Pennsylvania Department of Health
SENECA PLACE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SENECA PLACE
Inspection Results For:

There are 174 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.


SENECA PLACE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance, and an Abbreviated survey in response to five complaints completed on June 26, 2026, it was determined that Seneca Place 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:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed to provide bodily privacy during treatment procedures for one of six residents (Resident R10) and failed to maintain the dignity of two of six residents reviewed (Resident R43) who had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine) and (Resident 185) who had an urinary condom catheter (non-invasive external urinary catheter worn like a condom it collects urine as it drains from the bladder and sends it to a collection bag).

Findings include:

Review of the facility policy "Dignity" dated 5/21/26, indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Review of Resident R185's clinical record indicated re-admission date of 6/16/26, with diagnoses of hypertension (high blood pressure), Benign Prostate Hyperplasia (BPH- the prostrate grows and affects the urinary system in men) and anxiety.

During an observation completed on 6/22/26, at 9:57 a.m. Resident R185 was in bed a urinary catheter bag was viewed hanging on the bedframe. The bag failed to be covered as required.

Interview completed on 6/22/26, at 9:58 a.m. Registered Nurse (RN) Employee E10 confirmed Resident R185's urinary catheter bag was not covered as required.

Review of the admission record indicated Resident R43 was admitted to the facility on 6/7/25.

Review of Resident R43's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/9/26, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and obstructive uropathy (a blockage in the urinary tract that prevents normal urine flow).

Observation on 6/22/26, at 1:29 p.m. Resident R43 was observed lying in bed with a urinary catheter bag filled with urine. The bag failed to be covered as required.

Interview on 6/22/26, at 1:30 p.m. Nurse Aide (NA) Employee E14 confirmed the urinary catheter bag was not covered as required.

Review of the clinical record indicated Resident R10 was admitted to the facility on 2/18/26.

Review of Resident R10's MDS dated 5/20/26, indicated diagnoses of high blood pressure, wound infection, and muscle weakness.

Review of a physician order dated 6/16/26, indicated left medial (inner portion) heel and right heel - cleanse with Dakins (a wound cleanser), apply Medihoney (medical-grade honey used for wound healing), then calcium alginate (a highly absorbent dressing), cover with ABD (a highly absorbent dressing), and wrap with Kerlix (a bandage wrap) every day shift for wound care.

During a wound care treatment observation on 6/24/26, from 11:34 a.m. through 11:55 a.m. Wound Care Registered Nurse (WCRN) Employee E5 did not close the door or pull the privacy curtain to provide privacy for Resident R10 during the treatment observation.

During an interview on 6/24/26, at 11:58 a.m. WCRN Employee E5 confirmed the facility failed to provide bodily privacy during a treatment procedure for Resident R17.

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

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

Plan of Correction - To be completed: 07/17/2026

1.Facility cannot retroactively provide dignity for residents R10. Facility corrected the dignity for R43 and R185 at the time of the survey. The three residents will be interviewed by 7-10-2026 to ensure they did not suffer any lasting psycho-social impact.
2.The Nursing Home Administrator or designee will conduct facility wide observation will be completed by 7-10-2026 to ensure that all residents are being provided care in a way that aligns with facility Dignity policy in regard to dignity bags and privacy curtains.
3.The Nursing Home Administrator or designee will educate staff on the facility's Dignity policy to ensure that residents are being provided care in accordance with the policy by 7-10-2026.
4.The Nursing Home Administrator or designee will audit that care is being provided in accordance with the dignity policy in aligning with dignity bags and privacy curtains 5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policies, clinical record review, observations, and staff interviews, it was determined that the facility failed to properly monitor resident personal refrigerator temperatures for one of two refrigerators (Resident R98) which created the potential for food borne illness, failed to handle and wash facility linens in a safe an aseptic (free from disease-causing microorganisms) manner during an observation of the main laundry room, failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R10), and failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility.

Findings include:

Review of the facility policy "Refrigerators and Freezers" dated 5/21/26, indicated monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.

Review of the facility policy "Departmental (Environmental Services) - Laundry and Linen" dated 5/21/26, indicated to reprocess any linen that is not visibly clean upon completion of the cycle or any linen that falls onto the floor.

Review of facility policy "Dressings, Dry/Clean" dated 5/21/26, indicated steps in the procedure include clean bedside stand, establish a clean field. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached.

Review of facility policy "Legionella Water Management Program" dated 5/21/26, indicated the facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella.

Review of the admission record indicated Resident R98 was admitted to the facility on 6/12/26 with the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Observation on 6/23/26, at 1:22 p.m. Resident R98 was observed in bed. A personal refrigerator was in the room and failed to have a temperature log as required.

Interview on 6/23/26, at 1:22 p.m. Resident R98 indicated they'd have to get a log for June 2026.

Interview on 6/23/26, at 1:25 p.m. Unit Manager Employee E15 confirmed that the facility failed to properly monitor resident personal refrigerators and that Resident R98's personal refrigerator failed to have a temperature log for June 2026, as required.

Observation of the main laundry room on 6/24/26, at 8:35 a.m. Laundry Worker Employee E6 was loading clean linens into the facility's dryer. While loading the clean linen into the dryer, a washcloth fell to the floor. Laundry Worker Employee E6 was observed picking the washcloth off the floor and throwing it in the dryer with the clean linens.

Interview on 6/24/26, at 8:45 a.m. the Nursing Home Administrator was informed of Laundry Worker Employee E6's actions and that the facility failed to handle and wash facility linens in a safe an aseptic manner.

Review of the clinical record indicated Resident R10 was admitted to the facility on 2/18/26.

Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/20/26, indicated diagnoses of high blood pressure, wound infection, and muscle weakness.

Review of a physician order dated 6/16/26, indicated left medial (inner portion) heel and right heel - cleanse with Dakins (a wound cleanser), apply Medihoney (medical-grade honey used for wound healing), then calcium alginate (a highly absorbent dressing), cover with ABD (a highly absorbent dressing), and wrap with Kerlix (a bandage wrap) every day shift for wound care.

During a dressing change observation on 6/24/26, from 11:34 a.m. to 11:55 a.m. Wound Care Registered Nurse (WCRN) Employee E5 did not establish a clean field using the bedside stand. WCRN Employee E5 placed a trash can liner on the sheet at the foot of Resident R10's bed and placed opened wound care supplies on the trash can liner during the treatment.

During an interview on 6/24/26, at 11:58 a.m. WCRN Employee E5 confirmed the above observations and that the facility failed to prevent cross contamination during a dressing change for Resident R10.

Review of the facility's "Water Management Program" last reviewed 6/17/26, indicated ice machines have a Legionella culture test performed annually. The Water Management Program failed to indicate any additional areas that have Legionella culture testing performed.

During an interview on 6/26/26, at 10:25 a.m. the Nursing Home Administrator (NHA) stated, "I am unable to find proof of Legionella testing for 2025, I can only find results for 2024." During this interview, the NHA confirmed that the facility failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility.

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)(2)(5) Nursing services.

Plan of Correction - To be completed: 07/17/2026

1.The facility cannot retroactively complete refrigerator temperatures for resident R98, prevent potential cross contamination observed, or complete Legionella testing.
2.The Nursing Home Administrator or designee will review resident refrigerator logs to ensure compliance with Refrigerator and Freezer policy by 7-10-2026. Legionella testing will be scheduled to be completed.
3.The Nursing Home Administrator or designee will educate staff on cross contamination to include the Environmental Services – Laundry and Linen policy, Dressings Dry/Clean policy, Legionella Water Management Program, and Refrigerators and Freezers policy by 7-10-2026.
4.The Nursing Home Administrator or designee will audit resident refrigerator temperatures are being recorded, dressing changes and laundry services are being completed as required to prevent cross contamination 5 times a week for 2 weeks, 3 times a week for 2 weeks, and week for 4 weeks. Administrator will also ensure Legionella testing is completed as required.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§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.

Plan of Correction - To be completed: 07/17/2026

1.The facility is not able to retroactively adhere to the facility policy Labeling of Medication Containers. At the time of the survey, all medications that were in need of labelling were corrected. All medications that needed to be discharged and reordered were conducted at the time of the survey.
2.The Director of Nursing or designee will audit the medication carts and medication rooms to ensure adherence to the facility policy Labeling of Medication Containers by 7-10-2026.
3.The Director of Nursing or designee will educate all licensed nurses on the facility policy Labeling of Medication Containers by 7-10-2026.
4. The Director of Nursing or designee will audit the medication carts and medication rooms for properly labeled and dated medication 5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks.

483.25(l) REQUIREMENT Dialysis:

§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: 07/17/2026

1.The dialysis communication forms for residents R17, R34, and R86 cannot be retroactively obtained. The access site documentation for resident R17 and R86 were corrected at the time of the survey.
2.Director of Nursing or designee will review all residents who receive dialysis to ensure the facility's Dialysis Communication Documentation and Hemodialysis Catheters – Access and Care of policies are being followed by 7-10-2026.
3.The Director of Nursing or designee will educate licensed staff on the facility's Dialysis Communication Documentation and Hemodialysis Catheters – Access and Care by 7-10-2026.
4.The Director of Nursing or designee will audit all dialysis related communication and monitoring of access sites is being completed in accordance with facility policies 5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks.

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.

Plan of Correction - To be completed: 07/17/2026

1.Orders for residents R173, and R15 were obtained by physician by and notification of resident R15's hyperglycaemic episode will be reported to physician by 7-10-2026. It was verified that resident R 185 did not need external male condom catheter and catheter was removed at time of survey.
2.The Director of Nursing or designee will review residents to ensure physician orders for condom catheters along with hyperglycaemic and hypoglycaemic protocols are obtained for care being provided by 7-10-2026.
3.The Director of Nursing or designee will educate licensed nurses on ensuring physician orders for hypoglycemia and hyperglycemia are obtained and being followed by 7-10-2026.
4.The Director of Nursing or designee will audit physician orders for hypoglycemia and hyperglycemia5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

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

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R74).

Findings include:

Review of the facility policy "Self-Administration of Medications" dated 5/21/26, indicated facility should comply with policy with respect to resident self-administration of medications. The facility should assess and determine whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. Facility should ensure that orders for self-administration list the specific medications the resident may self-administer.

Review of the admission record indicated Resident R74 was admitted to the facility on 12/30/25.

Review of Resident R74's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/21/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident R74's clinical record failed to include an assessment or physician order to self-administer medications.

Observation on 6/22/26, at 11:34 a.m. Resident R74 was sitting on the bed with a bedside table pulled close to the bed. On the bedside table was a container of fluticasone (nasal spray used for inflammation), and an albuterol inhaler (used for asthma). Neither were stored in a bag, and neither were labeled with the date opened.

Interview with Resident R74 on 6/22/26, at 11:34 a.m. indicated the resident prefers to keep the medications at bedside so when they need them, they don't have to wait for nursing staff.

Interview with Unit Manager Employee E15 on 6/22/26, at 11:36 a.m. confirmed the clinical record failed to include an assessment or physician order to self-administer medications and that the facilityfailed to determine whether it was safe to self-administer medications for Resident R74.

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

Plan of Correction - To be completed: 07/17/2026

1.Resident R74 was assessed at the time of the survey to determine whether they are safe. cognitive, and appropriate for them to self-administer medication. R74 assessment and physician order was placed at the time survey.
2.The Director of Nursing or designee will review all residents who self-administer medication to ensure that the Self-Administration of Medications policy is being followed by 7-10-2026 which includes physician orders and assessments.
3.The Director of Nursing or designee will educate licensed nurses on the facility's policy for self-administration of medication to ensure appropriate assessments and physician orders are being provided in accordance with the policy by 7-10-2026.
4.The Director of Nursing or designee will audit that medication is being administered in accordance with the self-administration of medication policy 5 times a week for 2 weeks, 3 times a week for 2 weeks, and weekly for 4 weeks.

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

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Plan of Correction - To be completed: 07/17/2026

1.Resident CR194 was discharged from the facility on 5-21-2026 so the facility is unable to retroactively notify the family of behavioural concerns. During a meeting on June 16th, with family at the facility, family members were notified of mentioned behavioral concerns.
2.The Director of Nursing or designee will review residents with a change in condition or status and ensure notifications are made to appropriate parties by 7-10-2026.
3.The Director of Nursing or designee will educate licensed nurses on the facility's Change in a Resident Condition or Status policy to ensure that appropriate notifications are being made by 7-10-2026.
4.The Director of Nursing or designee will audit notifications are being made in accordance with the Change in a Resident Condition or Status policy 5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks.

483.10(e)(1),483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints:

§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 physical . . . 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 physical . . . restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Observations:

Based on review of facility policy, clinical records, observation, and staff interviews, it was determined that the facility failed to assess the functional status of the individual resident to determine if the use of a bolster (a long, thick cushion) is a restraint for one of four residents (Residents R23).

Findings include:

Review of facility policy "Use of Restraints" dated 5/21/26, indicated physical restraints are defined as any method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.

Review of the clinical record indicated Resident R23 was admitted to the facility on 12/3/24.

Review of Resident R23's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/25/26, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and anemia (too little iron in the blood).

Review of physician order dated 12/23/24, indicated bolster mattress to bed.

Review of Resident R23's care plan dated indicated the resident is at high risk for falls related to confusion, psychoactive drug use, history of fall at home with left hip fracture, and poor balance and safety awareness. Interventions include bolsters to bed when in bed.

During an observation on 6/23/26, at 9:47 a.m. Resident R23 was observed lying in bed and the mattress had bilateral (on both sides) raised edges on the top and bottom portions.

Review of Resident R23's clinical record failed to identify any assessments or ongoing evaluations for the usage of bolsters on the resident's mattress.

During an interview on 6/26/26, at 9:26 a.m. Unit Manager Employee E13 confirmed that the facility failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for one of four residents (Residents R23).

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

28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 07/17/2026

1.Resident R23 will be assessed by 7-10-2026 to ensure that the use of a bolster is not a restraint.
2.The Therapy Director or designee will assess the functional status of all residents who use a bolster to ensure that it is not a restraint by 7-10-2026.
3.The Therapy Director or designee will educate therapy staff on the need to assess resident who use a bolster to ensure it is not a restraint by 7-10-2026
4.The Therapy Director will audit that functional assessments were completed on residents using a bolster 5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Plan of Correction - To be completed: 07/17/2026

1.Resident CR194 was discharged from the facility on 5-21-2026 so the facility is unable to retroactively revise the comprehensive care plan.
2.The Director of Nursing or designee will review the care plans of residents that exhibit behaviours to ensure compliance with the facility's Care Plans, Comprehensive Person Cantered policy by 7-10-2026.
3.The Director of Nursing or designee will educate staff responsible for updating care plans on the Care Plans, Comprehensive Person Centered policy by 7-10-2026.
4.The Director of Nursing or designee will audit Behavioural Comprehensive Care Plans 5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks to ensure compliance with the facility policy.

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

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of five residents (Resident R10).

Findings include:

Review of facility policy Review of facility policy "Charting and Documentation" dated 5/21/26, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Review of the clinical record indicated Resident R10 was admitted to the facility on 2/18/26.

Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/20/26, indicated diagnoses of high blood pressure, wound infection, and muscle weakness.

Review of Resident R10's comprehensive care plan indicated the resident has potential/actual impairment to skin integrity related to deep tissue injury present on admission, stage 3 pressure injury (full thickness tissue loss) to bilateral (both) heels. Interventions include purple offloading boots at all times when in bed - may remove for care and skin checks and wound care as per orders see TAR (Treatment Administration Record).

Review of a physician order dated 5/2/26, indicated left medial heel (inner portion of the heel) - cleanse with Dakins (a wound cleanser), apply Medihoney (medical-grade honey used for wound healing), then calcium alginate (a highly absorbent dressing), cover with ABD (a highly absorbent dressing), and wrap with Kerlix (a bandage roll) every day shift for wound care.

Review of Resident R10's May 2026 and June 2026 TAR revealed the above treatment was not signed off as completed or refused on the following shifts:
5/3/265/5/265/6/265/7/265/15/265/16/265/17/265/26/265/27/265/29/266/2/266/5/266/10/266/14/26
Review of a physician order dated 5/2/26, indicated right heel - cleanse with Dakins 0.125%, apply medihoney, calcium alginate, cover with ABD, and wrap with kerlix every day shift for wound care.

Review of Resident R10's May 2026 and June 2026 TAR revealed the above treatment was not signed off as completed or refused on the following shifts:
5/3/265/5/265/6/265/7/265/15/265/16/265/17/265/26/265/27/265/29/266/2/266/5/266/10/266/14/26
Review of a physician order dated 5/18/26, indicated purple heel relief boots to both feet while in bed, may remove for care.

Review of Resident R10's May 2026 and June 2026 TAR revealed the above treatment was not signed off as completed or refused on the following shifts:
5/26/26 7 a.m. - 3 p.m. shift5/27/26 7 a.m. - 3 p.m. shift5/28/26 7 a.m. - 3 p.m. shift5/29/26 7 a.m. - 3 p.m. shift6/2/26 7 a.m. - 3 p.m. shift6/5/26 7 a.m. - 3 p.m. shift6/10/26 7 a.m. - 3 p.m. shift6/15/26 3 p.m. - 11 p.m. shift6/19/26 7 a.m. - 3 p.m. shift6/21/26 3 p.m. - 11 p.m. shift
During an interview on 6/25/26, at 2:43 p.m. the Director of Nursing confirmed that the facility failed to make certain that residents received proper treatment for pressure ulcers for Resident R10.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10 (c)(d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Plan of Correction - To be completed: 07/17/2026

1.Resident R10 will be assessed by 7-10-2026 to ensure resident is receiving proper treatments.
2.Director of Nursing or designee will ensure documentation on treatments for pressure ulcers is being completed for other residents by 7-10-2026.
3.Director of Nursing or designee will educate licensed nurses on facility's Charting and Documentation policy to ensure adherence with the policy by 7-10-2026.
4.Director of Nursing or Designee will audit documentation of pressure ulcer treatments to ensure compliance with the policy 5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks.

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

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

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

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

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

Observations:

Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for one of five residents (Resident R3).

Findings include:

Review of the facility policy "Medication Regimen Review" dated 5/21/26, indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. Within twenty-four hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity.

Review of the admission record indicated Resident R3 was admitted to the facility on 5/2/25.

Review of Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/9/26, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), atrial fibrillation (irregular heart rhythm), and high blood pressure.

Review of Resident R3's MRR's on the following dates were signed by a Physician Assistant and not by the physician as required:

-1/9/26 - MRR signed by PAC

-2/25/26 - MRR signed by PAC

-3/29/26 - MRR signed by PAC

-5/14/26 - MRR signed by PAC

-5/27/26 - MRR signed by PAC

Interview on 6/24/26, at 1:19 p.m. the Director of Nursing confirmed that a Physician Assistant signed Resident R3's MRR's on the dates noted instead of the physician as required.

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

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

Plan of Correction - To be completed: 07/17/2026

1.Resident R3 Medication Regimen Review will be provided to the physician by 7-10-2026 for review.
2.The Director of Nursing or designee will review the two previous months of tother residents' medication regime reviews to ensure that they were provided to physician by 7-10-2026.
3.The Director of Nursing or designee will educate the unit managers on the need to provide medication regimen reviews to the physician monthly.
4.The Director of Nursing or designee will audit documentation of the medication regimen reviews to ensure the physician is reviewing monthly 5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks.

§ 201.14(a) LICENSURE Responsibility of licensee.:

(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 state regulations, staff interview, and review of the facility's Infection Control Committee Meeting attendance records, it was determined that the facility failed to ensure that all the required nine multidisciplinary members were present at the Infection Control Committee meetings (physical plant personnel and a community member) for one of four quarters reviewed (Quarter 2 2026). Findings include: Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members at infection control meetings include medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, patient safety officer, a community member, and a member of the infection control team. Review of the facility's Infection Control Committee Meeting attendance for Quarter 2 2026 failed to reveal physical plant personnel and a community member were in attendance. During an interview on 6/25/26, at 10:12 a.m. the Director of Nursing confirmed that the facility failed to ensure that all the required nine multidisciplinary members were present at the Infection Control Committee meetings (physical plant personnel and a community member) for one of four quarters (Quarter 2 2026).

Plan of Correction - To be completed: 07/17/2026

1.The required members of the infection control committee cannot attend past meetings however the meetings were able to cover all required material.
2.The Director of Nursing or designee will educate all required members of the Infection Control Committee that attendance to the meetings in mandatory by 7-10-2026.
3.The Director of Nursing or designee will audit attendance monthly to ensure proper attendance.

§ 201.18(b)(2) LICENSURE Management.:

(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.

Plan of Correction - To be completed: 07/17/2026

1.Due to residents being discharged from facility documentation of return of personal items cannot be completed for residents CR178 and CR194
2.The Director of Nursing or designee will educate nursing staff on the Release of Resident's Personal Belongings policy by 7-10-2026.
3.The Director of Nursing or designee will audit completion of documentation regarding return of personal items upon discharge 5 times a week for 2 weeks, 3 times a week for 2 weeks and weekly for 4 weeks.

§ 201.19(3) LICENSURE Personnel policies and procedures.:

(3) Documentation of credentials, which shall include, at a minimum, current certification, registration or licensure, if applicable, for the position to which the employee is assigned.

Observations:

Based on a review of new hire files and staff interview, it was determined that the facility failed to verify a professional license prior to employment for one out of five personnel files reviewed (Nurse Aide (NA) Employee E3).

Findings include:

Review of NA Employee E3's personnel file indicated a date of hire on 5/12/26. Review of the provided personnel file included a completed license verification check dated 6/22/26, after NA Employee E3's date of hire.

During an interview on 6/23/26, at 1:27 p.m. Human Resources Employee E2 confirmed that the facility failed to verify a professional license prior to employment for one out of five personnel files reviewed (NA Employee E3).

Plan of Correction - To be completed: 07/17/2026

1.Employee E3 license verification will be completed by 7-10-2026.
2.Human Resources Manager or designee will audit other employee files to ensure license verifications were completed prior to hire as necessary.
3.The Nursing Home Administrator will educate the Human Resources Director on the need to verify license prior to hire by 7-10-2026.
4.The Human Resources Director will audit new hire files weekly for 2 months to ensure compliance.

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