with licensed nurses' staff regarding the routine cleaning of oxygen filters and assuring that the oxygen tubing is connected properly.
- The DON/Director of Maintenance/Designee will Oxygen concentrators weekly x 4 weeks then monthly x 2 months to assure that oxygen concentrator filters are free of dust and that oxygen tubing is connected. Findings of the audits will be reported to QAPI.

483.25(l) REQUIREMENT Dialysis:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:
Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to maintain effective communication with a dialysis provider for one of two residents reviewed (Residents R7).

Findings Include:



A review of the facility policy titled, " Dialysis Communication Log " , undated revealed, " It shall be the policy of that a resident receiving dialysis service at the offsite felicity will have dialysis communication log completed by the dialysis facility " .



A review of Resident R7's clinical record revealed that the resident was admitted to the facility on June 19, 2025, with the diagnosis of End Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life).



Review of Resident R2's clinical record revealed a physician order dated May 19, 2026, indicating Resident R7 receives dialysis on Tuesday/Thursday/Saturday.



Interview on September 4, 2026, at 9:56 a.m., with the Unit Manager, Employee E19, confirmed that dialysis communication for Resident R7 was requested by the facility. A binder containing communication sheets with residents ' information and documentation of communication between the facility and the dialysis team was provided.



Further review of the dialysis communication binder revealed that on several dates the communication sheets were not fully completed. Missing information included missing nursing signatures, missing dates, and missing dialysis pre? and post?treatment summaries. Additionally, the section titled " Communication from Dialysis Center " was not completed for the following dates: August 13 and 15, 2026; July 7, 11, 13, and 23, 2026; and June 2, 4, 6, 20. 23, 25 2026.



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



 Plan of Correction - To be completed: 09/18/2026

- R7 is no longer on dialysis. A call was made with the dialysis provider on 9/4/26 to assure accurate documentation is completed in the communication book.
- An audit was completed for current residents on dialysis to assure that their communication binder is up to date.
- Education was completed with licensed nurses regarding the necessity of assuring dialysis communication binders are completed timely.
- The DON/Designee will audit dialysis communication books weekly x 4 weeks then monthly x 2 months to assure that the daily communication sheets are being completed. Findings of the audits will be reported to QAPI.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

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

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:
Based on observations, and resident interviews, it was determined that the facility failed to provide food and drink that was palatable for taste and temperature for eight of 35 residents reviewed (Residents R38, R40, R67, R101, R116, R152, R233 and R189).



Findings include:

A review of the facility Test Tray form revealed that the cold foods served above 50 degrees got a score of 0 and were deemed unacceptable.

During the initial tour of the facility on September 1, 2026, the following resident interviews were obtained:

Interview with Resident R38 at 11:54 a.m. revealed that the food is nasty and Resident R38 further stating "I don't like the foods that they have, I would like different foods".

Interview with Resident R40 at 12:27 p.m. revealed that the facility does not serve what heshe is supposed to get. Resident R40 stated "I should have gotten turkey, and they sent the substitute meal eggplant and spaghetti".

Interview with Resident R67 at 11:16 a.m. revealed that the food is bad. Resident R67 stated "they send me things that I cannot have, with salt, like sausage. I am retaining fluids, so this is a problem".

Interview with Resident R101 at 12:01 p.m. revealed that the food is bad. Resident R101 stated "I don't like pork or eggs and they send it to me, I get eggs every morning".

Interview with Resident R116 at 12:05 p.m., revealed that the food is bad, stating "I don't like it. Look at it. Yuck!".

Interview with Resident R152 at 11:29 a.m. revealed that food is lousy, it is cold and taste nasty.

Interview with Resident R233 at 12:05 p.m. revealed that the resident doesn't like when the food is cold, which does happen.

Interview with Resident R189 at 12:09 p.m. revealed that the resident doesn't always get what they want, stating "today I should have gotten the turkey, and they sent me the eggplant with spaghetti and sauce"

Observations during a test tray conducted by the Food Service Director (FSD), Employee E15 on September 3, 2026, at 12:25 p.m. revealed that the whole milk was served at 56 degrees, and the turkey sandwich was served at 52 degrees, both above an acceptable range. The Saulsbury steak was thin, gristly and did not have a good beef flavor, the carrots were a little soft and bland, the sandwich had big, thick chunks of turkey and was difficult to chew and had no condiments.

Interview with the FSD on September 3, 2026, at 12:35 p.m. confirmed the results of the test tray.

On September 2, 2026, at 10:30 a.m., a resident council meeting was held with six alert and oriented residents (Residents R71, R116, R175, R189, R197, and R214). The residents reported that the food is often served cold when delivered to their rooms. For example, during breakfast that morning, there was no hot water available for making tea using a tea bag.

28 Pa. Code 201.14 (a) Responsibility of licensee.

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







 Plan of Correction - To be completed: 09/18/2026

- The interdisciplinary team interviewed residents R71, R116, R175, R189, R197, R214, R38, R40, R67, R101, R116, R152, and R233 to obtain their dietary likes, dislikes, and preferences. Meal tickets were updated as needed.
- The Dietary Manager/designee will interview residents (as applicable) to obtain their dietary likes, dislikes, and preferences. Meal tickets to be updated as needed.
- Dietary director will in-service cooks on to provide food and drink that is palatable for taste and temperature.
- The Dietician /designee will complete random (10 residents) interviews weekly x 4 and then monthly x2 to evaluate resident feedback. Audit results will be reported at QAPI.

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 and documentation, observations, and interviews with staffit was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.


Findings include:



The Policy: "Food Storage Policy", revised September 2025, states, "To ensure all food stored in the kitchen is handled, labeled, and maintained safely to prevent foodborne illness and comply with applicable public health regulations. All prepared and opened food items must be clearly labeled with: Name of product; Date prepared or opened".



An initial tour of the Food Service Department was conducted on September 1, 2026, at 9:30 a.m. with Employee E15, Food Service Director (FSD), and Employee E16, Regional Director of Operations (RDO) which revealed the following:



Observation in the receiving area revealed that the lid to the dumpster for recycling was missing allowing animals access to the inside of the dumpster.



Observations in the walk-in refrigerator revealed an open gallon of whole milk that was not dated when it was opened.



Observations outside the walk-in refrigerator revealed lose baseboard tiles which had cracks behind and were not sealed to the outside of the refrigerator. The aluminum around the walk-in refrigerator door openings were corroded at the floor level with a sharp edge exposed.



Observations in the Walk-in freezer revealed that the temperature was 14 degrees and several of the products were not frozen solid including meatballs, breakfast sausage, breaded veal, Italian sausage, turkey franks and tortellini.



Observations in the dish room revealed a heavy buildup of black substance on the floor underneath the dish tables, the electric service panel and conduit were corroded and discolored brownish red rust color, the fan blowing on the clean dishes was covered in a sticky black dust and dirt, the old booster heater covered in dust, dirt and food particles and was missing the lower panel cover revealing exposed wires hanging down and the garbage disposer was missing the outer cover exposing the motor, pulleys and belt.



The dish machine was running in a low temperature mode, and the chlorine test strips did not detect any chlorine in the rinse water revealing that the dishes were not being sanitized.



Observations of both top and bottom convection ovens revealed a heavy buildup of dark black burned on food spatters especially on the bottom inside of the oven.



Observations of the stove revealed a broken shelf over the cooktop and the shelf had a heavy buildup of dust, grease and dirt.



Observations of the tilt-skillet revealed the pipes underneath had a heavy buildup of yellowish-brown grease and dirt and the top back panel had a heavy dark black buildup of dirt, grease and grime.



Interview with FSD and RDO at 9:50 a.m. on May 14, 2024, confirmed the above findings.



Review of service inspection report from dish machine provider revealed that on September 1, 2026, the technician had to change 4 final rinse spray jets, change the sanitizer check valve and change the 1/8" sanitizer distribution line in order to obtain a proper chlorine reading in the final rinse.



28 Pa. Code 201.14 (a) Responsibility of licensee.



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




 Plan of Correction - To be completed: 09/18/2026

- The following was immediately corrected on site:
o Dumpster lid has been replaced
o Open and undated container was discarded
o Walk in Refrigerator tiles were replaced/sealed
o Aluminum at the Refrigerator door opening was repaired/replaced
o Walk in freezer temperature was recalibrated to meet standard temperature
o Area under dish table cleaned
o Fan cleaned
o Booster panel cleaned/repaired
o Garbage disposal cover replaced
o Chlorine added to the dish sanitizer
o Convection ovens cleaned
o Shelf over cooktop repaired/grease build up removed
o Grease cleaned and removed from tilt skillet
o Dish machine repaired to distribute proper amount of chlorine
- The administrator/designee audited the kitchen to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.
- The Administrator educated the kitchen staff to assure that food is stored, prepared, distributed, and served within professional standards for food safety.
- The NHA/FSD/Designee will audit the kitchen weekly x 4 weeks then monthly x 2 months to assure that food is stored, prepared, distributed, and served within professional standards for food safety Findings of the audits will be reported to QAPI.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on review of clinical record, observations, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program for one of five nursing units observed (700 Unit).



Findings Include:

Review of the facility policy titled, "Pest Control Services" with a revision date of October 24, 2025, states, "Services for pest control are handled under a contractual arrangement with an exterminating company. When a pest sighting is noted, it should be recorded in the pest control logbook. The exterminator will review any findings, and treat the area (s) as necessary. Records are kept of visits by administration.


On September 2, 2026, at 10:30 a.m., a resident council meeting was held with six alert and oriented residents (Residents R71, R116, R175, R189, R197, and R214). The residents reported that mice and flies were their main concern at the facility.


Observation of the 700 unit was made on September 1, 2026, at 10:30 a.m. During a tour of the unit, including common areas and resident rooms, flies were observed throughout the unit.

Observation on September 1, 2026, at 11:15 a.m. of Room 707 revealed a fly buzzing around Resident R89's head and landing on his/her head, on the trach tubing, and on his/her covers. Licensed Nurse, Employee E17, who was on duty in the hallway came into the room and confirmed the fly was on Resident R89 and began waving his/her arms and keeping the fly away from the resident. Employee E17 seemed upset about the fly bothering Resident R89 who is unable to speak or chase the fly herself. Employee E17 said he/she would call maintenance about the fly.

Observation of Room 714 revealed a fly flying around the resident's room.

Observation of Room 718 revealed a Styrofoam coffee cup that had fruit flies on and flying around it. There were 2 flies flying around the resident's room. Interview held with the resident revealed the resident stated, "when my door is open the flies come in".

Observation of Room 724 revealed a fly flying around the resident's room.

Observation of Room 725 revealed a fly flying around the resident's room.

Observation of the nurse's station on the 700-nursing unit on September 1, 2026, revealed three flies flying around the nurse's station.

On September 3, 2026, at 12:11 p.m. a fly was again observed at the nurse's station.

Review of pest control logbooks from the 700 unit revealed roaches reported on August 18, 2026, in the office, rooms 727, and room 728.

Review of pest control logbooks revealed a roach reported on August 21, 2026, in room 707.

Review of pest control logbooks revealed a roach reported on August 24, 2026, and August 27, 2026, in the office.

Review of pest control reports from July 31, 2026, stated, "512, 707, and 728 roach treatment room must be prepared July 24 confirmed via email Inspected and treated room 712 and 707. Room 728 was not prepared for treatment. Both residents were in bed and unable to come out. Baited and placed monitors. Observed positive roach acceptance on monitor placed behind the B bed." "718 roach treatment room must be prepared emailed July 28. Room 718 was not prepared for treatment. Spoke with admin regarding room not being prepared."

Review of pest control reports from August 7, 2026, stated, "Logbook/verbal reports of roach activity on the table in room 724."

28 Pa Code 201.14 (a) Responsibility of licensee.

28 Pa Code 201.18 (a) Management.







 Plan of Correction - To be completed: 09/18/2026

- Resident rooms 707, 714, 718,724, 725, and 700 Nurses Station were deep cleaned, and noted in the facility's pest control logbook to be treated by the exterminator. Residents R71, R116, R175, R189, R197, and R214 were interviewed and their pest control concerns were noted in the log book to ensure their areas were treated by the facility's exterminator. R89's room was logged in pest control logbook to be treated by facility's exterminator.
- An audit was completed for resident rooms and nursing stations to ensure that they are currently pests. Any sightings noted were placed in pest control logbook to be treated by the facility's exterminator.
- A house-wide education was completed to ensure staff know how to report and log any pest control sightings.
- The DON/Designee will conduct random (10 areas) audits of resident rooms and/or common areas weekly x 4 weeks then monthly x 2 months. Any sightings will be listed in facility's pest control logbook. Findings of the audits will be reported to QAPI.


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