Pennsylvania Department of Health
SOUTHWESTERN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SOUTHWESTERN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 237 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on February 20, 2026, it was determined that Southwestern Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(l) REQUIREMENT Dialysis:

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(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.

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

1. R8, R15, and R29's dialysis communication forms are being reviewed upon return from dialysis.
2. Current dialysis residents will have the dialysis communication form reviewed by the licensed staff after dialysis to identify any needed follow up.
3. DON or designee will re-in-service licensed nursing staff on reviewing dialysis communication forms when returning from dialysis to ensure needed follow up.
4. The DON or designee will randomly review 5 dialysis communication forms weekly x4 to ensure communication forms are completed and needed follow up is completed. The QAPI committee review the audits and they will determine the need for further audits.

483.25(n)(1)-(4) REQUIREMENT Bedrails:

�483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

�483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

�483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

�483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

�483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.

Observations: Based on observations, review of facility policy, clinical record review, and a staff interview, it was determined that the facility failed to assess and conduct ongoing assessments to ensure that bedrails/enabler bars were used to meet residents' needs and the risks associated with enabler bar usage for three of four residents (Residents R34, R44, and R48). Findings include: Review of facility policy "Policy on Bed Enablers/Side Rails" dated 12/5/25 with a previous review date of 1/16/25, indicated "Therapy will assess and determine if the need for enablers is warranted on an individualized bases." Review of the clinical record indicated Resident R34 was originally admitted to the facility on 11/1/21. Review of Resident R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/18/26, indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), diabetes mellitus (body cannot properly use or make insulin causing high blood sugar), and depression (persistent feeling of sadness, emptiness and loss of interest in life). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R34 on 2/19/26 at approximately 10:00 a.m., Resident R34 had two top enabler bars in use on Resident R34's bed. Review of Resident R34's clinical record on 2/19/26, failed to include an assessment for the resident's enabler bar usage. Review of the clinical record indicated Resident R44 was admitted to the facility on 8/26/25. Review of Resident R44's MDS dated 12/2/25, indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), depression (persistent feeling of sadness, emptiness and loss of interest in life), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R44 on 2/19/26 at approximately 10:00 a.m., Resident R44 had two top enabler bars in use on Resident R44's bed. Review of Resident R44's clinical record on 2/19/26, failed to include an assessment for the resident's enabler bar usage. Review of the clinical record indicated Resident R48 was originally admitted to the facility on 7/17/23. Review of Resident R48's MDS dated 1/5/26, indicated diagnoses of seizure disorder (sudden bursts of abnormal electrical activity in the brain), depression (persistent feeling of sadness, emptiness and loss of interest in life), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R48 on 2/19/26 at approximately 10:00 a.m., Resident R48 had two top enabler bars in use on Resident R48's bed. Review of Resident R48's clinical record on 2/19/26, failed to include a current assessment for the resident's enabler bar usage, last assessment completed on 8/21/24. During an interview on 2/18/26, at 2:18 p.m. the Director of Nursing confirmed that the facility failed to conduct assessments and ongoing assessments to ensure that enabler bars were used to meet residents' needs and the risks associated with enabler bar usage. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 04/07/2026

1. R34, R44 and R48 had a bed side rail evaluation completed and the care plan has been updated.
2. Current residents with side rails or enabler bars will be evaluated by the therapy staff and/or nursing staff and a bed side rail evaluation will be completed.
3. The DON or designee will re-in-service licensed staff on the completion of the bed side rail evaluation upon resident admission to the facility.
4. The DON or designee will review new admissions to ensure the bed side rail evaluation has been completed timely weekly x4 weeks. The QAPI committee will review the audits and determine the need for further auditing.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

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.

�483.20(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 the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for two of six residents (Resident R34, and R44). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2024, indicated that Section O: Special Treatments, Procedures, and Programs, Question O0100 "Check all of the following treatments, procedures, and programs that were performed." For Respiratory Treatments section C1 should be marked as "X" if the resident receives oxygen therapy with sub-sections C2 Continuous, C3 Intermittent, and C4 High concentration, D1 Suctioning sub-sections D2 Scheduled and D3 As needed, E1 Tracheostomy care, F1 Invasive Mechanical Ventilator, G1 Non-invasive Mechanical Ventilator with sub-sections G2 BIPAP and G3 CPAP. Review of the clinical record indicated Resident R34 was originally admitted to the facility on 11/1/21. Review of Resident R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/18/26, indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), diabetes mellitus (body cannot properly use or make insulin causing high blood sugar), and depression (persistent feeling of sadness, emptiness and loss of interest in life). Resident R34 MDS, Review of Section O: Special Treatments, Procedures, and Programs, Question O0100 Section G1 Non-invasive Mechanical Ventilator with sub-sections G2 BIPAP was not marked as receiving any respiratory treatments. Sections Z1 was marked as "None of the above" (indicating the resident was not receiving any special treatments, procedures, or programs). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R34 on 2/19/26 at approximately 10:00 a.m., Resident R34 had a Bilevel Positive Airway Pressure (BIPAP) device at her bedside it was confirmed that Resident R34 utilized the BIPAP. R34 stated she has used a BIPAP for years at the facility. Review of Resident R34's care plan reveals a BIPAP care plan was initiated on 9/29/22 and continues to be active. Review of Residents R34's physician orders, did not reveal an order for the BIPAP. Review of the clinical record indicated Resident R44 was admitted to the facility on 8/26/25. Review of Resident R44's MDS dated 12/2/25, indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), depression (persistent feeling of sadness, emptiness and loss of interest in life), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar). Resident R44 MDS, Review of Section O: Special Treatments, Procedures, and Programs, Question O0100 Section C1 Oxygen Treatments was not marked as receiving any respiratory treatments. Sections Z1 was marked as "None of the above" (indicating the resident was not receiving any special treatments, procedures, or programs). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R44 on 2/19/26 at approximately 10:00 a.m., it was confirmed that Resident R44 had oxygen in use at 4 liters. Review of Residents R44's physician orders revealed an order on 8/27/25 for oxygen at 4 liters to keep Peripheral Oxygen Saturation (SPO2) at greater than 90%. During an interview on 2/20/26, at approximately 8:47 a.m. Employee E1 RNAC confirmed the MDS periodic assessment failed to identify the respiratory treatments required and utilized by Residents R34 and R44. During an interview on 2/20/26, at approximately 9:40 a.m. the Director of Nursing confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed. 28 Pa. Code: 211.5(f) Clinical records.

Plan of Correction - To be completed: 04/07/2026

1. Resident R34's MDS has been corrected and physician orders obtained for the use of the Bipap. R44's MDS has been corrected to include oxygen use.
2. Current residents with Bipap and oxygen use will be reviewed by the MDS coordinator or designee to ensure the MDS is accurate and current physician orders are in place.
3.The Admin or designee will re-in-service the MDS coordinator on ensuring the MDS is completed timely and is accurate.
4.The Admin or designee will randomly review 10 MDS's weekly x4 to ensure Bipap and oxygen are documented on the MDS accurately.

483.25 REQUIREMENT Quality of Care:

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

Observations: Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for two of eight residents reviewed (Residents R8, and R44). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy "Nursing Care of the Older Adult with Diabetes Mellitus" reviewed 1/16/26, indicated diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. For further education and guidelines refer to the provider orders and instructions as well as the American Diabetes Association Standards of Medical Care in Diabetes. For glycemic targets use a glucometer for capillary blood sampling to measure current blood glucose levels. Target range for healthy older adults is considered 90-130 mg/dL (fasting or pre-prandial glucose). Glycemic targets for older adults with chronic illnesses, functional decline, or cognitive impairment may be less stringent. The provider will order the frequency of glucose monitoring and establish appropriate glycemic targets for individual residents. Manage hypoglycemia according to protocols and provider orders. Establish provider notification protocols, follow physician orders for parameters. Review of the clinical record indicated Resident R8 was re-admitted to the facility on 2/18/20. Review of Resident R8's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/20/26, indicated diagnoses of end stage renal disease (kidneys no longer function normally), diabetes (body cannot properly use or make insulin causing high blood sugar), high blood pressure, dementia (progressive decline in mental ability-specifically memory, thinking, and behavior that can interfere with daily life). Review of a physician's order dated 1/20/26, indicated to inject Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale, no parameters given as to when to notify MD (doctor). Review of physician's orders dated 12/18/25, indicated to administer glucose oral gel 40% if CBG below 60 and symptomatic or asymptomatic but conscious and able to swallow. Repeat CBG in 10-15 minutes and if CBG still less than 60 to notify MD. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the residents' CBG's were as follows: 12/5/25: 67 1/7/26: 57 2/16/26: 69 Review of Resident R8's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R44 was admitted to the facility on 8/26/25. Review of Resident R44's MDS dated 12/2/25, indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), depression (persistent feeling of sadness, emptiness and loss of interest in life), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar). Review of a physician ' s order dated 12/1/25, indicated to inject Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours). Review of a physician ' s order dated 12/1/25, indicated to inject Glargine (long-acting insulin that starts to work about 1 to 2 hours after injection and keeps working for up to 22 hours). Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the residents' CBG's were as follows: 2/3/25: 475 2/5/26: 461 Review of Resident R44's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. During an interview on 2/19/26, at approximately 9:00 a.m. Licensed Practical Nurse (LPN) Employee E3 stated if the blood glucose was under 70, they would call the doctor and follow orders. If the blood glucose was greater than 400, they would notify the supervisor and call the doctor. They would document in the MAR and progress notes. During an interview on 2/19/24, at approximately 9:05 a.m. LPN Employee E4 stated if the blood glucose was less than 70, they would give glucose gel, notify the supervisor, recheck blood glucose in 15 minutes, and call the doctor. If blood glucose was over 400, they would administer the ordered insulin and call the doctor. They would document in the progress notes. During an interview on 2/19/24, at approximately 9:10 a.m. Registered Nurse (RN) Employee E5 stated she would follow protocol for glucoses less than 70, notify the MD and recheck the CBG, if greater than 400 would administer medication as ordered, notify MD and Nursing supervisor. They would then document their actions in the progress notes. During an interview on 2/19/24, at 10:10 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose for Residents R8, and R44. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 04/07/2026

1. R8's physician was notified of the hypoglycemic episodes and physician orders obtained for call parameters. R44's physician has been notified of the hyperglycemic episodes and orders obtained for call parameters.
2. Current diabetic residents will be reviewed by the DON or designee to ensure call parameters are in place for notification to the physician for hypo/hyperglycemia episodes.
3. The DON or designee will re-in-service the licensed nursing staff on obtaining orders for call parameters for hypo/hyperglycemia episodes.
4.The DON or designee will review 24 hour progress notes to ensure the physician has been notified timely of hypo/hyperglycemia episodes, will review random 5 weekly x4 weeks. The QAPI committee will determine the audits and determine the need for further audits.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

�483.21 Comprehensive Person-Centered Care Planning
�483.21(a) Baseline Care Plans
�483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

�483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

�483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations: Based on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to develop a baseline or comprehensive care plan that included dialysis care and interventions needed to provide effective and person-centered care for one of three residents (Resident R29). Findings include: The facility policy "Care Plans - Baseline" dated 12/5/25 with a previous review date of 1/16/25, indicated a baseline care plan includes but is not limited to the following: The stated goals and objectives of the resident.A summary of the residents' medications and dietary instructions.Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.Any updated information based on the details of the comprehensive care plan a necessary. The facility policy "Care Plans, Comprehensive Person - Centered" dated 12/5/25 with a previous review date of 1/16/25, indicated a comprehensive, person centered care plan includes measurable objectives and time frames, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being, including, Reflects currently recognized standards of practice for problem areas and conditions. Review of the clinical record indicated Resident R29 was originally admitted to the facility on 2/5/26. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/18/26, indicated diagnoses of end stage renal disease (kidneys no longer function normally), respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar). Review of clinical records revealed, Resident R29 was sent to dialysis on 2/7/26, 2/10/26, 2/12/26, 2/14/26 and 2/17/16 R29 receives dialysis, at [Dialysis Center] three times a week. Dialysis days are Tuesday, Thursday and Saturday with a chair time of 9:00 am. Review of Resident R29's baseline care plan completed on 2/5/26 does not indicate the resident has been care planned for dialysis treatments including pre and post evaluation or dialysis line care (tube in a large vein that allows blood from you to be taken to the dialysis machine cleaned and returned to you). Review of Resident R29's comprehensive care plan initiated on 2/9/26 does not indicate the resident had been care planned for dialysis treatments or dialysis line care. During an interview on 2/20/26, at approximately 8:47 a.m. Employee E1 RNAC confirmed the base line or comprehensive care plan failed to identify the dialysis treatments required and utilized by Residents R29. During an interview on 2/20/26, at approximately 9:40 a.m. the Director of Nursing confirmed that the facility failed to make certain the baseline or comprehensive care plan was accurate, addressing any services and treatments received by the resident. 28 Pa. Code: 211.11 (a)(c)(d) Resident care plan. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Plan of Correction - To be completed: 04/07/2026

1. R29's dialysis care plan has been completed.
2. Current residents on dialysis have had care plans reviewed to ensure care plans are in place for dialysis by the DON or designee.
3. The DON or designee will re-in-service licensed nursing staff on baseline care plans and to ensure dialysis care plans are added as needed.
4. New or re-admission care plans will be reviewed by the DON or designee weekly x4 weeks to ensure dialysis care plans are completed timely. The QAPI committee will review the audits and determine the need for further audits.

483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:

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.

�483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.

Observations: Based on observations and a staff interview, it was determined the facility failed to post contact information for Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency as required, in the building on three of three locations where postings are (first floor lobby, second, and third floor nursing units). Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. During an observation completed on 2/18/26, at approximately 11:30 a.m., in the lobby, hallways in and around the nursing units, revealed the facility did not have the required elements (agency name, address, email address, and phone number) of Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency posted or accessible to residents or resident representatives. During an observation and an interview with the Nursing Home Administrator (NHA) on 2/19/26, at 9:00 a.m., the NHA confirmed the facility failed to post required information for Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Plan of Correction - To be completed: 04/07/2026

1. The facility cannot retroactively post required elements (agency name address, email address, and phone number) of adult protective services (aps), Medicaid fraud unit, and a statement that the resident may file a complaint with the state agency in accessible areas to resident and resident representatives.

2. Department of health postings of required elements (agency name address, email address, and phone number) of adult protective services (aps), Medicaid fraud unit, and a statement that the resident may file a complaint with the state agency have been posted in accessible areas to resident and resident representatives.

3. the RDO or designee will reeducate the LNHA on required elements (agency name address, email address, and phone number) of adult protective services (aps), Medicaid fraud unit, and a statement that the resident may file a complaint with the state agency and that must be posted in accessible areas to resident and resident representatives

4. The administrator or designee will observe the postings include required elements (agency name address, email address, and phone number) of adult protective services (aps), Medicaid fraud unit, and a statement that the resident may file a complaint with the state agency and that they are posted in accessible areas to resident and resident representatives weekly x4. The audits will be reviewed by the QAPI committee who will determine the need for further audits.

483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:

�483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

�483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.

Observations: Based on observations and a staff interview, it was determined the facility failed to ensure the availability of the most recent survey results and any plan of correction were accessible to residents and visitors. Findings Include: The resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. During an observation completed on 2/18/26, at approximately 11:30 a.m., the facility binder containing the Department of Health's survey results revealed the binder was last updated on 6/13/24. During an observation and an interview with the Nursing Home Administrator (NHA) on 2/19/26, at 9:00 a.m., the Nursing Home Administrator confirmed the facility failed to make the Department of Health's most recent survey results readily accessible to residents and visitors. 28 Pa. Code 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 04/07/2026

The Department of Health Survey binder was immediately updated.

2. Current Department of Health survey binders were observed by the Admin or designee to ensure binders are up to date with the most current survey results.

3. The RDO or designee will reeducate the LNHA on the regulation for posting the most current survey results to ensure binders are updated timely.

4. The Administrator or designee will observe the survey binders on each unit to ensure current survey results are up to date weekly x4. The audits will be reviewed by the QAPI committee who will determine the need for further audits.

483.10(g)(13) REQUIREMENT Posting/Notice of Medicare/Medicaid on Admit:

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.

�483.10(g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

Observations: Based on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building, on three of three locations where postings are (first floor lobby, second, and third floor nursing units). Findings include: The facility must display in the facility, written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During an observation completed on 2/18/26, at approximately 11:30 a.m., in the lobby, hallways in and around the nursing units, revealed that facility failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid. During an observation and an interview with the Nursing Home Administrator (NHA) on 2/19/26, at 9:00 a.m., the Nursing Home Administrator confirmed the facility failed to display (for residents and/or their responsible person) written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Plan of Correction - To be completed: 04/07/2026

1. The facility cannot retroactively display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid.

2. The facility has on display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid

3. The RDO or designee will reeducate the LNHA on the requirement to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid

4.The administrator or designee will observe that the postings are on display (for residents and/or their responsible person) and include written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid weekly x4. The audits will be reviewed by the QAPI committee who will determine the need for further audits.

� 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations: Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift on one of 21 days (12/14/25). Findings include: Review of the facility census data, nursing time schedules, and deployment sheets revealed the following LPN staffing shortages: On 12/14/25, census 75, day shift required 3.00 LPNs, facility provided 2.26. During an interview on 2/20/26, at 10:00 a.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift one of 21 days.

Plan of Correction - To be completed: 04/07/2026

.Findings of LPN nursing staff care ratios cannot be retroactively corrected.

2. The facility will provide a minimum of 1 LPN per 25 residents during the day, 1LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

3. The scheduling coordinators will be educated on the requirements of 1 LPN per 25 residents during the day, 1LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

4. NHA or designee will conduct random audits to verify that LPN ratios on all shifts meet the requirements of 1 LPN per 25 residents during the day, 1LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. Audits will be conducted daily x 7 days then weekly for 3 weeks and then monthly for 2 months. Audit results will be presented at QAPI meeting for review and recommendations.

Staff will be offered bonuses and staffing agencies will be utilized to facilitate replacement/procurement of staff.

� 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on eight of 21 days (12/14/25, 12/15/25, 12/17/25, 12/18/25, 1/11/26, 1/16/26, 1/17/26, and 2/15/26).

Findings include:
Review of the nursing three-week time schedules revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates:
On 12/14/25, census 75. Facility PPD was 2.80.

On 12/15/25, census 75. Facility PPD was 3.09.

On 12/17/25, census 73. Facility PPD was 3.14.

On 12/18/25, census 74. Facility PPD was 3.18.

On 1/11/26, census 74. Facility PPD was 3.15.

On 1/16/26, census 74. Facility PPD was 3.11.

On 1/17/26, census 74. Facility PPD was 3.06.

On 2/15/26, census 78. Facility PPD was 3.08.
During an interview on 2/20/26, at 10:00 a.m. the Director of Nursing confirmed the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on one of 21 days noted above.

Plan of Correction - To be completed: 04/07/2026

1. Findings of PPD cannot be retroactively corrected.

2. The facility will have daily staffing meetings to review staffing levels and make the necessary adjustments as possible to meet the state minimum requirements of 3.2

3. NHA or designee will provide re-education to nursing administration and scheduling that staffing levels must be 3.2 or above and have the appropriate staff to perform care in the facility.

4. Facility leadership will complete random audits weekly x 4 and then monthly x 2 months to ensure the facility had a PPD of 3.2 or above. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.

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