Pennsylvania Department of Health
ELKINS CREST HEALTH & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ELKINS CREST HEALTH & REHABILITATION CENTER
Inspection Results For:

There are 222 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.


ELKINS CREST HEALTH & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, a Civil Rights Compliance, and an Abbreviated survey completed on September 12, 2025, it was determined that Elkins Crest Health 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:

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

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

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of three nursing units. (Floors 2 and 3)

Findings include:

Observations on September 9, 2025, from 9:45 a.m. through 1:00 p.m. and on September 10, 2025, from 10:00 a.m. through 1:00 p.m. revealed the following:

Peeling paint was observed on the wall under the fire extinguisher in the hallway by room 202.

Peeling paint and a dried brown liquid were observed on the floor in front of the closets in room 208.

The hallway wall between rooms 204 and 205 was marred.

A bedside tray table in room 217 was missing a drawer, another drawer was crooked, and a metal drawer track was observed on the floor.

A bed curtain in room 219 was off its track.

Debris was observed on the floor in room 224.

Marks were observed on the walls in the second-floor dining room.

The handrail in the hallway across from the second-floor nursing station was missing a piece.

The handrail next to the elevator was loose.

Flies were observed in rooms 208, 224, and at the second-floor nursing station.

There was damage to the wall behind the A bed and ceiling tiles were damaged in the bathroom of room 304.

The radiator cover was damaged, and a sliding closet door was off the tracks in room 306.

The entrance door and a floor tile were damaged in room 315.

A sliding closet door was missing in room 322.

The wall across from bed A was damaged. Floor tiles in the bathroom in 325 were damaged.

There was an uncovered electrical outlet with wires exposed on the wall behind bed A in room 329.

An electrical outlet to the left of the television in the third floor dining room had no cover.

Ceiling tiles, the radiator under the television, and the piano in the third floor dining room were damaged.

Wheelchair bumper rails in the hallway between rooms 314 and the shower room, and between rooms 315 and 316 were damaged.

A red substance was observed on the back of the 3rd floor "High side" med cart.

The sharp's container cabinets on both 3rd floor med carts had broken vents on the sides.

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

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

Plan of Correction - To be completed: 10/13/2025

1. Room 304 wall damage repaired and ceiling tiles replaced, RM 306 radiator repaired and closet door placed back on tracks, rm 315-door has been ordered, RM 322 closet door ordered, RM 329 plate replaced over wires, third floor dining room outlet cover replaced and radiator repaired, RM 325 damaged wall was repaired, assist rails (bumper rails) repaired as needed, 217-1 bedside table repaired, Rm 219- curtain placed back on track, Rm 224-2 room was cleaned and AC issues addressed, outside Rm 202 wall was painted and marred walls were repaired outside of dining room, Rm 208-1 closet area was cleaned, rooms 204 and 205 walls have been repaired, rm 114-1 toilet has been cleaned, Rm 110 behand the bed area has been repaired, Rm 121 nightstand has been replaced and BR door has been repaired. Rm 219 curtained was replaced on track. Handrail next to elevator was tightened. No flies noted in rm 208, 224, or at the second floor nursing station. RM 304 behind the bed was repaired, ceiling tiles replaced in the bathroom. Wheelchair bumpers in hallway between 314 and the shower room, and between rooms 315 and 316 were repaired. Third floor high side med cart was cleaned. Third floor sharps container med carts have had new holders ordered.
2. To identify other areas affected, Maintenance and House Keeping Director have completed rounds to identify other areas of concern.
3. To prevent this from reoccurring, NHA developed a plan to address identified areas of concern. Maintenance and House Keeping Director have been educated regarding following round process, ensuring rooms and common areas are clean and in good repair.
4. Ongoing monitoring for compliance, NHA/designee will audit designated areas from plan weekly for 4 weeks and monthly for 2 months.
5. Results will be reviewed and revised as needed during monthly QAPI meeting.

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 clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of 33 sampled residents. (Resident 7)

Findings include:

Clinical record review revealed that Resident 7 had diagnoses that included cerebrovascular accident (stroke),respiratory failure, and dysphagia (difficulty swallowing). After a change in condition on May 21, 2025, the physician ordered the resident to begin receiving hospice services. The MDS assessments, dated May 21 and August 21, 2025, did not indicate that Resident 7 received hospice services.

In an interview on September 12, 2025, at 1:10 p.m., the Director of Nursing confirmed that Residents 7's MDS assessments were inaccurate and the resident was receiving hospice services.

Plan of Correction - To be completed: 10/13/2025

1. R 7 MDS assessments of May 21 and August 21 have been corrected to reflect Hospice status.

2. To identify other residents, Regional Reimbursement Specialist completed and audit of residents on Hospice services to ensure accurate coding of MDS assessments.
3. To prevent from reoccurring, Regional Reimbursement Specialist has educated the MDS staff on accurate coding of the MDS.
4. Ongoing monitoring for compliance, IDT will audit per MDS schedule for any new residents on hospice services to ensure accurate coding of MDS weekly for 3 months.

483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs:

§483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(a) Skilled Nursing Facilities
A facility-

§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(f) of this part, routine and emergency dental services to meet the needs of each resident;

§483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

§483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

§483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

§483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.

Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide routine and emergency dental services for one of 33 sampled residents. (Resident 67)

Findings include:

Clinical record review revealed that Resident 67 was admitted on October 4, 2024, and had diagnoses that included spinal stenosis, nutritional deficiency, and chronic inflammatory demyelinating polyneuritis (an autoimmune disorder that damages nerve cells).

During an interview on September 9, 2025, at 11:00 a.m. Resident 67 stated some of her teeth were damaged while she was hospitalized in October 2024. A dentist had referred her to an oral surgeon for extractions but no appointment had been made. On May 21, 2025, a dentist examined the resident and noted that she needed the damaged teeth removed by an oral surgeon. There was no documentation in the clinical record to support that the facility scheduled an examination with the oral surgeon to meet the needs of the resident.

During an interview on September 12, 2025, at 9:45 a.m., the Director of Nursing, confirmed that the facility had failed to provide recommended dental services to Resident 67.

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

28 Pa Code 211.15 Dental services.

Plan of Correction - To be completed: 10/13/2025

R 67 had a dental appointment on 9/19/25 and was referred to pick an oral surgeon from a list provided by the general dentist. R 67 states she will find her own oral surgeon and notify staff upon her decision.
2. To identify other residents with the potential to be affected, DON/designee will complete a house audit to ensure current residents have their dentist needs met and appointments made as needed.
3. To prevent this from recurring, DON/designee educated Unit Managers to bring Dental consult sheets for review during CMM to ensure any required follow up is completed.
4. Ongoing monitoring for compliance, DON/designee will review the dental visits for 3 months to ensure follow-up has been completed
5. Results will be reviewed and revised as needed during monthly QAPI meeting.

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

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

Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide necessary treatment and services to promote healing and to prevent new pressure sores from developing for one of two sampled residents with pressure sores. (Resident 4)

Findings include:

Clinical record review revealed that Resident 4 had diagnoses that included anoxic brain injury (lack of oxygen to the brain), respiratory failure, and diabetes. The Minimum Data Set assessment dated June 5, 2025, indicated that the resident was non-verbal, dependent on staff for activities of daily living, had a pressure sore, and was at risk for developing additional pressure sores. On July 22, 2025, a physician's order directed staff to keep the resident's ears floating using a supportive neck pillow every shift. A review of the wound care physician's note, dated August 21, 2025, indicated the resident had bilateral open ear wounds. The care plan indicated that the resident had bilateral ear wounds and was at risk for worsening skin problems due to reduced mobility. Interventions included keeping the resident's ears floating by applying a neck support pillow with turning and repositioning every two hours.

On September 9, 2025, at 11:05 a.m. and on September 11, 2025, at 11:30 a.m., 12:30 p.m., and 2:25 p.m., the resident was observed lying in bed without the neck pillow in place. The residents right ear was in direct contact with the bed pillow. On September 12, 2025, at 8:48 a.m., the resident was observed lying in bed without the neck pillow in place with his head facing forward. Bilateral ear wounds were observed.

On September 12, 2025, at 10:10 a.m., the Director of Nursing confirmed that the neck pillow was supposed to be in place, and that it was not at the time of the observations.

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

Plan of Correction - To be completed: 10/13/2025

1. R4's neck pillow was placed per physician order during survey.
2. To identify other resident with the potential to be affected, DON/designee will audit current residents with pressure wounds to ensure physician orders are being followed.
3. To prevent this from reoccurring, DON/designee will educate licensed staff regarding following physician orders for wound prevention.
4. Ongoing monitoring for compliance, DON/designee will audit 5 residents a week for 3 months to ensure physician pressure ulcer orders are in place and being followed.
5. Results will be reviewed and revised as needed during monthly QAPI meeting.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan that addressed an individual resident's needs as identified in the comprehensive assessment for two of 33 sampled residents. (Residents 75 and 76)

Findings include:

Clinical record review revealed that Resident 75 had diagnoses that included senile degeneration of the brain, major depression, and difficulty in walking. According to the Minimum Data Set (MDS) assessment dated August 16, 2025, the resident was occasionally incontinent of urine. The MDS Care Area Assessment (CAA) summary, dated February 13, 2025, indicated that the resident's urinary incontinence was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 75's urinary incontinence were addressed in the care plan.

Clinical record review revealed that Resident 76 had diagnoses that included dementia, muscle weakness, and difficulty in walking. According to the MDS assessment dated July 2, 2025, the resident was occasionally incontinent of urine. The MDS CAA summary, dated January 2, 2025, revealed the residents urinary incontinence was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 76's urinary incontinence were addressed in the care plan.

In an interview on September 12, 2025, at 10:10 a.m., the Director of Nursing confirmed the identified care areas were not addressed in the care plans.

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

Plan of Correction - To be completed: 10/13/2025

1. R 75 and R76's urinary continence care plan have been updated.
2. To identify other residents with the potential to be affected, Interdisciplinary team will audit the last comprehensive MDS assessment CAA report and ensure that the care plan reflects the assessment.
3. To prevent this from reoccurring, DON/designee will educate the IDT on ensuring the care plan reflects the comprehensive MDS assessment.
4. Ongoing monitoring for compliance, DON/designee will audit five MDS's CAAs to care plans a week for 4 weeks and monthly for 2 months.
5. Results will be reviewed and revised as needed during monthly QAPI meeting.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:

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.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

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

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

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

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

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

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

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

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

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify the State Ombudsman's office in writing of the transfer from the facility for six of six sampled residents who were transferred to the hospital. (Residents 2, 4, 6, 15, 16, 155)

Findings include:

Clinical record review revealed that Resident 2 was transferred to the hospital on May 12, 2025, after a significant change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 4 was transferred to the hospital on June 17, 2025, and on August 11, 2025, after significant changes in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 6 was transferred to the hospital on October 23, 2024, after a significant change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 15 was transferred to the hospital on June 14, 2025, and on June 27, 2025, after significant changes in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 16 was transferred to the hospital on April 2, 2025, after a significant change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 155 was transferred to the hospital on July 8, 2025, after a significant change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman.

In an interview on September 12, 2025, at 9:45 a.m., the Director of Nursing confirmed that the written copies of the discharge or transfer notices were not sent to the Office of the State Long Term Care Ombudsman.

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

Plan of Correction - To be completed: 10/13/2025

1. R 2 , R 4, R 6, R15, R 16, and R 155 have had their written discharge/transfer notices were sent to the Office of the State Long Term Care Ombudsman.
2. Three months of information will be sent to the State Ombudsman's office.
3. To prevent from reoccurring, NHA/designee has educated the Social Services department regarding the requirement to send monthly discharge information to the state Ombudsman's office.
4. Ongoing monitoring for compliance, NHA/designee will review the information sent to the state ombudsman's office monthly for 3 months.
5. Results will be reviewed and revised as needed during monthly QAPI meeting.

483.35(i)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:

§483.35(i) Nurse Staffing Information.
§483.35(i)(1) Data requirements. The facility must post the following information on a daily basis:

(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(i)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (i)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents, staff, and visitors.

§483.35(i)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(i)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift.

Findings include:

Observations during a tour of the facility conducted on September 9, 2025, at 9:45 a.m., revealed that staffing information posted in the lobby was dated for September 5, 2025.

In an interview on September 12, 2025, at 10:15 a.m., the Director of Nursing confirmed that the correct staffing information should have been posted.

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

Plan of Correction - To be completed: 10/13/2025

1. Staffing posting was addressed during survey and posted.
2. Staffing postings are addressed daily.
3. To prevent from reoccurring, DON/designee will educate the staffing coordinator and nursing supervisors on the requirement for the staffing posting.
4. Ongoing monitoring for compliance, DON/designee will audit 5 times a week for 4 weeks and randomly thereafter.
5. Results will be reviewed and revised as needed during monthly QAPI meeting.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations:

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly.

Findings include:

Observation of the dumpster area on September 9, 2025, at 10:30 a.m., revealed the side door of the dumpster was open. The grassy area adjacent to the dumpster had multiple pieces of plastic and paper debris. There were two dumpster lids laying on the ground next to the dumpster.

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

Plan of Correction - To be completed: 10/13/2025

1. Facility dumpster side door was closed, the grassy area adjacent to the dumpster, and two dumpster lids on the ground were removed during the survey.
2. There are no other external refuse areas.
3. To prevent this from reoccurring, NHS/designee will educate dietary director, maintenance director, and housekeeping director on maintaining the dumpster area. A schedule will be developed for cleaning of the dumpster area.
4. Ongoing monitoring for compliance, NHA/designee will complete weekly audits for 4 weeks and monthly for 2 months to ensure the dumpster area is in order.
5. Results will be reviewed and revised as needed during monthly QAPI meeting.

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