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

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ARMSTRONG REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  183 surveys for this facility. Please select a date to view the survey results.

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

Based on an Abbreviated Survey in response to three complaints, completed on February 25, 2026, it was determined that Armstrong Rehabilitation and Nursing 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 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 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 and documentation, staff and resident interview it was determined that the facility failed to protect resident from neglect for one of five residents (Resident R1).

Findings include:

Review of facility's policy dated 7/1/25, "Abuse, Neglect, and Exploitation" stated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse and neglect. Neglect means failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Review of Registered Nurse, Employee E1's signed job description dated 11/4/25, revealed major duties and responsibilities include ensuring policies and procedures are complied with by nursing personnel assigned, participates in the admission, discharge, and transfers of residents as required, assesses for changes in resident's status, notifying the physician and resident family or representative and documenting according, prepares and administers medications as per physicians' orders and observes for adverse effects as indicated.

Review of Residents R1's admission record indicated the resident was admitted on 2/12/26, with diagnoses of constipation, high blood pressure, and cervicalgia (neck pain).

Review of Resident R1's progress note dated 2/12/26, at 9:16 a.m. entered by Registered Nurse (RN), Employee E1 revealed Resident R1 was admitted from another facility and his last bowel movement was 2/5/26.

Review of Resident R1's progress note dated 2/12/26, at 5:35 p.m. entered by Registered Nurse (RN), Employee E1 revealed the resident requested to go to the hospital for abdominal pain and constipation. "He called 911 himself."

Review of facility documents revealed RN, Employee E1 was the RN, Supervisor on duty from 7 a.m. to 7 p.m.

Review of Nurse Aide (NA), Employee E2's witness statement dated 2/12/26, stated at 3:20 p.m. Resident R1 rang and wanted to see RN Supervisor, Employee E1 to go to the emergency room. NA, Employee E2 notified RN, Supervisor, Employee E1. While walking down the hall to take a break, Resident R1 rang again and stated he was going to call. RN Supervisor, Employee E1 stated she did his paperwork and wasn't going back. "I did not see her go to his room at all." NA, Employee E2 stated RN, Supervisor, Employee E1 told Resident R1 "he couldn't come back here while the ambulance workers were there."

Review of Licensed Practical Nurse (LPN), Employee E3's witness statement dated 2/12/26, revealed LPN, Employee E3 overheard Resident R1 tell NA, Employee E2 that he wanted to go to the hospital. RN, Supervisor, Employee E1 was made aware. LPN, Employee E3 stated Resident R1 told her he has been asking all day to be sent to the hospital. The resident was asked what was wrong and he indicated he has not had a bowel movement in 7-10 days and he had a short stay at hospital and the other facility he came from didn't really do anything for him. As LPN, Employee E3 was walking back down hall, RN, Supervisor Employee E1 stated she did his paperwork and didn't know what else she could do for him. Resident R1's call bell went off again and RN Supervisor, Employee E1 could be heard from desk saying, "I already know what he wants." LPN, Employee E3 alerted the Social Worker of a grievance concern, and the Director of Nursing was notified. When LPN, Employee E3 returned to Resident R1's room, he was on the phone with 911. Later, RN Supervisor Employee E3 asked LPN, Employee E3 "Do you think I should send him out if he wants sent out?" LPN, Employee E3 responded "Yes" and entered the resident's room and told the resident to wait until after dinner and she would call 911 and get him out. RN Supervisor then went to feed resident.

Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/26, indicated the diagnoses were current.

Review of information submitted to the State Agency on 2/16/26, by the Director of Nursing revealed on 2/13/26, Resident R1 stated he wanted to go to the hospital, and the Licensed Practical Nurse (LPN) and Nurse Aide (NA) reported to RN, Supervisor, Employee E1 that the resident was requesting to be sent out. RN Supervisor, Employee E1 refused to assess resident and refused to send him out to the hospital.

During an attempted phone interview on 2/25/26, at 10:24 a.m. RN, Employee E1 was unavailable for an interview.

During an interview on 2/25/26, at 10:38 a.m. the Director of Nursing (DON) confirmed Resident R1's "Discharge Transition Packet" dated 2/12/26, confirmed the resident's last bowel movement was 2/4/26, a total of eight days.

During an interview on 2/25/26, at 10:50 a.m. Resident R1 confirmed when he was initially admitted to the facility he complained of abdomen pain and had to go to the hospital.

During an interview on 2/25/26, at 10:58 a.m. Nurse Aide, Employee E2 stated Resident R1 wanted to go to the hospital and when she notified RN, Supervisor, Employee E1 she failed to go in and assess the resident. NA, Employee E2 stated the resident was complaining he hadn't moved his bowels.

During an interview on 2/25/26, at 11:07 a.m. LPN, Employee E4 stated if a resident has not had a bowel movement in three days, the bowel protocol would be initiated. It was indicated for residents newly admitted, their last bowel movement is assessed upon admission. Medications for the bowel protocol are automatically put in place upon admission. Staff can also review discharge paperwork to see when a residents last bowel movement was. If a resident has a change in condition, they must be assessed, vitals obtained, and the physician is notified.

During an interview on 2/25/26, at 11:09 a.m. LPN, Employee E3 stated she worked 3 p.m. to 11 p.m. on 2/12/26. LPN, Employee E3 was notified Resident R1 wanted to talk with a supervisor and go to the hospital. It was indicated Resident R1 was asking all day. Around 5 p.m. Resident R1 rang his call bell again and requested to see supervisor and go to hospital. RN, Supervisor R1 failed to assess resident and Resident R1 called 911 himself. LPN, Employee E3 stated the resident was having abdomen pain from a bowel obstruction. LPN, Employee E3 stated "The resident had an order for citrus magnesium from the other facility, and I don't think he got any of it."

During an interview on 2/25/26, at 1:18 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to protect resident from neglect for one of five residents (Resident R1).

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.10 (a) (d) Resident care policies





 Plan of Correction - To be completed: 04/06/2026

1. Employee E1 was suspended pending investigation and subsequently resigned. Resident R1 was transferred to the hospital, admitted and treated.

2. A 30 day lookback was completed to review all risk events to ensure no abuse and neglect occurred, no incidents found that were not already reported.

3. The Director of Nursing, or designee, will educate all staff on the abuse and neglect policy as well as the facility bowel protocol and resident assessment requirements for bowel protocol.

4. DON or designee will conduct audits of risk events and audits of bowel protocol to ensure abuse and neglect did not occur 5x/weekly times 2 weeks, 2x/weekly times 2 weeks and monthly times 2. All audits are reviewed through the QA/QI process.
483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§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:


Findings include:

Review of facility's policy dated 7/1/25, "Abuse, Neglect, and Exploitation" stated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse and neglect. Neglect means failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within a specific timeframe; immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Review of Residents R1's admission record indicated the resident was admitted on 2/12/26, and readmitted 2/17/26, with diagnoses of constipation, high blood pressure, and cervicalgia (neck pain).

Review of Resident R1's progress note dated 2/12/26, entered by Registered Nurse (RN), Employee E1 revealed the resident requested to go to the hospital for abdominal pain and constipation. "He called 911 himself."

Review of information submitted to the State Agency on 2/16/26, by the Director of Nursing revealed on 2/13/26, Resident R1 stated he wanted to go to the hospital, and the Licensed Practical Nurse (LPN) and Nurse Aide (NA) reported to RN, Supervisor, Employee E1 that the resident was requesting to be sent out. RN Supervisor, Employee E1 refused to assess resident and refused to send him out to the hospital. The facility failed to report the allegation of neglect within 24 hours to the local state field office.

During an interview on 2/25/26, at 12:37 p.m. the Director of Nursing confirmed allegations of neglect must be reported to the appropriate agencies within 24 hours.

During an interview on 2/25/26, at 1:18 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R1).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(1) Management.
28 Pa. Code: 207.2(a) Administrator's responsibility.
28 Pa. Code: 211.10(d) Resident care policies.





 Plan of Correction - To be completed: 04/06/2026

1. Allegation of neglect was reported to the DOH through the ERS system.

2. A 30 day lookback was completed to review all risk events to ensure no abuse and neglect occurred, no incidents found that were not already reported.

3. Nursing Home Administrator will educate the Director of Nursing on the requirements for reporting, including timeframe to report and agencies that need reported to.

4. DON or designee will conduct audits of risk events to ensure abuse and neglect did not occur 5x/weekly times 2 weeks, 2x/weekly times 2 weeks and monthly times 2.

5. Nursing Home Administrator will monitor DOH ERS site and conduct an audit weekly on timely reporting of events to Department of Health.

6. All audits are reviewed through the QA/QI process.
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 review of facility documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five residents (Resident R1).

Findings include:

Review of facility "Bowel Routine Policy" last reviewed 7/1/25, indicated each resident will have routine bowel elimination. The purpose is to address the resident's individual needs with respect to routine bowel movements, initiate appropriate strategies and interventions, and monitor and evaluate resident outcomes. Give Milk of Magnesia 30 ml if no bowel movement in 72 hours (Day 3 without a bowel movement), if ineffective give Dulcolax Suppository. Administer fleet enema if Dulcolax Suppository is ineffective. Call physician if fleet enema is ineffective.

Review of Residents R1's admission record indicated the resident was admitted on 2/12/26, with diagnoses of constipation, high blood pressure, and cervicalgia (neck pain).

Review of Resident R1's progress note dated 2/12/26, at 9:16 a.m. entered by Registered Nurse (RN), Employee E1 revealed Resident R1 was admitted from another facility and his last bowel movement was 2/5/26.

Review of Resident R1's clinical record for 2/12/26, failed to reveal Resident R1 had a bowel movement.

Review of Resident R1's physician order dated 2/12/26, indicated to administer 30 milliliter (ml) Milk of Magnesia Suspension 7.75 % (Magnesium Hydroxide) by mouth as needed for constipation, if no bowel movement in 48 hours.

Review of Resident R1's physician order dated 2/12/26, indicated to insert 1 Dulcolax Suppository 10 MG (Bisacodyl) suppository rectally as needed for constipation if Milk of Magnesia is ineffective.

Review of Resident R1's physician order dated 2/12/26, indicated to insert 1 Fleet Enema 7-19 GM/118ML (Sodium Phosphates) applicatorful rectally as needed for constipation, if no bowel movement after Dulcolax suppository.

Review of Resident R1's February 2026 Medication Administration Record (MAR) failed to include evidence the resident's medications were administered as ordered on 2/12/26.

Review of Resident R1's progress note dated 2/12/26, at 5:35 p.m. entered by Registered Nurse (RN), Employee E1 revealed the resident requested to go to the hospital for abdominal pain and constipation. "He called 911 himself."

Review of Nurse Aide (NA), Employee E2's witness statement dated 2/12/26, stated at 3:20 p.m. Resident R1 rang and wanted to see RN Supervisor, Employee E1 to go to the emergency room. NA, Employee E2 notified RN, Supervisor, Employee E1. While walking down the hall to take a break, Resident R1 rang again and stated he was going to call. RN Supervisor, Employee E1 stated she did his paperwork and wasn't going back. "I did not see her go to his room at all." NA, Employee E2 stated RN, Supervisor, Employee E1 told Resident R1 "he couldn't come back here while the ambulance workers were there."

Review of Licensed Practical Nurse (LPN), Employee E3's witness statement dated 2/12/26, revealed LPN, Employee E3 overheard Resident R1 tell NA, Employee E2 that he wanted to go to the hospital. RN, Supervisor, Employee E1 was made aware. LPN, Employee E3 stated Resident R1 told her he has been asking all day to be sent to the hospital. The resident was asked what was wrong and he indicated he has not had a bowel movement in 7-10 days and he had a short stay at hospital and the other facility he came from didn't really do anything for him. As LPN, Employee E3 was walking back down hall, RN, Supervisor Employee E1 stated she did his paperwork and didn't know what else she could do for him. Resident R1's call bell went off again and RN Supervisor, Employee E1 could be heard from desk saying, "I already know what he wants." LPN, Employee E3 alerted the Social Worker of a grievance concern, and the Director of Nursing was notified. When LPN, Employee E3 returned to Resident R1's room, he was on the phone with 911. Later, RN Supervisor Employee E3 asked LPN, Employee E3 "Do you think I should send him out if he wants sent out?" LPN, Employee E3 responded "Yes" and entered the resident's room and told the resident to wait until after dinner and she would call 911 and get him out.

Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/26, indicated the diagnoses were current.

During an attempted phone interview on 2/25/26, at 10:24 a.m. RN, Employee E1 was unavailable for an interview.

During an interview on 2/25/26, at 10:38 a.m. the Director of Nursing (DON) confirmed Resident R1's "Discharge Transition Packet" dated 2/12/26, confirmed the resident's last bowel movement was 2/4/26, a total of eight days.

During an interview on 2/25/26, at 10:50 a.m. Resident R1 confirmed when he was initially admitted to the facility he complained of abdomen pain and had to go to the hospital.

During an interview on 2/25/26, at 10:58 a.m. Nurse Aide, Employee E2 stated Resident R1 wanted to go to the hospital and when she notified RN, Supervisor, Employee E1 she failed to go in and assess the resident. NA, Employee E2 stated the resident was complaining he hadn't moved his bowels.

During an interview on 2/25/26, at 11:07 a.m. LPN, Employee E4 stated if a resident has not had a bowel movement in three days, the bowel protocol would be initiated. It was indicated for residents newly admitted, their last bowel movement is assessed upon admission. Medications for the bowel protocol are automatically put in place upon admission. Staff can also review discharge paperwork to see when a residents last bowel movement was. If a resident has a change in condition, they must be assessed, vitals obtained, and the physician is notified.

During an interview on 2/25/26, at 11:09 a.m. LPN, Employee E3 stated she worked 3 p.m. to 11 p.m. on 2/12/26. LPN, Employee E3 was notified Resident R1 wanted to talk with a supervisor and go to the hospital. It was indicated Resident R1 was asking all day. Around 5 p.m. Resident R1 rang his call bell again and requested to see supervisor and go to hospital. RN, Supervisor R1 failed to assess resident and Resident R1 called 911 himself. LPN, Employee E3 stated the resident was having abdomen pain from a bowel obstruction. LPN, Employee E3 stated "The resident had an order for citrus magnesium from the other facility, and I don't think he got any of it."

Review of Resident R1's Hospital Discharge Summary on 2/25/26, revealed the resident was hospitalized from 2/13/26, to 2/17/26 for a rectal fecal impaction, severe constipation, requiring oral laxatives, disimpacting and soap suds enema.

During an interview on 2/25/26, at 12:27 p.m. the Nursing Home Administrator confirmed that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five residents (Resident R1).

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12 (d)(1)(5) Nursing services.





 Plan of Correction - To be completed: 04/06/2026

1. Employee E1 was suspended pending investigation and subsequently resigned. Resident R1 was transferred to the hospital, admitted and treated.

2. A 7-day lookback was completed to ensure all residents with no BM had the bowel regime followed.

3. The Director of Nursing, or designee, will educate licensed staff on resident assessment and implementation the bowel protocol for residents without a bowel movement after 3 days, and how to follow up if the bowel protocol is ineffective.

4. Daily Clinical meeting will be updated to review residents that are on the BM list.

5. DON or designee will audit all charts to ensure that the bowel protocol is in place for all residents. DON or designee will audit the BM report to ensure the protocol was followed 5x/weekly times 2 weeks, 2x/weekly times 2 weeks and monthly times All audits are reviewed through the QA/QI process.

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