Pennsylvania Department of Health
EMBASSY OF TUNKHANNOCK
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF TUNKHANNOCK
Inspection Results For:

There are 123 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


EMBASSY OF TUNKHANNOCK - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and Abbreviated Complaint survey completed on January 30, 2026, it was determined that Embassy of Tunkhannock was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

This is a less serious (but not lowest level) 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 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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:

Based on staff interview and a review of employee credentials, it was determined the facility failed to ensure the registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department.

Findings include:

A review of a facility provided job description for the Registered Dietitian (RD) indicated the position purpose includes planning, organizing, developing, and directing the nutritional care of the residents in accordance with current federal, state and local standards, guidelines, regulations and established facility policies and procedures. Major duties and responsibilities included the following: to provide registered dietitian services in one or more sites according to policies and procedures; plan, organize, develop, and direct the nutritional care of the residents in accordance with current federal, state and local standards, guidelines and regulations; assesses/monitors the residents' nutritional status and provides recommendations to clinical/medical staff; observes resident meal services to ensure diets are correct and modifications are followed; educates residents, families, and staff on nutrition concepts and diet modification; work with other members of the interdisciplinary team to ensure that modified texture or therapeutic diets are in compliance with the resident's medical condition; reviews menu changes to ensure compliance with the facility's policy and procedures and state and federal guidelines; updates diet orders and menu changes as required; conducts audits of relevant nutritional care on a routine basis; completes nutritional assessments on residents on admission, readmission, quarterly, annually, and with any changes in condition as per guidelines; performs inspections of food service areas for sanitation, order, safety, and proper performance of assigned duties; monitors residents for weight changes, nutrition support, and skin breakdown, and makes recommendations as needed; and participates in inspection surveys, ensuring compliance with nutritional and dietary policies and procedures as per state and federal guidelines.

During an interview conducted on January 28, at 12:00 PM, the Nursing Home Administrator (NHA), reported the facility's RD worked 24-32 hours per pay period (two-week intervals) and most hours worked were remotely (off-site) with one day per pay period on-site on a Saturday or Sunday. The NHA confirmed the RD had a full-time job elsewhere and was not available to the facility during regular day shift hours of 8:00 AM to 4:00 PM.

Additionally, the NHA reported that since the RD could not perform duties on-site, the facility's full-time certified dietary manager (CDM) reviews weights, performs admission interviews with residents or families and communicates the information to the RD for the assessment and documentation to be performed remotely.

The NHA also confirmed the RD did not conduct on-site supervisory oversight of the food and nutrition services department, including staff training, direct observation of residents for nutritional assessments, or monitoring of meal services.

The facility failed to ensure compliance with federal requirements by not providing the necessary on-site oversight and consultation by a qualified dietitian or clinically qualified nutrition professional. This failure created the potential for inadequate monitoring and coordination of food and nutrition services necessary to meet residents' clinical and nutritional needs.

Refer F 692

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

28 Pa Code 201.18 (b)(1)(3)(e)(1)(6) Management.

Plan of Correction - To be completed: 03/20/2026

1. Facility cannot retroactively correct the deficiency. Registered dietician works part time for the facility remotely with required visits to the facility once per week to complete nutritional assessments and monitor food production and service to ensure resident diets are adhered to. A certified dietary manager is full-time and provides direct oversight to the dietary department.
2. A review of responsibilities was conducted for Dietician and CDM (certified dietary manager). Dietician educated by regional dietician on oversight of resident diets, meal planning and substitution, and significant weight loss/gains.
3. Dietician will remotely communicate with CDM daily for oversight of resident clinical issues and attend a weekly IDT meeting to review significant weight losses/gains, recommendations, care planning and any additional clinical concerns from the IDT.
4. NHA/designee will review daily communication logs weekly x 4 weeks, then monthly x 2 months. Results of audits will be reviewed by the QAPI committee to ensure continued compliance with resident dietary needs, nutrition assessments and oversight of responsibilities within the dietary department.
5. Date of Compliance: March 13, 2026

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

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.

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to implement procedures to fully screen four employees out of five to ensure they were eligible for employment in a long term care nursing care facility. (Employees 1, 2, 3, and 4).

Findings include:

A review of the facility's Resident Abuse policy last reviewed by the facility on January 23, 2026, revealed the requirement for screening potential employees including obtaining references from the most recent or previous employer.

Review of employee personnel files revealed the following:

Employee 1 (Licensed Practical Nurse): Hired on September 30, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility.

Employee 2 (Social Services): Hired on November 4, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer.

Employee 3 (Dietary Aide): Hired on November 17, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer.

Employee 4 (Nurse Aide): Hired on July 18, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the employees' most recent former employer.

Interview with the Nursing Home Administrator (NHA) on January 29, 2026, at 1:15 PM confirmed there was no evidence that previous employers were contacted for information regarding the employees' past work history. The facility failed to follow its own abuse prohibition policy by not verifying previous employment for two out of five new hires.

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

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

28 Pa. Code 201.19 (1) Personnel records.

Plan of Correction - To be completed: 02/28/2026

1. Facility cannot retroactively correct the deficiency. References for employee 1, 2, 3 and 4 were contacted and references received. No indication of abuse patterns or specific occurrences were established.
2. HR and NHA performed an audit of all new hires from last annual to current to verify references were contacted and abuse policy/procedure followed.
3. HR educated NHA on employee file criteria including items associated with the abuse policy/procedure. Checklist established to ensure a complete HR employee file.
4. Regional HR will perform employee file reviews of all new hires X 2 months to ensure all components of onboarding are complete and abuse policy followed for references. Results will be sent to the QAPI committee to ensure compliance.
5. Date of compliance 02/28/2026

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training:

§483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

§483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12.

§483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

§483.95(c)(3) Dementia management and resident abuse prevention.

Observations:

Based on staff interviews and review of facility training and orientation records, it was determined that the facility failed to ensure that all employees received required annual education on the facility's abuse prohibition policy and procedures.

Findings include:

A review of the facility's policy entitled "Abuse, Neglect, Exploitation and Misappropriation of Resident Property" last reviewed by the facility on January 23, 2026, indicated the facility would educate its staff upon hire and annually thereafter regarding the facility's policy concerning abuse, neglect, exploitation and misappropriate of resident property and how to handle resident-to-resident abuse and injuries of unknown sources.

During an interview with the Nursing Home Administrator (NHA) on January 30, 2026, at 12:45 PM, the NHA reported that the Human Resources Director position was eliminated in mid-December 2025 due to budgetary reductions and that the responsibilities of the position were reassigned to administration.

The NHA provided the educational content intended for the facility's annual abuse prevention training program. However, the facility was unable to provide documented evidence demonstrating that the annual abuse prevention education was completed for facility staff.

The NHA provided the educational content intended for the facility's annual abuse prevention training program. However, the facility could not provide documented evidence demonstrating that the annual abuse prevention education was completed for facility staff.

Additionally, the interview on January 30, 2026, at 12:55 PM, confirmed that documentation verifying completion of the facility's mandatory annual abuse prevention training could not be located. As a result, the facility was unable to demonstrate that its required annual abuse prevention training program was implemented to ensure that all facility staff received the facility's abuse prohibition policy and procedures to identify and report abuse, neglect, exploitation, or misappropriation of resident property or resident abuse prevention.

28 Pa. Code 201.20(a)(b) Staff development.

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

28 Pa Code 211.10 (c) Resident care policies.

Plan of Correction - To be completed: 03/20/2026

Facility cannot retroactively correct deficiency.
2. Regional Operator educated NHA, who is currently the acting HR manager, the requirement to maintain adequate records indicating mandatory in-services for facility personnel. A calendar and copy of relevant policies were reviewed.
3. Abuse in-service to be completed for all staff and ongoing annually and at time of new hire. Employees will utilize a sign-in form and conclude the in-service with a quiz. All documents are to be maintained by the NHA annually for all mandatory in-services.
4. An employee list will be audited weekly by the NHA/designee to ensure employees and newly hired employees undergo abuse training. Results of audit will be reviewed by the QAPI committee monthly X 3 months to ensure compliance with abuse training
5. Date of Compliance: March 20, 2026

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of facility documents and staff interview, it was determined the facility failed to ensure the Medical Director or designee participated in the facility's Quality Assurance and Performance Improvement (QAPI) Committee meetings on a quarterly basis for two of four quarters (Quarter 1 and Quarter 2 of 2025).

Findings include::

A review of the facility policy titled Quality Assurance Performance Improvement (QAPI) last reviewed by the facility on January 23, 2026, revealed the would develop and maintain an effective, comprehensive, data-driven QAPI program. However, the policy did not clearly identify required QAPI committee membership, did not specify required participation of the Medical Director or a designated physician representative, and did not outline attendance expectations or accountability for participation in quarterly meetings.

A review of QAPI committee meeting sign-in sheets for the period of March 2025 through January 2026 revealed that although QAPI meetings were conducted quarterly, the Medical Director or the Medical Director's designated physician representative was not in attendance at the meetings held on March 19, 2025; July 17, 2025; and September 22, 2025, representing two of four quarters reviewed in 2025.

Interview with the Director of Nursing and the Nursing Home Administrator on January 30, 2026, at 11:00 AM confirmed review of the findings related to the absence of the Medical Director or designee from the identified QAPI committee meetings.

28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical director.

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

Plan of Correction - To be completed: 03/20/2026

1. Facility cannot retroactively correct deficiency.
2. Regional Operator educated NHA on QAPI Committee quorum requirements including facility medical director involvement quarterly. Medical director updated to required attendance of QAPI meetings.
3. QAPI monthly meetings will be completed on the day the medical director/designee is in the facility.
4. Attendance sheets to QAPI meetings will be completed to verify quorum attendees as outlined by the deficiency.
5. Date of Compliance: March 3, 2026

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

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.

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

Observations:

Based on facility policy and clinical record review and staff interview, it was determined the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect their current needs and services required for one of 23 residents sampled (Resident 45).

Findings include:

A review of the facility policy entitled "Comprehensive Care Planning" last reviewed on January 23, 2026, revealed the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.

A clinical record review revealed Resident 45 was admitted to the facility on September 21, 2021, with diagnoses to include Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period.) and cerebral infarction (a type of stroke where the blood flow to the brain is blocked or reduced).

A review of Resident 45's clinical record revealed a document labeled Advance Directive (a written or verbal instruction that states a person's wishes for health care treatment or names another person to make health care decisions if the person becomes unable to make those decisions) dated September 20,2021, that indicated Resident 45 did want Cardiopulmonary Resuscitation (CPR) (a lifesaving technique used in emergencies when the heart stops) .

A review of Resident 45's comprehensive care plan, last revised on July 10, 2022, failed to reflect Resident 45's Advanced Directive choice for CPR and indicated Resident 45's code status (a patient's preference regarding emergency treatment, particularly in situations when their heart or breathing stops) was Do Not Resuscitate (DNR).

An interview with the Director of Nursing on January 30, 2026, at 11:00 AM confirmed the facility failed to review and revise Resident's 45's care plan to accurately reflect their code status.

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

28 Pa Code 211.10 Resident care policies.

Plan of Correction - To be completed: 02/28/2026

1. Facility corrected the cited deficiency. Resident 45 code status order was reviewed and verified, comprehensive care plan updated.
2. Social Service Director completed an audit on all residents' code status to ensure code status order is accurate and verified comprehensive care plans are updated to reflect same.
3. DON/designee will educate all clinical licensed staff including agency staff to review code status with resident or responsible party at time of admission, via the facilities advanced directive policy.
4. DON or designee to audit all new admissions code status orders and care plans during morning meetings to ensure code status is documented, accurate, and care plans are updated. Audits will occur weekly X 3 weeks then monthly X 2 months with results to QAPI committee to ensure compliance.
5. Date of compliance 02/28/2026

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on observations, clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure Licensed Practical Nurses (LPN) were properly trained and validated as competent prior to administering intravenous (IV) medications through a central venous catheter for one of twenty-three residents reviewed (Resident 52).

Findings include:

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) require the following:

The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice.

Chapter 21.145 b. IV therapy curriculum requirements:
(f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under 21.145 a (relating to prohibited acts), and only under supervision as required under paragraph (1).

(1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as a CRNP, physician, physician assistant, podiatrist or dentist).

(g) An LPN who has met the education and training requirements of 21.145 b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under 21.145 and only under supervision as required under subsection (f):

(1) Adjustment of the flow rate on IV infusions.

(2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions.

(3) Administration of IV fluids and medications.

(4) Observation of the IV insertion site and performance of insertion site care.

(5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes.

(6) Discontinuance of medication or fluid infusion, including infusion devices.

(7) Conversion of a continuous infusion to an intermittent infusion.

(8) Insertion or removal of a peripheral short catheter.

(9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders.

(10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route.

(11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system.

(12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions.

(13) Collection of blood specimens from an IV access device.

A review of a facility policy titled "Catheter Insertion and Care-Flushing Central Vascular Access Devices (tube placed into a large vein near the heart to deliver medications or fluids) and Midline Catheters" last reviewed by the facility on January 23, 2026, revealed the facility is to verify the scope of practice for Registered Nurses and Licensed Practical Nurses and competency requirements for this procedure with the State Nurse Practice Act.

Clinical record review revealed that Resident 52 was admitted to the facility on January 17, 2026, with diagnosis to include pneumonia (an infection that inflames the air sacs of the lungs) and septic arterial embolism (an infected blood clot that travels through the blood stream), and was admitted to the facility with a PICC line (a peripherally inserted central catheter, a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart).

A review of the clinical record revealed physician orders dated January 17, 2026, to administer the following medications through the intravenous (IV) catheter:

Normal Saline Flush (Sodium Chloride Flush), 10 milliliters IV every eight hours to maintain patency (to keep the catheter open and prevent blockage).

Ceftriaxone Sodium, 2 grams IV once daily until February 21, 2026. Ceftriaxone Sodium is an antibiotic medication used to treat bacterial infection and was ordered related to an intestinal abscess (a pocket of infection in the intestine).

Vancomycin HCL, 1,000 milligrams IV twice daily until February 21, 2026. Vancomycin HCL is an antibiotic medication used to treat serious bacterial infections and was also ordered related to an intestinal abscess.

During an observation of medication administration on Green Hall on January 29, 2026, at 8:45 AM, Employee 5, a Licensed Practical Nurse (LPN), was observed washing her hands, putting on gloves, flushing the resident's peripherally inserted central catheter (PICC line) with normal saline, and administering Ceftriaxone Sodium through the PICC line.

The facility was unable to produce any documentation verifying that Employee 5, LPN had current competency validation, supervision documentation, or internal training specific to PICC line administration.

During an interview conducted on January 29, 2026, at 10:30 AM, the Director of Nursing (DON) confirmed that the facility did not provide education or training to LPNs for the administration of medications through PICC (central) lines. The DON further stated that it was the facility's policy that only Registered Nurses were permitted to administer medications via central lines.

Despite this stated policy, an LPN was observed administering IV medication through a PICC line without documented training or competency validation, indicating the facility failed to ensure nursing services were provided in accordance with professional standards and failed to ensure staff were properly trained prior to performing high-risk nursing procedures.

28 Pa. Code 201.20(a) Staff development.

28 Pa. Code 211.10 (c) Resident care policies.

28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 02/28/2026

1. The Facility cannot retroactively correct citation as it relates to resident 52.
2. The facility identified all residents who have PICC lines or central venous catheters. Medication administration records audited to ensure RNs are signing for administration of all IV medications administered via PICC or CVC line.
3. DON or designee educated all clinical staff including agency, on the facility's CVC
4. care and flush policies. LPNs to notify RN supervisor when a medication needs to be administered through a PICC line or CVC. The RN supervisor will administer medication to residents. LPN may provide saline flush post administration. RN supervisor to administer and sign off medication in MAR.
5. DON/designee to audit medical records of residents with PICC line and CVC to ensure that RN supervisor is providing medication administration. Audit to be completed 3 X a week X 2 weeks then monthly X 2 months with results to QAPI committee to ensure compliance.
6. Date of compliance 02/28/2026

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure that residents with limited mobility received the necessary services, equipment, and assistance to maintain or improve mobility for one of 18 residents reviewed (Resident 1).

Findings Include:

Review of the clinical record revealed that Resident 1 was admitted to the facility on December 21, 2021, with diagnoses which include cerebral ischemia (a condition in which reduced blood flow to the brain limits oxygen and nutrients needed for brain function) and flaccid hemiplegia to the right dominant side (a condition where there is complete paralysis or weakness of the muscles on one side of the body). These conditions affected Resident 1's ability to move and use the right hand and arm.

A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 22, 2025, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 5 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates cognition is severely impaired).

Review of Resident 1's current physician orders revealed an order dated August 11, 2022, for a functional position hand splint to the right hand and wrist with instructions to wear it continuously, perform skin checks every shift, and remove it only for hygiene before reapplying it.

Review of Resident 1's current care plan reflected the same intervention, which directed that the right hand splint always remain in place, be removed each shift for skin inspection, and that staff monitor for skin breakdown. The care plan was initiated July 20, 2022.

During an observation conducted in the dining room on January 29, 2026, at 11:00 AM Resident 1 was observed without the ordered right hand splint in place. The splint was observed lying on the resident's bedside table rather than being applied as ordered.

A review of Resident 1's Documentation Survey Report v2, which reflected care tasks completed for December 2025 and January 2026, revealed inconsistent, incomplete, and conflicting documentation related to restorative and functional nursing services intended to maintain mobility. Multiple entries were documented as "not applicable" or left blank.

Documentation revealed the following:

On December 8, 2025, evening shift was documented as "not applicable."

On December 9, 2025, evening shift was documented as "not applicable."

On December 13, 2025, evening shift was documented as "not applicable."

On December 18, 19, 20, 24, and 25, 2025, the day shift was documented as "not applicable."

On January 4 and January 18, 2026, the day shift was documented as "not applicable."

On January 27, 2026, the evening shift was documented as "not applicable."

On January 29, 2026, the same date the resident was observed without the splint at 11:00 AM., documentation indicated the splint had been applied at 7:04 AM, which conflicted with direct observation.

During an interview with the Director of Nursing on January 29, 2026, at 1:30 PM, the Director of Nursing was unable to provide documented evidence that Resident 1's functional nursing program, including the ordered right-hand splint intended to maintain mobility and prevent loss of function, was consistently implemented according to the physician's order and care plan.

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

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

Plan of Correction - To be completed: 02/28/2026

1. Facility cannot retroactively correct deficiency as it relates to resident 1.
2. DON or designee to audit all residents with splints to ensure orders are accurate and care plans are updated, and information flows to Kardex.
3. The DON or designee educated all clinical staff including agency staff on application and documentation of splints.
4. RN supervisor to perform splint audit 3 X weekly X 2 weeks, then weekly X 2 weeks then monthly X 2 months with results to QAPI.
5. Date of compliance 02/28/2026

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Plan of Correction - To be completed: 02/28/2026

1. Facility cannot retroactively correct deficiency as it relates to resident #5
2. Current residents will be reviewed to determine if a significant weight loss has occurred in the past month and, if so, a nutritional assessment will be completed, interventions will be implemented as appropriate, the resident's care plan will be adjusted as appropriate, and the resident's physician and responsible party will be notified.
3. The Regional Dietitian/Designee will educate the registered dietitian on identification of significant weight loss, initiation of nutritional assessment, implementation of interventions to prevent further weight loss, and adjustments to the resident's care plan. The ADON/Designee(s) will re-educate the licensed nursing staff on identification of a significant weight loss and notification of the registered dietitian and the resident's physician and responsible party.
4. Residents with identified significant weight loss will be audited weekly by the registered dietitian/designee to ensure that there is a new nutritional assessment completed, implementation of interventions to prevent further weight loss, and adjustments to the resident's care plan. These audits will be performed weekly x 4, then monthly x 3 and results of these audits will be brought to the facility QAPI meeting monthly for further review and recommendation
5. Date of compliance 02/28/2026

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

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

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

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

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

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

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

Plan of Correction - To be completed: 02/28/2026

1. Facility cannot retroactively correct the deficiency for residents 4 and 58
2. DON/ designee performed an audit on all residents receiving narcotics to ensure proper documentation of administration record matches the residents MARs.
3. DON/designee educated all clinical staff including agency on the facilities Medication Administration Policy.
4. DON/designee will perform random residents' narcotic administration records and MARs weekly X 4 then monthly X 2 months.
5. Date of compliance 02/28/26

§ 201.14(g) LICENSURE Responsibility of licensee.:

(g) A facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident ' s health and safety are jeopardized.

Observations:

Based on a review of the facility's outstanding accounts payable and interviews with staff, it was determined the facility failed to pay, in a timely manner, bills incurred in the operation of the facility, that are not in dispute and are for services without which the residents' health and safety are jeopardized.

Findings include:

Interview with the facility's Nursing Home Administrator (NHA) on February 3, at 11:14 AM, revealed the facility's bills were conveyed to the facility's corporation for payment. The outstanding bills were not paid at the facility level.

A review of the facility aging report (financial report which shows unpaid invoices by date ranges) conducted at the time of the survey ending January 30, 2026, revealed outstanding accounts payable balances, which required payment of goods and services within 91-120 days.

Vendor #1 (Pharmacy) $54,911.91

The aging report indicated the facility owed this balance of $54,911.91 for greater than 211 plus days.

Vendor #2 (Staffing Agency) $34,398

The aging report indicated the facility owed this balance of $34.398 for greater than 151 plus days.

Vendor #3 (Medical Supply Company) $27,834.76

The aging report indicated the facility owed this balance of $27,834.76 for greater than 121 plus days.

Vendor #4 (information technology services) $43,562.06

The aging report indicated the facility owed this balance of $43,562.06 for greater than 91 plus days.

Vendor #5 (Durable Medical Equipment) $7.745.88

The aging report indicated the facility owed this balance of $7,745.88 for greater than 91 plus days.

Vendor #6 (staffing agency) $223.133.94

The aging report indicated the facility owed this balance of $223,133.94 for greater than 181 plus days.

Vendor #7 (Fire Company) $15,315.00

The aging report indicated the facility owed this balance of $15,315.00 for greater than 91 plus days.

During an interview with the Nursing Home Administrator on February 3, at 11:30 AM, no evidence could be provided that the above outstanding bills were paid in a timely manner.

Plan of Correction - To be completed: 03/20/2026

Facility cannot retroactively correct deficiency. All vendors listed in the deficiency sent to the Accounts Payable office and provided to the Regional Operations Director.
2. Vendors contacted to ensure compliance with the AP process as outlined in vendor business agreements.
3. NHA/designee will obtain a current aging report at the beginning of the month to determine which, if any, accounts require attention.
4. NHA/designee, along with regional directors will continue to ensure ongoing delivery of all necessary goods and services. Corporate has verbal agreements with its primary suppliers/affiliate companies to continue with weekly payments, ensuring no interruption in service. Results of those meetings will be included in the QAPI meeting to ensure no interruptions in goods/services.
5. Date of Complaince: 3/20/2026

§ 211.5(i) LICENSURE Medical records.:

(i) The facility shall assign overall supervisory responsibility for the medical record service to a medical records practitioner. Consultative services may be utilized; however, the facility shall employ sufficient personnel competent to carry out the functions of the medical record service.

Observations:

Based on staff interview it was determined the facility failed to assign a qualified medical records practitioner to carry out the functions of the medical records department.

Findings include:

At the time of the survey ending January 9, 2026, the facility failed to provide evidence of a qualified medical records practitioner carrying out the functions of the facility's medical records service.

During an interview with the facility's Director of Nursing (DON) on January 29, 2026, at 11:43 AM revealed an individual left employment as a medical records staff member on December 19, 2025. After December 19, 2025, the facility failed to employ a person who was certified or eligible for certification as a registered records administrator.

An interview with the Nursing Home Administrator (NHA) on January 29, 2026, at 11:33 AM confirmed the facility failed to employ a person who was certified or eligible for certification as a registered records administrator since December 9, 2025.

Plan of Correction - To be completed: 03/20/2026

1. Facility cannot retroactively correct deficiency.
2. ADON will be assigned the task of medical records compliance within the facility. The ADON will be educated by the Medical Records consultant on regulatory compliance of Medical Records.
3. Medical records consultant is certified as RHIA. Initially, she will be in the facility 4 hrs. per week for 4 weeks, then monthly for 2 months. After that time, she will continue to provide ongoing oversight monthly indefinitely.
4. RHIA will follow up with ADON regarding any further education requirements. Monthly RHIA audits will be reviewed by NHA/ADON to ensure audit results are evaluated and corrected. Results will be sent to QA Committee for review and compliance.
5. Date of Compliance: March 20, 2026

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

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

Plan of Correction - To be completed: 03/20/2026

Facility cannot retroactively correct deficiency for ratios of CNA to resident for the specified time frames.
2. NHA/DON educated by Regional Operator on regulatory ratio requirements for direct care staff to residents. A Staffing calculator is to be used for forecasting staffing levels to ensure correct ratio of direct care provider to resident is upheld
3. Facility uses 2 dedicated recruiters to increase staffing levels to meet ratios in resident care. Facility is using multiple platforms to attract talent. Interviews are completed timely and onboarding initiated day of interview if hired. Agency personnel continue to be used to offset facility employees.
4. DON/designee will complete scheduling of direct care staff and ensure ratios are met by regulation. Results of daily staffing calculator will be reviewed by the QAPI committee to ensure compliance
5. Date of Compliance: March 20, 2026

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse ratio to resident ratio was provided on each shift for 9 shift out of 63 shifts reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.

December 22, 2025-2.03 LPNs on the evening shift, versus the required 2.23, for a census of 67.

December 24, 2025-2.16 LPNs on the evening shift, versus the required 2.23, for a census of 67.

December 25, 2025-2.56 LPNs on the day shift, versus the required 2.68 for a census of 67.

December 25, 2025-2.00 LPNs on the evening shift, versus the required 2.23 for a census of 67.

December 25, 2025-1.00 LPNs on the night shift, versus the required 1.68 for a census of 67.

December 26, 2025-2.16 LPNs on the evening shift, versus the required 2.27 for a census of 68.

December 27, 2025-2.06 LPNs on the evening shift, versus the required 2.27 for a census of 68.

January 15, 2026-2.09 LPNs on the evening shift, versus the required 2.23 for a census of 67.

January 16, 2026-2.00 LPNs on the evening shift, versus the required 2.27 for a census of 68.

On the above date mentioned, no additional excess higher-level staff were available to compensate for this deficiency.

The findings regarding the facility's failure to consistently provide minimum licensed practical nurse (LPN) staff were reviewed with the Nursing Home Administrator, on February 4, 2026, at 12:00 PM via telephone.

Plan of Correction - To be completed: 03/20/2026

1. Facility cannot retroactively correct deficiency for LPN ratios to residents during the specified time frame.
2. NHA/DON educated by Regional Operator on regulatory ratio requirements for direct care staff to residents. A Staffing calculator is to be used for forecasting staffing levels to ensure correct ratio of direct care provider to resident is upheld
3. Facility uses 2 dedicated recruiters to increase staffing levels to meet ratios in resident care. Facility is using multiple platforms to attract talent. Interviews are completed timely and onboarding initiated day of interview if hired. Agency personnel continue to be used to offset facility employees.
4. DON/designee will complete scheduling of direct care staff and ensure ratios are met by regulation. Results of daily staffing calculator will be reviewed by the QAPI committee to ensure compliance
5. Date of Compliance: March 20, 2026

§ 211.12(i)(2) LICENSURE Nursing services.:

(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.

Plan of Correction - To be completed: 03/20/2026

1. Facility cannot retroactively correct deficiency for direct care PPDs not meeting 3.2.
2. NHA/DON educated by Regional Operator on regulatory PPD requirements for direct care staff. A Staffing calculator is to be used for forecasting staffing PPD levels to ensure correct adequate direct care staff are onsite for regulatory PPD level.
3. Facility uses 2 dedicated recruiters to increase staffing levels. Facility is using multiple platforms to attract talent. Interviews are completed timely and onboarding initiated day of interview if hired. Agency personnel continue to be used to offset facility employees.
4. DON/designee will complete scheduling of direct care staff and ensure PPD staffing level is met. Results of daily staffing calculator will be reviewed by the QAPI committee to ensure compliance with PPD requirement.
5. Date of Compliance: March 20, 2026

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