Pennsylvania Department of Health
VALLEY MANOR REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

VALLEY MANOR REHABILITATION AND HEALTHCARE 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.


VALLEY MANOR REHABILITATION AND HEALTHCARE 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, Civil Rights Compliance survey completed February 26, 2026, it was determined that Valley Manor Rehabilitation and Healthcare 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 as they relate to the Health portion of the survey.\~

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 maintain resident environment and equipment in a sanitary and homelike manner on four of six nursing units. (Nursing unit 200, 400, 500, and 600)

Findings include:

Observation on February 24, 2026, from 10:05 a.m. to 2:20 p.m., and February 25, 2026, from 9:15 a.m. to 12:15 p.m., revealed the following:

There was a block of floor tiles missing at the entrance to the main kitchen.

The refrigerator in the nourishment room behind the nursing station of the central 200 nursing unit revealed that the shelves in the refrigerator were splattered with juice stains.

In resident room 208, the over the toilet handrails in the bathroom were very loose and not sturdy.

The shared bathroom between room 400 and room 402 had black spots on the floor.

The privacy curtain between beds in room 404 had a large stain.

In room 406, the screws holding the window curtain rod in the wall were coming out and the curtain rod was partially hanging from wall.

In room 407 next to bed B, there were yellow spots on the floor at the foot of bed, brown stains on the bottom of the tube feeding pole, the bedside nightstand had two drawers off track and on the ground beside the bed, and the dresser had two broken drawers.

In room 410, the bathroom floor had dark brown spots with a dirty urine collection container on the floor. The room had unpainted spackle on the wall under the window and next to the sink. There were black marks on the ceiling at the entrance to the room.

In room 412 the walls in resident room were marred and scratched near the window.

In the 400-unit bathing suite, there were stains on two ceiling tiles, the bathtub had a brown and yellow substance near the drain, and the water was running continuously from the faucet. There was a hole in the wall between the tub and shower room. In the toilet room, the soap dispenser by the sink was empty and there were stains on the doorway privacy curtain. In the shower room, the privacy curtain on one stall did not cover the opening fully and the second shower stall did not have a privacy curtain on it.

The wall in the hallway between rooms 505 and 507, had two holes and was marred.

In room 512 bed B, there were stained ceiling tiles above the resident's bed.

In room 601 bed A, there were brown stains at the base of the tube feeding pole.

In an interview on February 26, 2026, at 10:35 a.m. the Administrator confirmed the environmental issues were present.

CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment
Previously cited 3/6/25

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

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

Plan of Correction - To be completed: 03/24/2026

The missing tile at the entrance to the main kitchen has been replaced. The refrigerator behind the central nursing station has been cleaned. The loose handrail in room 208 bathroom has been repaired. The black spot on the floor in the shared bathroom between rooms 400 and 402 has been cleaned. The privacy curtains with a stain in room 404 have been cleaned. The curtain rod hanging off of the wall in room 406 has been repaired. The yellow spots on the floor at the foot of bed "B" in room 407 and the tube feed pole have been cleaned. The two drawers in the bedside stand and the two broken dresser drawers in room 407 bed "B" have been repaired. The bathroom floor in room 410 has been cleaned and the dirty urine container has been cleaned. The unpainted spackle under the window and sink in room 410 has been sanded and painted, and, the black marks on the ceiling at the entrance to the room has been painted. The stained ceiling tiles in 400-unit bathing suite have been replaced and the faucet that was continuously running was repaired. The brown and yellow substance in the in the tub in the 400-unit bathing suite has been cleaned and the empty hand-soap dispenser has been filled. The stained privacy curtain in the doorway to the 400-unit bathing suite has been cleaned and new shower room privacy curtains have been installed in both shower stalls. The holes in the wall and marred areas of the wall in the hallway between rooms 505 and 507 have been repaired and painted. The stained ceiling tiles above the resident's bed "B" in room 512 have been replaced. The brown stains on the bottom of the tube feed pole in room 601 bed "A" have been cleaned.

The kitchen floor has been assessed for additional missing tiles. Where missing tiles were identified they have been replaced. All refrigerators behind nurse stations have been assessed for cleanliness and where identified to need cleaning, were cleaned. Toilet handrails in all resident room bathrooms have been audited to ensure that they are sturdily secured. All resident room and bathing suites on the 400 nursing unit have been audited to ensure that the room floors and bathroom floors are clean and free of stains and are clean. Where room floors and bathroom floors were identified to have stains or need cleaning, the floors were cleaned. All resident rooms and bathing suites on the 400 nursing unit have been audited to ensure that the privacy curtains are present, fully cover the intended area to ensure proper privacy, clean and free of stains. Where privacy curtains were found to not be present, fail to ensure proper privacy, have stains or need cleaning, they were cleaned or replaced. All resident room and hallway area walls and ceilings will be audited for holes, stains and spackling and painting needs. Where walls and ceilings are identified to need repair, painting or ceiling tile replacement identified issues have been repaired. All resident room side table drawers and dresser drawers have been audited for proper function. Where resident room side table drawers and dresser drawers were found to not function properly, they were repaired to ensure proper function. All bathing suite soap dispensers were audited to ensure that they contained soap. Where soap dispensers were identified not to contain soap, they were filled. The 500 nursing unit hallway walls were audited for the presence of holes and marred areas. Where holes or marred areas were identified, they have been repaired and painted. Resident rooms on the 500 nursing unit have been audited for stained or broken ceiling tiles. Where stained or broken ceiling tiles were identified the have been replaced. An audit was completed of all tube feed poles in the facility to ensure that they are clean. Where tube feed poles were found to need cleaning, they were cleaned.

Housekeeping staff have been educated regarding the need to keep resident room, resident bathrooms and shared bathing suite floors and tube feed poles clean and free of debris and stains, to keep refrigerators behind nursing stations clean, to wash privacy curtains when they are stained or dirty, to clean bathing suite tubs and ensure no removable staining or debris is present and to ensure that bathing suite soap dispensers have soap in them and are not empty. Maintenance staff have been educated regarding the need to replace missing floor tiles and repairing broken handrails, curtain rods and resident furnishing drawers that fail to function properly. Maintenance staff have been educated regarding the need to maintain walls and ceilings in good order; including repairing holes, spackling and painting scratched or marred walls as is necessary, replacing ceiling tiles where broken or stained ceiling tiles are identified and regarding repairing faucets to ensure that they can be shut off completely.

Housekeeping Director or designee will audit (5) resident rooms and (1) bathing suite per week for (4) weeks and then (5) resident rooms and (1) bathing suite per month for (2) months to ensure that resident room, resident bathrooms and shared bathing suite floors and tube feed poles clean and free of debris and stains, to keep refrigerators behind nursing stations clean, to wash privacy curtains when they are stained or dirty, to clean bathing suite tubs and ensure no removable staining or debris is present and to ensure that bathing suite soap dispensers have soap in them and are not empty. Maintenance Director or designee will audit (5) resident rooms and (1) common area per week for (4) weeks and then (5) resident rooms and (1) common area per month for (2) months to ensure that missing floor tiles are replaced, broken handrails are repaired, curtain rods are secured and resident furnishing drawers that fail to function properly are repaired, walls and ceilings are maintained in good order; including repairing holes, spackling and painting scratched or marred walls as is necessary, replacing ceiling tiles where broken or stained ceiling tiles are identified and regarding repairing faucets to ensure that they can be shut off completely.

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 and staff interview, it was determined that the facility failed to provide treatment and services as ordered by the physician to promote healing and prevent new pressure sores for two of three sampled residents who had pressure sores. (Resident 4, 10)

Findings include:

Clinical record review revealed that Resident 4 had diagnoses that included early onset of Alzheimer's disease. A review of a skin assessment dated February 13, 2026, revealed that the resident had a pressure sore on her right buttock and a scar on her coccyx. The Minimum Data Set (MDS) assessment dated February 16, 2026, indicated that the resident required substantial assistance with overall care and that she had two pressure sores. A review of the care plan revealed that the resident had an actual wound on her right buttock and sacral slit. There was an intervention for staff to provide treatments as ordered by the physician. Review of a physician's order dated February 19, 2026, directed staff cleanse the sacral slit with soap and water and apply a cream for wound healing (Triad Paste) every day and evening shift. Review of the Treatment Administration Record (TAR) for February 2026, revealed that there was no documented evidence the treatment was completed on the day shift (7:00 a.m. to 3:00 p.m.) February 20 and 21, 2026, and on the evening shift (3:00 p.m. to 11:00 p.m.) February 22, 2026.

Clinical record review revealed that Resident 10 had diagnoses that included a sacral pressure ulcer and diabetes. A review of a wound care note dated February 19, 2026, revealed that the resident had a pressure sore on the sacrum. The MDS assessment dated December 29, 2025, indicated that the resident was dependent on staff for all care and had two pressure sores. A review of the care plan revealed that the resident had an actual wound on the bottom of the sacrum. There was an intervention for staff to provide treatments as ordered by the physician. Review of a physician's order dated January 29, 2026, directed staff to cleanse the sacrum with an antiseptic cleansing solution and apply a collagen dressing and a calcium alginate foam dressing every day and evening shift and as needed. Review of the TAR for February 2026, revealed that there was no documented evidence the treatment was completed on the day shift (7:00 a.m. to 3:00 p.m.) February 2, 5, 7, and 12, 2026, and on the evening shift (3:00 p.m. to 11:00 p.m.) February 2, 13, and 21, 2026.

In an interview on February 26, 2026, at 9:32 a.m., and 12:53 p.m., the Director of Nursing stated that there was no documented evidence that the treatments had been completed to the wounds on the shifts listed above as ordered by the physician.

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

Plan of Correction - To be completed: 03/24/2026

Residents 4 and 10's wounds were assessed by nursing to ensure appropriate treatments in place and are effective. Residents 4 and 10 suffered no ill effects of treatments not being properly documented in the medical record.

An audit was completed of all residents with pressure ulcers to identify additional residents whose treatments were not properly documented in the medical record.

Nurses have been educated regarding proper documentation for pressure ulcer treatments and documenting same.

Director of Nursing or Designee will audit (3) residents who have pressure ulcers weekly X (4) weeks, and then, (1) X month for (2) months to ensure proper documentation and will audit (3) residents who on bowel protocols weekly X (4) weeks, and then, (1) X month for (2) months to ensure proper documentation. Findings will be reported at QAPI Meeting for any additional recommendations.

483.25 REQUIREMENT Quality of Care:

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for five of 33 sampled residents. (Residents 1, 66, 78, 86, and 118)

Findings include:

Clinical record review revealed that Resident 1 had diagnoses that included hypotension (low blood pressure). A physician's order dated March 11, 2024, directed staff to administer a medication (midodrine) three times a day for hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 120 millimeters of mercury (mm/Hg). Review of Resident 1's January 2026 and February 2026 medication administration records (MARs) revealed that staff administered the medication 19 times in January and 10 times in February when the resident's SBP was greater than 120 mm/Hg.

Clinical record review revealed that Resident 66 had diagnoses that included seizure disorder and traumatic subdural hemorrhage (a collection of blood between the brain and the outer covering due to ruptured veins from a head injury). Review of Resident 66's February 2026 MAR revealed that the resident received a medication for seizure disorder (levetiracetam) twice a day. A physician's order dated February 7, 2026, directed staff to obtain a lab test to check the blood level of levetiracetam. There was no documented evidence that the test was completed.

Clinical record review revealed that Resident 78 had diagnoses that included hypertension (high blood pressure). A physician's order dated August 15, 2023, directed staff to administer a medication (amlodipine besylate) one time a day for hypertension. Staff were not to administer the medication if the resident's SBP was less than 110 mm/Hg. Review of Resident 78's January 2026 and February 2026 MARs revealed that staff administered the medication four times in January and three times in February when the resident's SBP was less than 110 mm/Hg.

Clinical record review revealed that Resident 86 had diagnoses that included constipation and dementia. A physician's order dated August 12, 2024, directed staff to administer 30 milliliters of Milk of Magnesia (MOM) every 24 hours as needed and /or if no bowel movement in three days. A physician's order dated August 12, 2024, directed staff to administer a bisacodyl suppository rectally if there were no results from the MOM. A physician's order dated August 12, 2024, further directed staff to insert an enema if there were no results from the bisacodyl suppository. A physician's order dated May 30, 2023, directed staff to administer Dulcolax one tablet by mouth every 24 hours as needed for constipation. Review of bowel movement tracking documentation for Resident 43 revealed that there were no bowel movements recorded from February 17, 2026, at 2:07 p.m., through February 24, 2026, at 2:58 p.m. Review of the MAR for February 2026, revealed that the resident was not provided with any as needed medications for constipation until a Dulcolax tablet was provided at 2:58 p.m. on February 24, 2026, seven days after the last documented bowel movement.

Clinical record review revealed that Resident 118 had diagnoses that included hypotension. A physician's order dated December 14, 2024, directed staff to administer a medication (midodrine) three times a day for hypotension. Staff were to administer the medication if the resident's systolic blood pressure SBP was less than 100 mm/Hg. Review of Resident 118's January 2026 and February 2026 MARs revealed that staff administered the medication 60 times in January and 30 times in February when the resident's SBP was greater than 100 mm/Hg.

In interviews on February 26, 2026, at 10:17 a.m., 11:44 a.m., and 12:56 p.m., the Director of Nursing confirmed that the medications were administered outside established parameters for Residents 1,78, and 118, that the lab test for Resident 66 was not obtained and should have been, and that none of the as needed medications for constipation were administered for Resident 86, and should have been before seven days with no documented bowel movement.

CFR 483.25 Quality of Care
Previously cited 3/6/25, 5/15/25

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

Plan of Correction - To be completed: 03/24/2026

Checks were conducted for residents 1, 66,78, 86 and 118's to ensure compliance with blood pressure parameters prior to medication administration. Nurses were educated regarding the requirement(s) to check blood pressure parameters for residents 1, 66,78, 86 and 118 prior to medication administration.

An audit of all residents on medications that require blood pressure parameters to be followed was completed.

Nurses were educated on following physician orders, including transcription.

Director of Nursing or Designee will audit (3) residents who are on medications requiring blood pressure parameters be followed weekly X (4) weeks, and then, (1) X month for (2) months and report findings at the Monthly QAPI Meeting for any additional recommendations.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

�483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in �483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

�483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

�483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

�483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

�483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

�483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to maintain accurate reconciliation records for controlled substances on one of seven medication carts. (400 Unit medication cart)

Findings include:

Review of the facility policy entitled, "Controlled Medication Storage," last reviewed January 22, 2026, revealed that at shift change, a physical inventory of all controlled medications was to be conducted by two licensed nurses and documented on the individual resident's controlled medication accountability record.

In an interview on February 26, 2026, at 1:30 p.m., the Director of Nursing stated that the nurse coming on duty and nurse going off duty were to count all controlled substances and other medications with the risk of abuse or diversion at the change of each shift and document on a "Shift Count" sheet that the count on the resident accountability card was accurate. The nurse coming on duty was responsible for the cart. This shift-to-shift count was to be completed at the same time by both nurses. Following shift to shift count, both nurses were to sign the Shift Count sheet. Any discrepancies of the controlled substances were to be immediately reported to the Director of Nursing.

Observation of the medication cart on the 400 Unit, on February 26, 2026, at 8:15 a.m., revealed that the controlled substance log the facility used entitled, "Shift Count," had missing signatures from licensed staff from the February 2026 log for various shifts.

Review of the Shift Count log for the 400 Unit medication cart from January 5 through 24, 2026, and February 2 through 25, 2026, revealed the following number of missing licensed nursing signatures:

Coming on duty at 7:00 a.m., 21 of 44 days reviewed.
Coming on duty at 3:00 p.m., 28 of 44 days reviewed.
Coming on duty at 11:00 p.m., 28 of 44 days reviewed.
Going off duty at 7:00 a.m., 27 of 44 days reviewed.
Going off duty at 3:00 p.m., 25 of 44 days reviewed.
Going off duty at 11:00 p.m., 25 of 44 days reviewed.

In an interview on February 26, 2026, at 1:30 p.m., the Director of Nursing confirmed that the signatures were not there at the previously mentioned times as per facility policy and should have been.

28 Pa. Code 211.9 (j.1)(5) Pharmacy Services.
28 Pa Code 211.12 (d)(1)(5) Nursing Services.

Plan of Correction - To be completed: 03/24/2026

Nurses immediately educated regarding signing shift count at the beginning and the end of their shifts in the Controlled Substance Books.

An audit was completed of all controlled substance books to identify any additional non-compliance regarding nurses signing shift count at the beginning and the end of shifts. Nurse were educated.

Nurses have been educated regarding proper process; including documentation requirements in the Controlled Substance Book.

Director of Nursing or Designee will audit all Controlled Substance Books (3) times a week X (4) weeks, and then, (1) X month for (2) months and report findings at the Monthly QAPI Meeting for any additional recommendations.

483.25(m) REQUIREMENT Trauma Informed Care:

�483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to assess residents with a diagnosis of post-traumatic stress disorder (PTSD) and develop and implement an individualized person-centered care plan to render trauma informed care for three of five sampled residents diagnosed with PTSD. (Residents 4,16 and 77)

Findings include:

Clinical record review revealed that Resident 4 was admitted to the facility on February 10, 2026, with diagnoses that included Post Traumatic Stress Disorder (PTSD), schizoaffective disorder and early onset of Alzheimer's disease. The Minimum Data (MDS) assessment dated February 16, 2026, indicated that the resident had some memory impairment and had a diagnosis of PTSD. There was no documentation to support that the resident was assessed for symptoms or triggers related to the diagnosis of PTSD. The care plan for Resident 4 did not include any measures to address the resident's history of trauma or identify triggers. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.

Clinical record review revealed that Resident 16 was admitted to the facility on January 24, 2025, with diagnoses that included PTSD and anxiety. The MDS assessment dated February 2, 2026, revealed that the resident was cognitively intact and had a diagnosis of PTSD. There was no documentation to support that the resident was assessed for symptoms or triggers related to the diagnosis of PTSD. Resident 16's care plan did not include any measure to address the resident's history of trauma or identify triggers. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.

Clinical record review revealed that Resident 77 was admitted to the facility on January 28, 2026, with diagnoses that included PTSD and major depressive disorder. Review of the MDS assessment dated February 3, 2026, revealed that the resident was cognitively intact and had a diagnosis of PTSD. On February 1, 2026, the nurse documented that the resident had previously reported that he suffers from bad PTSD from the Vietnam war, which gave him anxiety and triggered recurring episodes of vomiting. On February 2, 2026, the Nurse Practitioner documented that the resident was seen for follow up regarding nausea, vomiting, and PTSD. On February 20, 2026, the provider documented that the resident was evaluated for worsening cognitive and emotional symptoms, including increased difficulty with focus and concentration, escalating anxiety, and persistent insomnia. There was no documentation to support that symptoms or triggers were assessed related to the diagnosis of PTSD. Resident 77's care plan did not include any measure to address the resident's history of trauma or identify triggers. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization on the care plan.

In an interview on February 26, 2026, at 9:32 a.m., the Director of Nursing confirmed that Residents 4, 16, and 77 were not assessed or care planned for PTSD.

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

Plan of Correction - To be completed: 03/24/2026

Completed Trauma assessments for residents 4,16 and 77, implemented appropriate interventions and care plans.

Completed an audit of all facility residents to determine if they have been assessed for trauma. All residents not previously assessed for trauma have been assessed and appropriate interventions and care plans were put in place.

Social Services staff have been educated regarding the need to assess all residents for trauma upon admission and as otherwise may be necessary and to implement appropriate interventions and care plans.

Social Services Director or Designee will audit all newly admitted residents each week for (4) weeks, and then, (5) newly admitted residents each month for (2) months and report findings at the Monthly QAPI Meeting for any additional recommendations.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) 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 provide copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for five out of five residents who were transferred out of the facility. (Residents 6, 11, 14, 117, and 159)

Findings include:

Clinical record review revealed that Resident 6 was transferred to the hospital on January 31, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 11 was transferred to the hospital on February 6, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 14 was transferred to the hospital on December 22, 2025, January 5 and 16, 2026, after changes in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 117 was transferred to the hospital on October 9, 2025, and February 7, 2026, after changes in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 159 was transferred to the hospital on February 1, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.

In an interview on February 26, 2026, at 10:30 a.m., the Director of Nursing confirmed that the written copies of the 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: 03/24/2026

The LTC Ombudsman Office has been notified of the involuntary discharges and transfers for residents 6, 11, 14, 117 and 159.

An audit was completed to identify residents who involuntarily discharged or transferred during the prior month of February, 2026 and notices have been provided to the LTC Ombudsman Office. Facility has created a log for residents who involuntarily discharge and transfer. Social Services Director or designee will maintain the log and send it to the LTC Ombudsman Office by the fifth day of the month with involuntary discharges and transfers from the prior month.

Social Services staff have been educated regarding the requirement that the LTC Ombudsman Office must be notified of involuntary discharges and transfers.

Social Services Director or Designee will audit the Involuntary discharge and Transfer Log each month for 3 MONTHS and provide a copy to be recorded at the Monthly QAPI Meeting for review and recommendations.

� 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for three of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 3, 2026, through February 24, 2026, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on February 14, 16, and 22, 2026.

In an interview on February 26, 2026, at 12:30 p.m., the Director of Nursing stated that the facility failed to meet the minimum nurse aide to resident ratio on the dates listed above.

Plan of Correction - To be completed: 03/24/2026

CNA staffing ratios were reviewed for 7:00 a.m. to 3:00 p.m. shifts on February 14, 16 and 22, 2026 and the facility did provide care in excess of the required overall daily ppd.

The facility staffs the facility to at least meet the required staffing ratios of CNAs, including the use of agency staff if necessary. When there are staff call-outs, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance.

NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation.

To monitor the corrective action and ensure that it does not recur, the Director of Nursing or designee will audit nursing staff to resident ratios (3) weekly for (4) weeks and then (3) times monthly X 2. The results will be reviewed at the QAPI Meeting for further recommendation.

� 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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for one of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from February 3, 2026, through February 24, 2026, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11:00 p.m.) on February 14, 2026.

In an interview on February 26, 2026, at 12:30 p.m., the Director of Nursing stated that the facility failed to meet the minimum LPN to resident ratio on the date listed above.

Plan of Correction - To be completed: 03/24/2026

LPN staffing ratio was reviewed for 3:00 p.m. to 11:00 p.m. shift on February 11, 2026 and the facility did provide care in excess of the required overall daily ppd.

The facility staffs the facility to at least meet the required staffing ratios, including the use of agency staff if necessary. When there are staff call-outs, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance.

NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation.

To monitor the corrective action and ensure that it does not recur, the Director of Nursing or designee will audit nursing staff to resident ratios (3) times weekly for (4) weeks and then (3) times monthly X 2. The results will be reviewed at the QAPI Meeting for further recommendation.

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