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

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GREENFIELD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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GREENFIELD HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance Survey completed on January 27, 2026, it was determined that Greenfield Healthcare and Rehabilitation Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.12 Freedom from Abuse, Neglect, and Exploitation
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)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:



Based on review of facility policy, review of clinical and facility records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2025 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined that the facility failed to ensure Resident R6 was free of neglect during care, which resulted in actual harm of a laceration to the left posterior head, fracture of left pubic bone with a two part fracture that extended into the pubic symphysis (the front and lower part of left hip bone which separated and fractured), left scapholunate ligament tear (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and shock (a life-threatening medical emergency caused by inadequate blood flow to tissues resulting in oxygen not getting to organs of body resulting in potential organ failure and death) for one of 17 residents reviewed (Resident R6).


Findings include:

A facility policy entitled, "Abuse, Neglect and Exploitation," dated 11/01/25, revealed, "It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. "Neglect" means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. "Willful" means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm."

A facility policy entitled, "Safe Resident Handling/Transfers," dated 11/01/25, revealed, "It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Two staff members must be utilized when transferring residents with a mechanical lift."

Resident R6's clinical record revealed an admission date of 2/08/25, with diagnoses that included shock, closed head injury (occurs when a sudden, violent impact to the head damages the brain without breaking the skull), fall, left scapho-lunate dissociation (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and closed fracture dislocation of left pubis symphysis with diastasis (the front and lower part of left hip bone which separated and fractured creating a diastasis [a widened gap]).

Resident's R6's Minimum Data Set (MDS periodic assessment of resident care needs), Section GG0170 Functional abilities Mobility dated 9/29/25, revealed Resident R6 was dependent for transfers (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity).

Resident R6's task order summary (a program used by nursing staff to verify transfer orders) revealed task order reviews dated 9/24/25, 9/25/26, and 9/26/25, all indicating Resident R6 was dependent for transfers.

Facility provided documentation of an incident report for Resident R6 dated 9/29/25, at 6:50 a.m. revealed nursing description - Entered resident room, observed resident on floor. Resident stated he/she hit his/her head. Skin assessment done on resident, observed laceration to back of head, and abrasions to right arm. Bruising to left hand. Resident bleeding from laceration on back of head and on right arm.

Resident R6's clinical record revealed a nutritional progress note dated 9/29/25, at 12:02 p.m. which stated, "Resident sent out to ER [emergency room] today after fall." Resident R6's clinical record lacked evidence of further progress notes related to a fall on 9/29/25.

Facility provided documentation, "Corrective Action Form," dated 10/03/25, revealed Nursing Assistant (NA) Employee E6 with a Final Written/Discharge warning for Nature of Infraction - Any deviation from a resident's course of treatment that creates the risk of/or results in serious or substantial harm to resident. Willful or reckless in attention to the needs of a resident. Description: Description of Incident [NA Employee E6] did not follow transfer order for a resident as evidenced by using Hoyer lift [mechanical lift utilized in lifting a person who is dependent for assistance with transfers]to transfer resident by [herself/himself] instead of using assist of two."

Resident R6's clinical documentation dated 10/02/25, (hospital admission date 9/29/25, and discharge date 10/08/25), revealed progress notes from his/her hospitalization which indicated Resident R6 remained critically ill at this time after being dropped from a Hoyer lift approximately five feet. Progress notes stated, "Currently treating this patient for fall from Hoyer lift on anticoagulants [blood thinning medication], scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension [low blood pressure] and shock requiring vasopressors [medications used to raise low blood pressure] and fluid. V. tach [ventricular tachycardia - life-threatening heart rhythm disorder], hypokalemia [low potassium in blood]."

Interview with Resident R6 on 1/25/26, at 9:55 a.m. revealed that he/she was dropped from a Hoyer lift a few months ago and received a laceration to his/her head. Resident R6 stated, "I was lifted up and fell out of the lift. I hit the floor hard (rubbing the back of his/her head) and got a terrible gash to the back of my head." Resident R6 further indicated that only one NA assisted him/her during the time of fall from the Hoyer lift, and he/she was transferred to the hospital and stayed several days related to the fall.

Interview with the Nursing Home Administrator (NHA) on 1/26/26, at 2:55 p.m. confirmed that Resident R6 was transferred via a Hoyer lift on 9/29/25, by NA Employee E6, which resulted in a fall with substantial harm of a laceration to his/her posterior head, fracture of pelvis, and injury to his/her wrist. The NHA further confirmed that Resident R6 was dependent for transfers and required a Hoyer lift and a two person assist for all transfers, however on 9/29/25 Resident R6 was transferred with only one person and Hoyer lift which resulted in Resident R6's fall and substantial harm of laceration and fractures.

The facility failed to ensure that Resident R6 was free from neglect which resulted in actual harm of a laceration to his/her posterior head, fracture of pelvis, and injury to his/her wrist from a fall from a Hoyer lift.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.12(c) Nursing services

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






 Plan of Correction - To be completed: 02/24/2026

1. R6 was transferred to the hospital for treatment after the incident. Aide responsible was re-educated on transfer policy of 2 people, neglect, and received a disciplinary action.
2. Residents were interviewed to ensure that no other incident of neglect had occurred by the Director of Nursing/designee. It is impossible to determine whether non-interviewable residents sustained injuries in September under the same circumstances of lacking documentation.
3. The transfer status and care plans of all residents has been reviewed by the Director of Nursing/designee and instruction given to nursing staff to use 2 staff for Hoyer transfers.
All staff were re-educated by Director of Nursing and Administrator on Abuse and Neglect reporting and policy. Nursing staff were re-educated on proper use of 2 staff for Hoyer transfers.
4. Three resident transfers will be observed by Director of Nursing/designee 3 times a week for 4 weeks to check the transfer is per order/policy and that neglect is not identified, then weekly for two months. The same staff who are being observed will be asked if they understand what constitutes neglect. Results will be presented to the monthly Quality Assurance team for recommendations. Director of Nursing to monitor.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of facility policy, review of facility documentation and clinical records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2025 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall for one of 17 residents (Resident R6), which resulted in actual harm of a laceration to the left posterior head, fracture of left pubic bone with a two part fracture that extended into the pubic symphysis (the front and lower part of left hip bone which separated and fractured), left scapholunate ligament tear (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and shock (a life-threatening medical emergency caused by inadequate blood flow to tissues resulting in oxygen not getting to organs of body resulting in potential organ failure and death).


Findings include:

A facility policy entitled, "Safe Resident Handling/Transfers" dated 11/01/25, revealed, "It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Two staff members must be utilized when transferring residents with a mechanical lift."

Resident R6's clinical record revealed an admission date of 2/08/25, with diagnoses that included shock, closed head injury (occurs when a sudden, violent impact to the head damages the brain without breaking the skull), fall, left scapho-lunate dissociation (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and closed fracture dislocation of left pubis symphysis with diastasis (the front and lower part of left hip bone which separated and fractured creating a diastasis [a widened gap]).

Resident's R6's Minimum Data Set (MDS periodic assessment of resident care needs), Section GG0170 Functional abilities Mobility dated 9/29/25, revealed Resident R6 was dependent for transfers (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity).

Resident R6's task order summary (a program used by nursing staff to verify transfer orders) revealed task order reviews dated 9/24/25, 9/25/26, and 9/26/25, all indicating Resident R6 was dependent for transfers.

Facility provided documentation of an incident report for Resident R6 dated 9/29/25, at 6:50 a.m. revealed nursing description - Entered resident room, observed resident on floor. Resident stated he/she hit his/her head. Skin assessment done on resident, observed laceration to back of head, and abrasions to right arm. Bruising to left hand. Resident bleeding from laceration on back of head and on right arm.

Resident R6's clinical record revealed a nutritional progress note dated 9/29/25, at 12:02 p.m. which stated, "Resident sent out to ER [emergency room] today after fall." Resident R6's clinical record lacked evidence of further progress notes related to a fall on 9/29/25.

Facility provided documentation, "Corrective Action Form," dated 10/03/25, revealed Nursing Assistant (NA) Employee E6 with a Final Written/Discharge warning for Nature of Infraction - Any deviation from a resident's course of treatment that creates the risk of/or results in serious or substantial harm to resident. Willful or reckless in attention to the needs of a resident. Description: Description of Incident [NA Employee E6] did not follow transfer order for a resident as evidenced by using Hoyer lift [a mechanical lift utilized in lifting a person who is dependent for assistance with transfers] to transfer resident by [herself/himself] instead of using assist of two."

Resident R6's clinical documentation dated 10/02/25, (hospital admission date 9/29/25, and discharge date 10/08/25), revealed progress notes from his/her hospitalization which indicated Resident R6 remained critically ill at this time after being dropped from a Hoyer lift approximately five feet. Progress notes stated, "Currently treating this patient for fall from Hoyer lift on anticoagulants [blood thinning medication], scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension [low blood pressure] and shock requiring vasopressors [medications used to raise low blood pressure] and fluid. V. tach [ventricular tachycardia - life-threatening heart rhythm disorder], hypokalemia [low potassium in blood]."

Interview with Resident R6 on 1/25/26, at 9:55 a.m. revealed that he/she was dropped from a Hoyer lift a few months ago and received a laceration to his/her head. Resident R6 stated, "I was lifted up and fell out of the lift. I hit the floor hard (rubbing the back of his/her head) and got a terrible gash to the back of my head." Resident R6 further indicated that only one NA assisted him/her during the time of fall from the Hoyer lift, and he/she was transferred to the hospital and stayed several days related to the fall.

Interview with the Nursing Home Administrator (NHA) on 1/26/26, at 2:55 p.m. confirmed that Resident R6 was transferred via a Hoyer lift on 9/29/25, by a single staff member, NA Employee E6, which resulted in a fall with substantial harm of a laceration to his/her posterior head, fracture of pelvis, and injury to his/her wrist. The NHA further confirmed that Resident R6 was dependent for transfers and required a Hoyer lift and a two person assist for transfers, however on 9/29/25 Resident R6 was transferred with only one person via a Hoyer lift, which resulted in Resident R6's fall and substantial harm of laceration and fractures.


28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.12(c) Nursing services

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





 Plan of Correction - To be completed: 02/24/2026

1. R6 was transferred to the hospital for treatment after the incident. Aide responsible was re-educated on transfer policy of 2 people, neglect, and received a disciplinary action.
2. Residents were interviewed to ensure that no other incident of neglect had occurred by the Director of Nursing/designee. It is impossible to determine whether non-interviewable residents sustained injuries in September under the same circumstances of lacking documentation.
3. The transfer status and care plans of all residents has been reviewed for accuracy by the Director of Nursing/designee and instruction given to nursing staff to use 2 staff for Hoyer transfers.
All staff were re-educated by Director of Nursing and Administrator on Abuse and Neglect reporting and policy. Nursing staff were re-educated on proper use of 2 staff for Hoyer transfers.
4. Three lift transfers will be audited by Director of Nursing/designee 3 times a week for 4 weeks, then weekly for two months, to assure the transfer is done per policy and that neglect in the process is not identified. The same 2 staff will be asked questions to confirm their understanding of neglect. Results will be presented to the monthly Quality Assurance team for recommendations. Director of Nursing to monitor.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and residents Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent and failed to ensure that the resident/responsible party were provided with written information on advanced directives or assisted with the opportunity to formulate advanced directives regarding life sustaining treatment for six of 20 residents reviewed (Residents R1, R5, R7, R30, R50 and R62).

Findings include:

Review of facility policy entitled "Communication of Code Status" dated 11/1/25, indicated "It is the policy of this facility to adhere to residents' rights to formulate advance directives." "The facility will follow facility policy regarding a resident's right to request ... to formulate an Advance Directive/POLST."

Review of Resident R1's clinical record revealed an admission date of 8/11/23, with diagnoses that included chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), bipolar disorder (a mental illness that causes extreme mood swings with emotional highs and emotional lows), and general anxiety disorder (a condition that causes a person to be nervous, uneasy, or worried about something or someone).

Review of Resident R1's clinical record revealed a physician's order for Full Code (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) dated 12/10/25. Review of resident R1's POLST revealed DNR (do not resuscitate allow natural death).


Review of Resident R5's clinical record revealed an admission date of 12/18/25, with diagnoses that included surgical care following surgery on the digestive system, enterocolitis due to clostridium difficile (an intestinal inflammation caused by toxins from a bacteria usually after antibiotics that change the normal gut bacteria), convulsions (involuntary, rapid muscle contractions causing violent, uncontrollable shaking of the body), and atrial fibrillation (a rapid, irregular heartbeat caused by disorganized electrical signals of the atria, heart's upper chambers).

Review of Resident R5's clinical record lacked evidence that he/she and/or his/her representative were provided with written information on advanced directives or assisted with the opportunity to formulate advanced directives regarding life sustaining treatment.


Review of Resident R7's clinical record revealed an admission date of 3/26/25, with diagnoses that included hypertension (high blood pressure), COPD, and cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked).

Review of Resident R7's clinical record lacked evidence that he/she and/or his/her representative were provided with written information on advanced directives or assisted with the opportunity to formulate advanced directives regarding life sustaining treatment.


Review of Resident R30's clinical record revealed an admission date of 7/6/24, with diagnoses that included hypertension, weakness, and hyperlipidemia (high cholesterol).

Review of Resident R30's clinical record revealed a physician's order for DNR dated 12/29/25. Review of Resident R30's POLST revealed Full Code.


Review of Resident R50's clinical record revealed an admission date of 12/4/25, with diagnoses that included protein calorie malnutrition, iron deficiency, and major depressive disorder.

Review of Resident R50's clinical record lacked evidence that he/she and/or his/her representative were provided with written information on advanced directives or assisted with the opportunity to formulate advanced directives regarding life sustaining treatment.


Review of Resident R62's clinical record revealed an admission date of 10/17/25, with diagnoses that included gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), hypertension, and hyperlipidemia.

Review of Resident R62's clinical record revealed a physician's order for Full Code dated 10/18/25, the clinical record lacked evidence he/she and/or his/her representative were provided with written information on advance directives or assisted with the opportunity to formulate advance directives regarding life sustaining treatment.

During an interview on 1/25/26, at 2:20 p.m. Registered Nurse Employee E1, revealed that during an emergent situation the staff refer to the POLST book to determine resident life sustaining wishes. He/she confirmed that Residents' R1 and R30's physician's orders and POLST were not consistent with one another and that Residents R5, R7, R50, and R62's clinical records lacked evidence reflecting their and/or their representative's wishes for advanced directives and that the clinical records should reflect resident's current wishes.

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

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.5(f)(i) Medical records

28 Pa. Code 211.10(c) Resident care policies




 Plan of Correction - To be completed: 02/24/2026

1. Resident R1 Physician Ordered Life Sustaining Treatment (POLST – a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) has been updated to match the physician orders. It is expected that R30 will be revealed in the all- house audit. Residents R5, R7, R50 have been given written information on advanced directives and clinical record updated to reflect their wishes. It is expected that R62 will be discovered during the house audit and clinical record updated.
2. Director of Nursing or designee will oversee a house audit of all POLST documents, matching them to physician orders in the clinical record. Any conflicting orders will be resolved and updated according to the resident wishes.
3. Director of Nursing educated Social Services and Nurses on assuring accuracy of POLST with physician orders. Social Services will verify advance directive status from resident upon admission and nursing services will receive appropriate physician orders to reflect those wishes. Admission chart will be reviewed during clinical morning meeting 5x week by Director of Nursing or designee to ensure POLST matches clinical record. This will be ongoing.
4. Resident's POLST will be reviewed at quarterly care plan meetings by social worker to ensure resident's wishes have not changed.
5. Director of Nursing/designee will conduct a weekly audit for 3 residents per audit x4, then monthly x2 to verify POLST matches clinical record and reflects resident wishes for advance directives. Audits will be reviewed during the Quality Assurance meetings and recommendations followed by interdisciplinary team. Administrator to monitor.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 policy, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for two of two resident units (East and West Unit).


Findings include:

Facility policy, "Enhanced Barrier Precautions," dated 11/01/25, revealed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. "Enhanced barrier precautions" (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Implementation of Enhanced Barrier Precautions - Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound protection may also be needed if performing activity with risk of splash or spray (i.e., wound protection may also be needed if performing activity with risk of splash or spray (i.e., wound protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). Personal Protective Equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. High contact resident care activities include: Dressing-Bathing-Transferring-Providing hygiene-Changing linens-Changing briefs or assisting with toileting-Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, peripheral inserted central catheter (PICC) lines-midline catheters-Wound care: any skin opening requiring a dressing.


Observations on 1/23/26, and 1/24/26, revealed no educational signage or PPE maintained for EBP for residents with indwelling devices, wounds, or infections throughout the facility.

During an interview on 1/25/26, at 12:00 p.m. Registered Nurse (RN) Employee E1 confirmed that no EBPs are maintained throughout the facility for residents with indwelling devices, chronic wounds, or infections, and staff does not utilize PPE during high contact care for these residents. RN Employee E1 further indicated that the facility did have EBPs maintained, but the facility no longer has the EBPs in place.

During an interview on 1/25/26, at 12:00 p.m. Licensed Practical Nurse (LPN) Employee E4 confirmed that no EBPs are maintained for residents on the East Unit with indwelling devices, chronic wounds, or infections, and staff does not utilize PPE during high contact care for these residents.

During an interview on 1/25/26, at 2:10 p.m. LPN Employee E3 confirmed that no EBPs are maintained for residents on the West Unit with indwelling devices, chronic wounds, or infections, and staff does not utilize PPE during high contact care for these residents.

During an interview on 1/25/26, at 2:15 p.m. the Nursing Home Administrator confirmed the facility lacked signage and PPE readily available when providing care for residents with indwelling devices, chronic wounds, or infections, who should have EBP maintained.


28 Pa. Code 211.10(c) Resident care policies

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




 Plan of Correction - To be completed: 02/24/2026

1. Enhanced barrier precautions were implemented on 1/25/26 for both wings.
2. All resident charts were reviewed and personal protective equipment and signage was placed where indicated. Director of Nursing/designee reviews all new admissions to determine if resident needs enhanced barrier precautions. Infection Preventionist will review all new orders to determine if enhanced barrier precautions is needed.
3. All staff were re-educated by the Director of Nursing on the need for enhanced barrier precautions and policy and given the tools to understand and implement usage of the supplies.
4. Director of Nursing/designee will audit 2 resident cares weekly x4 and monthly x2 to ensure both the correct donning/doffing of personal protective equipment and the signage and supplies of residents requiring enhanced barrier precautions is present. Results of audits will be reviewed by the monthly Quality Assurance committee and recommendations will be followed. Director of Nursing to monitor.

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

Based on review of facility policy, manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure expired medications were discarded in a timely manner in two of two medication carts reviewed (West North Cart and East North Cart).

Findings include:

A facility policy entitled, "Labeling of Medications and Biologicals" dated 11/01/25, revealed "Labels for multi-use vials must include: All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies (shorter or longer) date for that opened vial."

Manufacturer's guidelines for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), revealed that after opened vials and pre-filled pens should be discarded after 28 days.

Manufacturer's guidelines for Lantus insulin (a long-acting insulin used to manage blood sugar levels in people with diabetes), revealed that after opened vials and pre-filled pens should be discarded after 28 days.

Observation on 1/24/26, at 4:15 p.m. of the West North medication cart revealed an open vial of Lantus with an open date of 12/26/25, therefore the medication was expired. This was witnessed and confirmed at that time by Licensed Practical Nurse (LPN) Employee E5.

Observation on 1/24/26, at 4:29 p.m. of the East North medication cart revealed an opened Humalog vial with an open date of 12/18/25, and two open vials of Lantus, one with an open date of 12/21/25, and the other with an open date of 12/26/25, therefore the medications were expired. This was witnessed and confirmed at that time by LPN Employee E4.


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) Resident care policies

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services




 Plan of Correction - To be completed: 02/24/2026

1. Expired insulins were destroyed.
2. Medication carts were audited by nursing staff to remove any other expired medications.
3. Director of Nursing re-educated all nurses on the importance of reviewing insulin dates prior to administrating and the labeling policy. Night shift has been assigned the job to audit medication carts and check for expired medications weekly. RN Supervisor to monitor.
4. Director of Nursing/designee will audit contents of two medication carts 2x week for 4 weeks, then monthly x2 to ensure that no expired medications are present. Results will be given to monthly Quality Assurance team for recommendations and review. Director of Nursing to monitor.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
§483.35 Nursing Services.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a) Sufficient Staff.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (f) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (f) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:


Based on resident and staff interviews, and review of resident council minutes and grievances, and review of nursing staffing documentation, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for six of 20 residents interviewed (Residents R6, R8, R9, R30, R53, and R57).


Findings include:

Interviews during the Resident Council meeting on 1/25/26, between 12:00 p.m. and 12:30 p.m., revealed Residents R8, R9, R30, R53, and R57, in attendance stated the call bells are not answered in a timely manner with all indicating they wait greater than 30 minutes.

Resident R30 had concerns related to staff not responding to his/her call bell timely and it took hours for call bell response on 1/14/26, which resulted in him/her soiling his/her brief (incontinence product).

Resident R9 had concerns related to staff responding timely to their call bell to close their bathroom door. Resident R9 indicated that he/she can transfer themselves to the toilet independently, however, cannot shut the bathroom door afterwards. He/She further indicated that it takes a very long time for staff to respond to his/her call bell, and he/she typically sits on toilet with door open allowing the roommate to see. Resident R9 indicated that the lengthy call bell response time is due to lack of staffing.

Review of resident council minutes for November 2025, December 2025, and January 2026, revealed the following:

On November 26, 2025, there were 13 residents in attendance that indicated they would like staff to answer call bells in a timely manner.

On December 16, 2025, there were 10 residents in attendance that indicated call bell response times continued to be an issue.

On January 20, 2026, there were 10 residents in attendance that indicated residents would like management to do an audit on call bell response times, because it continued to be an issue.

Review of the Grievance Logs from June 2025, through December 2025, revealed a grievance related to call bell response time on 11/9/25.

Review of facility nursing staffing documents for day of a fall incident, 9/29/25, which involved Nursing Assistant (NA) Employee E6 participating in a transfer of Resident R6 utilizing a two-person mechanical lift independently, which resulted in injury to Resident R6 falling out of the mechanical lift, it was revealed that the hours of direct resident care was below 3.2 minimum per patient per day (PPD) at 3.16 PPD, andNA staffing shortages for the dayshift where the NA ratios were not met with 6.59 NA worked and 7.0 were required for a census of 70 residents.

During an interview on 1/27/26, at 9:50 a.m. the Nursing Home Administrator (NHA) confirmed that the facility does not have sufficient nursing staff and services to promote the physical and mental well-being and meet the needs of the residents. The NHA further confirmed that nursing hours for 9/29/25, day of Resident R6's fall incident, was below state mandated levels.

Refer to F686 and F600.

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

28 Pa. Code 211.12(d)(4)(5) Nursing services




 Plan of Correction - To be completed: 02/24/2026

1. Since all examples given were based on interviews and not identified to facility, solution provided will be for entire facility.
2. All staff re-educated through mandatory in-service meetings on the expectation of any staff aware of an activated call light to offer assistance. Spot checks on all shifts by administrator/Director of Nursing/designee are being done to check call light response time. Administrator/director of nursing will follow up with resident council to see if response times have improved.
3. Director of Nursing/designee will audit 3 call bell response times randomly for 4 weeks, then monthly x 2. Results will be given to monthly Quality Assurance team for recommendations and review. Administrator to monitor.

483.30(c)(1)-(4) REQUIREMENT Physician Visits-Frequency/Timeliness/Alt NPP: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.
§483.30(c) Frequency of physician visits
§483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.

§483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

§483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.

§483.30(c)(4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with paragraph (e) of this section.
Observations:


Based on review of clinical records, resident interviews and staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least once every 30 days for the first 90 days after admission and at least 60 days thereafter for three of 17 residents reviewed (R8, R11, and R62).

Findings include:

Review of facility policy entitled "Physician Visits and Physician Delegation" dated 11/1/25, indicated "The physician should: See resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law ... Date, write and sign a progress note for each visit. Sign and date all orders ..."

During an interview on 1/25/26, at approximately 10:30 a.m. Resident R8 expressed that he/she has not seen his/her physician face to face since he/she was admitted to the facility.

Review of Resident R8's clinical record revealed an admission date of 1/14/22, with diagnoses that included chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure).

Review of Resident R8's clinical record lacked evidence that Resident R8 was seen by his/her physician every 60 days as required.


Resident R11's clinical record revealed an admission date of 8/30/24, with diagnoses that included chronic respiratory failure (a long term condition where the lungs cannot exchange oxygen and carbon dioxide adequately), hypertensive heart disease with heart failure (a condition resulting from chronic uncontrolled blood pressure), chronic obstructive pulmonary disease (COPD a lung disease caused by airway damage and inflammation causing breathing issues), and protein calorie malnutrition (a deficiency of protein intake leading to impaired growth, muscle wasting and weakened immunity).

Resident R11's clinical record revealed a progress note dated 1/09/26, at 3:51 p.m. related to refusal of medications, ..."you say the doctor ordered it but I want to know WHAT doctor" ...

Review of Resident R11's clinical record lacked evidence that Resident R11 was seen by his/her physician every 60 days as required.

During an interview on 1/25/26, at 9:40 a.m. Resident R11 indicated that he/she has not seen their physician, and no physician has assessed him/her while being a resident at the facility.


Review of resident R62's clinical record revealed an admission date of 10/17/25, with diagnosis that included gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).

Review of Resident R62's clinical record lacked evidence that he/she was seen by his/her physician every 30 days for the first 90 days after admission as required.


During an interview on 1/26/26, at 2:35 p.m. Registered Nurse Employee E2 confirmed that the clinical records lacked evidence that Resident's R8, R11, and R62 were seen by their physician as required. He/she also confirmed that all residents should be seen by their physician every 30 days for the first 90 days then every 60 days thereafter.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3) Management

28 Pa. Code 211.5(f)(ii)(vii) Medical records





 Plan of Correction - To be completed: 02/24/2026

1. Physician is providing notes from resident encounters for November and December for R11 and others that were not uploaded into medical records. R8 and R62 are unknown.
2. Director of Nursing did a chart review and any resident who has not been seen in the last 60 days, or cannot remember the visit, will be seen by physician this month and notes uploaded into the medical record.
3. Administrator spoke to physician and he is aware of the requirements for frequency of visits. Facility has implemented a different way of ensuring physician is notified of new admissions and encounter notes uploaded into the medical record timely. All nurses were educated on the importance of timely physician visits.
4. Director of Nursing/designee will audit two charts weekly x4 and monthly x4 to ensure that needed physician visits have occurred. Results will be given to the Quality Assurance committee and recommendations followed. Administrator to monitor.

483.30(b)(1)-(3) REQUIREMENT Physician Visits - Review Care/Notes/Order: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.
§483.30(b) Physician Visits
The physician must-

§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;

§483.30(b)(2) Write, sign, and date progress notes at each visit; and

§483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
Observations:

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician signed and dated all orders during visits for seven of 20 residents reviewed (Residents R1, R7, R8, R10, R11, R30, and R62).

Findings include:

Review of facility policy entitled "Physician Visits and Physician Delegation" dated 11/1/25, indicated "The physician should: See resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law ... Sign and date all orders ..."

Review of Resident R1's clinical record revealed an admission date of 8/11/23, with diagnoses that included chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), bipolar disorder (a mental illness that causes extreme mood swings with emotional highs and emotional lows), and general anxiety disorder (a condition that causes a person to be nervous, uneasy, or worried about something or someone).

Review of Resident R1's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days.


Review of Resident R7's clinical record revealed an admission date of 3/26/25, with diagnoses that included hypertension (high blood pressure), COPD, and cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked).

Review of Resident R7's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days.


Review of Resident R8's clinical record revealed an admission date of 1/14/22, with diagnoses that included chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension.

Review of Resident R8's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days.


Review of Resident R10's clinical record revealed an admission date of 5/10/23, with diagnoses that included diabetes, hyperlipidemia (high cholesterol), and hypertension.

Review of Resident R10's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days.


Review of Resident R11's clinical record revealed an admission date of 8/30/24, with diagnosis that included chronic respiratory failure (a condition where your lungs don't exchange air properly), obstructive sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping), and hyperlipidemia.

Review of Resident R11's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days.


Review of Resident R30's clinical record revealed an admission date of 7/6/24, with diagnoses that included hypertension, weakness, and hyperlipidemia.

Review of Resident R30's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days.


Review of resident R62's clinical record revealed an admission date of 10/17/25, with diagnoses that included gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), hypertension, and hyperlipidemia.

Review of Resident R62's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days.

During an interview on 1/26/26, at 2:35 p.m. Registered Nurse Employee E2 confirmed that physician orders for Residents R1, R7, R8, R10, R11, R30, and R62 were not reviewed and signed by the physician in the required 60 days and confirmed that physician orders should be reviewed and signed with every physician visit on admission then every 30 days for the first 90 days then every 60 days.


28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3) Management

28 Pa. Code 211.5(f)(i) Medical records



 Plan of Correction - To be completed: 02/24/2026

1. Signing orders within the required timeframe cannot be corrected retroactively.
a3. Administrator re-educated the physician and he is aware of the requirements for timely visits and signing orders every 60 days. He is also aware that visits must occur at 30,60, and 90 days following admission.
4. Director of Nursing/designee will audit three charts weekly x4 and monthly x2 to ensure that physician orders have been signed with the 60 day visit. Results will be given to the monthly Quality Assurance committee and recommendations followed. Administrator to monitor.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on a review of facility policy, clinical records, resident and staff interviews, it was determined that the facility failed to provide a bath/shower as resident preference for two of 20 residents reviewed (Residents R8 and R62).

Findings include:

Review of facility policy entitled "Resident Showers" dated 11/1/25, indicated "Residents will be provided showers as per request or as per facility schedule ..." and "Document resident shower in point of care if refused, given, or bed bath given."

Review of Resident R8's clinical record revealed an admission date of 1/14/22, with diagnoses that included chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure).

Interview with Resident R8 on 1/26/26, at approximately 10:30 a.m. revealed that he/she stated, "I have not received a shower in weeks, it would be nice to get a shower and not just washed up in the bathroom."

Review of resident R8's bath/shower documentation for 1/1/26, through 1/25/26, revealed he/she was scheduled for a bath/shower on Tuesday/Friday on the daylight shift. Further review revealed on 1/6/26 no shower was documented, on 1/9/26, 1/13/26, 1/16/26, 1/20/26, and 1/23/26, N/A (not applicable) was documented.


Review of Resident R62's clinical record revealed an admission date of 10/17/25, with diagnoses that included gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), hypertension, and hyperlipidemia (high cholesterol).

Interview with Resident R62 on 1/25/26, at approximately 3:15 p.m. revealed that he/she stated, "I have not taken a shower in a long time, I wash up in the bathroom in the morning, but I would really like to get a shower every other day if not every day."

Review of Resident R62's clinical record for bath/shower documentation lacked evidence of a bath/shower schedule for Resident R62.

During an interview on 1/26/26, at 3:00 p.m. the Nursing Home Administrator confirmed that Residents R8 and R62's clinical records lacked evidence of showers/baths being given as residents' preferences. He/she also confirmed that shower/baths should be given per resident request/schedule.


28 Pa. Code 211.10 (d) Resident care policies


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



 Plan of Correction - To be completed: 02/24/2026

1. Resident R8 has an updated shower preference schedule. Resident R62 is unknown, it is expected that they will be discovered and given a shower schedule in #2.
2. All current residents have been interviewed and shower schedules revised per their preference by the Director of Nursing/designee
3. Nurse Supervisor will ask shower preference when creating the baseline care plan. Shower schedule will be reviewed at care plan conferences and as needed to ensure resident preference is followed. Nursing staff have been educated to notify charge nurse of refusals or unavailability so that the shower can be rescheduled.
4. Director of Nursing or designee will complete whole house audit of showers for accuracy in the medical record.
5. Director of Nursing or designee monitor for compliance and audit 3 residents for shower receiving and schedules weekly x 4, and monthly x2, then report to the Quality Assurance Committee for further recommendations.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of facility policy, review of clinical and facility records, and resident and staff interviews, it was determined that the facility failed to complete a thorough investigation related to falls for one of 17 residents reviewed (Resident R6).


Findings include:

Review of facility policy, "Fall Prevention Program" dated 11/01/25, revealed "Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury."

Resident R6's clinical record revealed an admission date of 2/08/25, with diagnoses that included shock, closed head injury (occurs when a sudden, violent impact to the head damages the brain without breaking the skull), fall, left scapho-lunate dissociation (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and closed fracture dislocation of left pubis symphysis with diastasis (the front and lower part of left hip bone which separated and fractured creating a diastasis [a widened gap]).

Facility provided documentation of an incident report for Resident R6 dated 9/29/25, at 6:50 a.m. revealed nursing description dated 9/29/25 5:54 p.m. - Entered resident room, observed resident on floor. Resident stated he/she hit his/her head. Skin assessment done on resident, observed laceration to back of head, and abrasions to right arm. Bruising to left hand. Resident bleeding from laceration on back of head and on right arm. Assisted to resident to bed using mechanical lift. Vital signs obtained, within normal limits. Wound care done on laceration on abrasions. Resident stated he hit his head during fall.

Resident R6's clinical record revealed a nutritional progress note dated 9/29/25, at 12:02 p.m. which stated, "Resident sent out to ER [emergency room] today after fall." Resident R6's clinical record lacked evidence of further progress notes related to a fall on 9/29/25.

Facility provided documentation, "Corrective Action Form," dated 10/03/25, revealed Nursing Assistant (NA) Employee E6 with a Final Written/Discharge warning for Nature of Infraction - Any deviation from a resident's course of treatment that creates the risk of/or results in serious or substantial harm to resident. Willful or reckless in attention to the needs of a resident. Description: Description of Incident NA [NA Employee E6] did not follow transfer order for a resident as evidenced by using Hoyer lift [mechanical lift utilized in lifting a person who is dependent for assistance with transfers] to transfer resident by [herself/himself] instead of using assist of two."

Resident R6's clinical documentation dated 10/02/25, (hospital admission date 9/29/25, and discharge date 10/08/25), revealed progress notes from his/her hospitalization which indicated Resident R6 remained critically ill at this time after being dropped from a Hoyer lift approximately five feet. Progress notes stated, "Currently treating this patient for fall from Hoyer lift on anticoagulants [blood thinning medication], scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension [low blood pressure] and shock requiring vasopressors [medications used to raise low blood pressure] and fluid. V. tach [ventricular tachycardia - life-threatening heart rhythm disorder], hypokalemia [low potassium in blood]."

Interview with Resident R6 on 1/25/26, at 9:55 a.m. revealed that he/she was dropped from a Hoyer lift a few months ago and received a laceration to his/her head. Resident R6 stated, "I was lifted up and fell out of the lift. I hit the floor hard (rubbing the back of his/her head) and got a terrible gash to the back of my head." Resident R6 further indicated that only one NA assisted him/her during the time of fall from the Hoyer lift, and he/she was transferred to the hospital and stayed several days related to the fall.

Interview on 1/27/26, at 11:00 a.m. the Nursing Home Administrator (NHA) confirmed that the incident report and investigation of Resident R6's fall from a Hoyer lift on 9/29/25, was incomplete and lacked evidence of a complete timely investigation which included, but not limited to, witness statements, nursing response to a resident falling from a Hoyer lift including response to a staff member utilizing a Hoyer lift independently resulting in a resident's fall from the Hoyer lift, fall assessment, and notification of physician and family at time of fall. The NHA further confirmed it is the responsibility of the facility to ensure all incidents, including falls, are investigated and documented thoroughly in a timely manner.

There was no evidence that the facility thoroughly investigated the fall incident involving Resident R6 falling out of a Hoyer lift on 9/29/25.


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

28 Pa. Code 211.5(f)(ii)(iii) Medical records

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




 Plan of Correction - To be completed: 02/24/2026

1. On 1/26/26, current administrator initiated and investigated the prior fall of R6 from 9/29/25. Interviews of the nurse supervisor who worked that shift, the aide involved, and the resident were conducted. R6 fall incident was reported to the Pennsylvania Department of Health..
2. Staff and residents were interviewed to determine if there are other events that had not been investigated or reported. A review of incident reports from September to present were reviewed by administrator to determine if any were underreported.
3. Director of Nursing/designee conducted the following educations: a)All nurses were re-educated on completing a fall investigation packet to determine root cause of an accident and report it timely and to determine if any neglectful act occurred. b)All staff were re-educated on the Abuse Neglect Policy which includes proper reporting after investigation.
4. Director of Nursing/designee to audit all incident reports and investigations for accuracy as they occur, 5x week for 4 weeks, then weekly for 2 months. Audits will be submitted to monthly Quality Assurance team for review and recommendations followed. Administrator to monitor.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:


Based on observations and interviews, it was determined that the facility did not ensure the garbage and refuse was disposed of properly for one dumpster.

Findings include:

No facility policy provided.

Observations on 1/24/26, at 5:15 p.m. revealed the dumpster open, without a full lid to secure the top of the dumpster, allowing garbage to be freely exposed.

During an interview on 1/24/26, at 5:15 p.m. the Dietary Manager confirmed that the top of the dumpster was open without a lid, allowing the garbage to be freely exposed. He/She further confirmed that the dumpster lids should always be closed and tightly fitted when not in use to prevent insect/rodents to be attracted to area.

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




 Plan of Correction - To be completed: 02/24/2026

1. Dumpster lid was repaired by trash contractor.
2. Dietary staff have been re-educated on importance of notifying manager if lid is missing. All staff have been educated to close dumpster lids and side doors.
3. Dietary Manager/Environmental Services will inspect dumpsters weekly and report any missing lids to Administrator to be replaced or repaired. They will also monitor that lids are closed in keeping with regulation. No policy is needed for standard practice of closing a trash or dumpster lid.
4. Environmental Services Manager/Designee will audit dumpster lids weekly and report results to Quality Assurance for recommendations. Administrator to monitor.

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:


Based on review of facility policy and review of clinical and facility records and resident and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to falls for one of 17 residents reviewed (Resident R6).


Findings include:

Review of facility policy entitled, "Fall Prevention Program" dated 11/01/25, revealed "Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury."

Resident R6's clinical record revealed an admission date of 2/08/25, with diagnoses that included shock, closed head injury (occurs when a sudden, violent impact to the head damages the brain without breaking the skull), fall, left scapho-lunate dissociation (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and closed fracture dislocation of left pubis symphysis with diastasis (the front and lower part of left hip bone which separated and fractured creating a diastasis [a widened gap]).

Resident R6's clinical record revealed a nutritional progress note dated 9/29/25, at 12:02 p.m. which stated, "Resident sent out to ER [emergency room] today after fall." Resident R6's clinical record lacked evidence of further progress notes related to a fall on 9/29/25.

Facility provided documentation, "Corrective Action Form," dated 10/03/25, revealed Nursing Assistant (NA) Employee E6 with a Final Written/Discharge warning for Nature of Infraction - Any deviation from a resident's course of treatment that creates the risk of/or results in serious or substantial harm to resident. Willful or reckless in attention to the needs of a resident. Description: Description of Incident NA [NA Employee E6] did not follow transfer order for a resident as evidenced by using Hoyer lift [mechanical lift utilized in lifting a person who is dependent for assistance with transfers] to transfer resident by [herself/himself] instead of using assist of two."

Resident R6's clinical documentation dated 10/02/25, (hospital admission date 9/29/25, and discharge date 10/08/25), revealed progress notes from his/her hospitalization which indicated Resident R6 remained critically ill at this time after being dropped from a Hoyer lift approximately five feet. Progress notes stated, "Currently treating this patient for fall from Hoyer lift on anticoagulants [blood thinning medication], scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension [low blood pressure] and shock requiring vasopressors [medications used to raise low blood pressure] and fluid. V. tach [ventricular tachycardia - life-threatening heart rhythm disorder], hypokalemia [low potassium in blood]."

Interview with Resident R6 on 1/25/26, at 9:55 a.m. revealed that he/she was dropped from a Hoyer lift a few months ago and received a laceration to his/her head. Resident R6 stated, "I was lifted up and fell out of the lift. I hit the floor hard (rubbing the back of his/her head) and got a terrible gash to the back of my head." Resident R6 further indicated that only one NA assisted him/her during the time of fall from the Hoyer lift, and he/she was transferred to the hospital and stayed several days related to the fall.

During an interview on 1/26/26, at 2:55 p.m. the Nursing Home Administrator (NHA) confirmed that Resident R6's clinical record lacked evidence of the nursing response to Resident R6's fall from a Hoyer lift on 9/29/25, including nursing assessment of resident and actions, fall assessment, and notification of physician and family. The NHA further confirmed it is the responsibility of the facility to ensure all documentation of resident care, including falls, is accurate and complete in each resident's clinical record.


28 Pa. Code 211.5(f)(ii)(iii) Medical records

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



 Plan of Correction - To be completed: 02/24/2026

1. The medical record was updated with a late entry by the current Director of Nursing to reflect that resident was sent out to the hospital and returned related to injuries sustained in a fall on 9/29/25. The incident report was updated to include witness statements and the information that the resident was sent to the hospital.
2. Incidents since 1/26/26 have been reviewed to ensure that documentation exists in the medical record to reflect the incident and any treatment provided. Administrator reviewed all incidents between 9/29/25 and 1/26/26 to see if any stood out as not being handled appropriately. It is impossible to determine if an incident was not documented but occurred in the past.
3. All nurses have been re-educated on the importance of linking the incident report to the progress notes and documenting any transfers out or returns from hospital after an incident. Director of Nursing/designee will review all incident reports 5x a week to determine that care given is reflected in the medical record
4. Director of Nursing/designee will audit all incidents as they occur, weekly x5 and monthly x2 to verify that incident reports and actions following are reflected in the resident medical record. Results will be reported to the monthly Quality Assurance Committee and recommendations followed. Director of Nursing to monitor.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
§483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:


Based on review of facility policy and infection control documentation, and staff interview, it was determined that the facility failed to develop and implement an antibiotic stewardship program.

Findings include:

Review of the facility policy "Antibiotic Stewardship Program", dated 11/01/25, revealed it is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Medical Director, Director of Nursing, and Consultant Pharmacist serve as the leaders of the Antibiotic Stewardship Program and receives support from the Administrator and other governing officials of the facility. The Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' efforts by working with the following partners: Infection Preventionist-Consultant Laboratory-State and Local Health Departments. Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. The program includes antibiotic use protocols and a system to monitor antibiotic use. Nursing will monitor the initiation of antibiotics on residents and conduct an "antibiotic timeout" within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. New or changed orders for antibiotics based on the antibiotic timeout recommendations will be obtained from the practitioner. At least annually or per facility policy, feedback shall be provided on the facility's antibiotic use data in the form of a written report shared with administration, medical, and nursing staff, resident and family council, and the Quality Assessment and Assurance (QAA) Committee. At least annually or per facility policy, each attending physician shall be provided feedback on his/her antibiotic use data in the form of a written report (i.e "antibiotic report card") to improve prescribing practices and resident outcomes. Education regarding antibiotic stewardship shall be provided at least annually to facility staff, prescribing practitioners, residents, and families. The elements of the program and associated protocols are reviewed on an annual basis and as needed as part of the facility's review of the overall infection prevention and control program. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to Action plans and/or work plans associated with the program-Assessment forms-Antibiotic use protocols/algorithms-Data collection forms for antibiotic use, process, and outcome measures-Antibiotic stewardship meeting minutes-Feedback reports-Records related to education of physicians, staff, residents, and families-Annuals reports. Data obtained from antibiotic stewardship monitoring activities is discussed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings.

From 1/24/26, through 1/27/26, no evidence of the above noted facility Antibiotic Stewardship program was provided for review.

During an interview on 1/26/26, at 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3) Management

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



 Plan of Correction - To be completed: 02/24/2026

1. An antibiotic stewardship program has been implemented and documented by the Director of Nursing/designee.
2. Antibiotic usage and review is being done by Director of Nursing/designee. An infection control meeting was held 2/13/26 to review January infections and antibiotic usage. All members required were present. This meeting will be held monthly.
3. A method for documenting and keeping record of meetings was implemented by the Director of Nursing/designee, and will proceed at a minimum quarterly. All staff were educated on the importance of Antibiotic Stewardship. Infection Preventionist will be responsible for the program.
4. Administrator will monitor for compliance. Quality Assurance team will review reports and give recommendations.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(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 review of facility infection control records and staff interview, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1).

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:
(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient-safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.
1303.405(a)- Patient Safety Authority Jurisdiction states:
(a)The occurrence of a healthcare-associated infection is deemed a serious event. Written notification to the resident of the serious event should be documented.

A review of the facility Infection Control Program on 1/26/26, at 3:30 p.m. revealed no evidence of infection control meeting attendance sign in sheets for any quarter in 2025 and 2026.

During an interview on 1/26/26, at 3:30 p.m. the Nursing Home Administrator confirmed the facility lacked evidence that infection control meetings with above noted attendees occurred during the time-period of 2/04/25 and 1/26/26.




 Plan of Correction - To be completed: 02/24/2026

1. An infection control meeting was held 2/13/26 to review January infections and antibiotic usage. Director of Nursing/designee notified members and all members required were present.
2. Past meeting documentation cannot be located. Infection Control meetings will be held at a minimum of quarterly. Infection Preventionist will schedule meetings and notify members. This will be monitored by the Director of Nursing.
3. All staff required to be in the infection control committee were educated on the importance of Infection Control meetings by the Director of Nursing. It was also a part of our whole house inservicing, so that all staff could understand why meetings and a program were important. A method for keeping record of meetings was established by the Director of Nursing.
4. Administrator will monitor for compliance. Quality Assurance team will review reports and give recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of facility nursing staffing documents and staff interviews, it was determined that the facility failed to provide the minimum number of general nursing care hours of 3.20 hours of direct resident care hours per resident in a twenty-four hour period for six of 21 days reviewed (1/1/26, 1/12/26, 1/16/26, 1/17/26, 1/22/26, and 1/25/26).

Findings include:

Review of facility nursing staffing documents for the time period of 1/5/26, through 1/25/26, revealed that the hours of direct resident care was below 3.20 minimum per patient day (PPD) on the following dates:

1/1/26 3.10
1/12/26 3.02
1/16/26 3.03
1/17/26 3.17
1/22/26 3.05
1/25/26 2.69

During an interview on 1/27/26 at 9:50 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum PPD requirements on the above date.



 Plan of Correction - To be completed: 02/24/2026

1. Per Patient Day minimum of 3.20 will be provided each day.
2. Daily review of scheduled direct care hours by Director of Nursing/Administrator will confirm that enough staff have been scheduled to meet PPD. We are advertising for a scheduler, so in this meantime the Director of Nursing is responsible for the schedule.
3. Director of Nursing/Administrator are aware of the need to meet PPD requirements. Nursing supervisors have been educated on how to cover shifts when there is a call-off. Pickup bonuses are being offered to replace staff call-offs. Discipline is being rendered to frequent absentees.
4. 5x weekly review of deployment sheets to confirm staff scheduled to meet 3.20 PPD is being done by Director of Nursing/Administrator. Schedule deficiencies will be reviewed by Quality Assurance during regular meetings and recommendations followed.



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