Pennsylvania Department of Health
 EDENBROOK SOUTH
Patient Care Inspection Results

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EDENBROOK SOUTH
Inspection Results For:

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EDENBROOK SOUTH - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on February 11, 2026, it was determined that Edenbrook South 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(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations: Based on observations and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen and store a resident's tube feed in a safe and sanitary location on one of four nursing units reviewed (North Hall Nursing Unit, Resident 11). Findings include: Initial tour of the facility's main kitchen with Employee 9, Dietary Director, on February 8, 2026, at 9:10 AM revealed the following: A hand-washing sink was starting to detach from the wall. A section of wall behind the dishwasher had flaking paint. A temperature booster box for the dishwasher located on the floor adjacent to the dishwasher was observed to be leaking water from underneath the unit. Employee 9 revealed this unit started leaking recently and a work order (a system used to keep track of maintenance work requests) was placed. A refrigerator contained a pitcher of a brown colored liquid and a yellowish colored liquid. The items were not labeled. A facility placed date on the yellowish colored liquid was unreadable. A lid on a garbage receptacle had an extensive build-up of dried stains and food debris. An unlabeled plastic cup was observed on a small table near the spices. The cup contained a liquid and plastic lid. Employee 9 revealed that it was sanitizer for the kitchen thermometer. Another refrigerator contained a small stainless-steel pan with tin foil. There were no dates or labels on the pan. This refrigerator also contained a container with what Employee 9 identified as diced peppers. There were no labels or dates on the pan. A refrigerator adjacent to the tray line preparation area contained multiple small glasses of liquid drinks that were not labeled or dated. There were multiple unlabeled small plastic containers that contained cooked eggs. Review of a maintenance work order provided by facility staff for the leaking booster box under the dishwasher observed as noted above revealed a creation date of February 8, 2026, at 10:38 AM, after the observation occurred. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:10 PM. Observation of Resident 11's room on February 8, 2026, at 11:03 AM, February 9, 2026, at 12:23 PM, and February 10, 2026, at 10:33 AM revealed there was a box stored directly on the floor of Resident 11's room with six containers of Osmolite (tube feeding formula). Reviewed the above findings with the Nursing Home Administrator and Director of Nursing on February 10, 2026, at 2:40 PM, who confirmed to prevent the potential for contamination, the tube feeding formula should not be stored directly on the floor. 483.60(i)(1)-(2) Food safety requirements Previously cited deficiency 1/24/25 28 Pa. Code 201.14(a) Responsibility of licensee
 Plan of Correction - To be completed: 03/31/2026

1. The hand-washing sink was resecured to the wall.

The flaking paint behind the dishwasher will be repaired.

The booster box for the dishwasher is being removed.

The unlabeled pitchers of a brown colored liquid and yellowish colored liquid, small stainless-steel pan with tin foil containing diced peppers, multiple small glasses of liquid drinks, and small plastic containers that contained cooked eggs have all been removed from the refrigerators.

The lid on the garbage receptacle was cleaned.

The unlabeled plastic cup for the sanitizer for the kitchen thermometer has been removed.

The tube feeding for Resident 11 is being stored appropriately.

2. A review of the kitchen will be conducted to identify any additional areas that require further cleaning or repair, as well as any items that are not labeled appropriately. A review will be completed of residents receiving enteral tube feedings to validate the tube feeding formula is not being stored directly on the floor. Corrective actions will be taken as necessary.

3. Education will be completed with the Dietary Director and dietary staff related to proper labeling of food items, cleaning and sanitation in the kitchen environment and identification of items needing repaired as well as the process to initiate the repair. Education will be provided to licensed nurses related to the proper storage of tube feeding formulas in resident rooms.

4. Audits will be conducted by the Nursing Home Administrator/designee to validate that food is stored, prepared, distributed and served in accordance with professional standards. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations: Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and safe environment on three of four nursing units (South, East and West, Residents 2, 8, 9, 29, and 85). Findings include: Observation of Resident 2's room on February 8, 2026, at 11:30 AM and on February 9, 2026, at 12:30 PM revealed the left side bathroom door frame had a chip of wood out of it, a chip of wood out of the bathroom door near the bottom corner, and a scrape down to the wood, horizontally around the middle of the inside of his room door. There was loose dirt behind the door to his room. It was also noted that the floor was dirty from the doorway to the resident's bed with loose dirt and a hazy dull streak indicating where feet had tracked. Observation of Resident 29's room on February 9, 2026, at 12:41 PM revealed loose dirt on the floor with pieces of paper. It was also noted that Resident 29's first and third dresser drawer handles were hanging down on one side. She indicated that they had been that way for a while. Observation of Resident 85's room on February 10, 2026, at 1:30 PM revealed dust and dirt noted to the right as you enter the room. The cove base was noted to be coming off in the corner to the right as you entered her room. The door to her room was marred with chips of wood out near the bottom. The Nursing Home Administrator and the Director of Nursing were made aware of the above noted environmental concerns for Residents 2, 29, and 85 during a meeting on February 11, 2026, at 9:35 AM. Observation of the resident lounge at the end of the East Hall Nursing Unit on February 8, 2026, at 12:31 PM revealed four ceiling lights that had a significant accumulation of debris in the protective covers. Observation of Resident 8's room on February 8, 2026, at 2:45 PM revealed a large brown colored stain on the corner ceiling tile located above the resident's recliner. A concurrent interview with Resident 8 revealed the stain was from a previous leak in the roof. The above information for the resident lounge and Resident 8 were reviewed in a meeting with the Nursing Home Administrator on February 10, 2026, at 10:56 AM. Interview with Resident 9 on February 8, 2026, at 1:13 PM revealed concerns related to a leak in the roof at the corner of his room. The resident stated that the leak initiated about a week prior and was described as a waterfall but had since slowed to a trickle. Concurrent observation revealed that a large commercial sized round yellow garbage bin on a wheeled base was sitting in the corner of Resident 9's room. Further inspection revealed that one of the tiles from the drop ceiling above the garbage bin was removed, exposing a pipe that was dripping into the garbage bin. The garbage bin was noted to be 5 inches from being filled with clear liquid. Two additional resident room sized trash bins were noted to be partially filled with clear liquid to the left of the yellow bin. On the floor to the right of the large garbage bin was a white towel that appeared to have been left on the floor wet, but was now dried and wrinkled, with yellowing edges. Observation on February 9, 2026, at 9:07 AM and again on February 10, 2026, at 10:05 AM revealed the state of the above-mentioned items in Resident 9's room to be unchanged. Resident 9's room environment was discussed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment Previously cited 1/24/25 28 Pa. Code 201.14(a) Responsibility of licensee
 Plan of Correction - To be completed: 03/31/2026

1. The bathroom door frame and bathroom door will be repaired in Resident 2's room.

The floor in Resident 2's room has been cleaned.

The floor in Resident 29's room has been cleaned. The dresser in Resident 29's room will be repaired.

The floor in Resident 85's room has been cleaned. The cove base and door in Resident 85's room will be repaired.

The ceiling lights in the lounge at the end of East Hall have been cleaned.

The ceiling tile in Resident 8's room will be replaced.

The roof leak above Resident 9's room has been repaired, and the room has been cleaned.

2. Resident rooms and common areas will be observed to identify items that need repaired or additional cleaning. Corrective action will be taken upon discovery.

3. To prevent the deficient practice from recurrence, the Maintenance Director and housekeeping staff will be educated by the NHA (Nursing Home Administrator)/designee on the facility processes to maintain a clean and orderly environment.

4. Audits will be conducted weekly x 4 weeks and then monthly X 2 months to ensure maintenance of a clean and orderly environment. Audits will be completed by the NHA/designee with trends reported through the QAPI committee.

5. Date of compliance: 3/31/2026
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 observation and resident and staff interview, it was determined that the facility failed to secure medications on two of four nursing units (West and North, Resident 11). Findings include: Observations of Resident 11's room on the North nursing unit on February 8, 2026, at 11:20 AM, February 9, 2026, at 9:45 AM, and February 10, 2026, at 10:52 AM, revealed a container of Normal Saline Solution (used to restore or maintain fluid volume, especially when oral intake is not possible), on the resident's bedside stand with an expiration date of February 19, 2022. The above findings for Resident 11 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on February 10, 2026, at 2:30 PM. Observation of the North nursing unit medication cart on February 11, 2026, at 8:15 AM revealed the cart was in use by Employee 8, licensed practical nurse, during a medication pass. Observation of this medication cart revealed the following: There were several unsecured and unidentified medications found in the bottom of two of the drawers that included: five round white-colored pills; a blue/green colored capsule; a green oblong tablet; a white oblong tablet; a round, brown-colored pill; a round, yellow-colored pill; and half an oblong, white-colored tablet. The above findings were reviewed in a meeting with the Nursing Home Administrator on February 11, 2026, at 9:47 AM. Observation on the West nursing unit on February 8, 2026, at 12:17 PM revealed the West nursing unit medication cart parked along a wall in the hallway near the nursing station. Residents were observed ambulating in the hallway by the cart. The cart was unattended and unlocked. The surveyor was able to open the cart and access resident medications within the cart. Concurrent interview with Employee 12, licensed practical nurse, confirmed that this medication cart should have been locked before it was left unattended. Observation on the North nursing unit on February 9, 2026, at 3:00 PM revealed the North nursing unit treatment cart parked along a wall near the nursing station as residents were ambulating in the hallway by the cart. The cart was unattended and unlocked. The surveyor was able to open the cart and access resident medicated treatments and medical supplies. Concurrent interview with Employee 8, licensed practical nurse, confirmed that this treatment cart should have been locked before it was left unattended. The above medication storage and security concerns related to the West nursing unit medication cart, and the North nursing unit treatment cart were reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. 483.45(g)(h)(1)(2) Label/store Drugs and Biologicals Previously cited deficiency 2/16/24 and 1/24/25 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/31/2026

1. The Normal Saline Solution at Resident 11's bedside stand was removed and discarded. The unsecured and unidentified medications in the bottom of the medication cart were removed and discarded. The medication cart on the West nursing unit and the treatment cart on the North nursing unit are being locked when unattended.

2. A review of current resident rooms will be completed to identify any unsecured or outdated drugs or biologicals. A review of medication carts will be completed to validate there are no unsecured or unidentified medications. A review of facility medication and treatment carts will be conducted to validate that they are secured when unattended. Corrective action will be taken as necessary.

3. Licensed Nurses will receive education related to proper labeling and storage of drugs and biologicals.

4. Audits will be conducted by the Director of Nursing/designee to validate medications are labeled and stored appropriately in locked compartments when unattended. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.35(e)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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(e)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations: Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 1, 2, and 3). Findings include: The facility noted the following hire dates for three employees reviewed for performance evaluations (EPR, employee performance review): Employee 1's hire date of September 21, 2022. Employee 2's hire date of May 1, 2019. Employee 3's hire date of September 29, 2021. A request to review the annual performance evaluations revealed no documented evidence that the facility completed performance evaluations for Employees 1, 2, and 3 (nurse aides) at least once every 12 months. Employees 1 and 3's last performance evaluations were December 5, 2024. Employee 2's last performance evaluation was November 20, 2024. Interview with the Nursing Home Administrator and Director of Nursing on February 10, 2026, at 2:23 PM confirmed that performance evaluations were not completed annually on the three employees requested. 28 Pa. Code 201.19 (2) Personnel policies and procedures
 Plan of Correction - To be completed: 03/31/2026

1. Performance evaluations will be completed for Employees 1,2 and 3.

2. A review of current nurse aide employee files will be reviewed to determine if a performance evaluation has been completed at least once every 12 months. Corrective action will be taken as necessary.

3. Education will be completed with the Human Resource Director, Director of Nursing and Assistant Director of Nursing related to the requirements to have a performance review completed for all nurse aides at least once every 12 months.

4. Audits will be conducted by the Nursing Home Administrator/designee to validate that nurse aide performance evaluations are completed at least once every 12 months. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.25 REQUIREMENT Quality of Care: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.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations: Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care for one of 19 residents reviewed for advance care planning (Resident 11), and one of three residents reviewed for skin conditions (Residents 3). Findings include: Observation of Resident 3 on February 8, 2026, at 12:48 PM revealed that the skin on his cheeks and forehead was reddened and he had white flaking skin noted to his forehead, cheeks, and eyebrows. Many white flakes were also noted to be around the collar of the resident's shirt. Observation of Resident 3 on February 9, 2026, at 9:19 AM revealed the skin on his cheeks and forehead was reddened and he had white flaking skin noted to his forehead, cheeks, and eyebrows. Clinical record review for Resident 3 revealed a medical progress note dated December 31, 2025, which stated the resident "has some dried skin on face." No further documentation could be identified regarding the dry skin. The above information related to Resident 3 was reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. Observation of Resident 11 on February 8, 2026, at 11:03 AM revealed he was in bed sleeping, with a tube feeding hung at his bedside. Interview with Resident 11 on February 9, 2026, at 12:23 PM revealed he does not want his tube feeding. Clinical record review revealed the facility admitted Resident 11 on October 18, 2019. Review of Resident 11's physician orders revealed a current order for enteral feedings, initiated October 3, 2025. Review of a POLST (Physician Orders for Life Sustaining Treatment, a medical order that communicates a patient's wishes for end of life) dated November 17, 2024, signed by Resident 11 indicated that he did not want artificial hydration or nutrition. Resident 11's POLST was updated January 22, 2025, noting he continues to not want hydration and artificial nutrition by tube. Further review of Resident 11's clinical record revealed a physician assistant progress note dated January 22, 2025, noting a discussion with Resident 11 regarding advance care planning and Resident 11 requested a do not resuscitate order (cardiopulmonary resuscitation (CPR) would not be attempted if the resident stopped breathing) with limited additional interventions, including no antibiotics, hydration, or artificial nutrition by tube. Reviewed the above findings for Resident 11 with the Nursing Home Administrator and Director of Nursing on February 10, 2026, at 2:33 PM. Further discussion with the Nursing Home Administrator and Director of Nursing on February 11, 2026, at 9:38 AM, revealed that the facility spoke to Resident 11 and he wants to discuss discontinuing his tube feeds with his physician. The facility failed to provide the highest practical care to Resident 11 related to his advance care planning. 483.25 Quality of Care Previously cited deficiency 1/24/25 and 3/4/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/31/2026

1. Resident 3 received new orders for his flaking skin and reddened face on 2/10/26. Resident 11 met with a primary care provider to review his advanced care planning wishes. A new POLST was completed.

2. A review of current residents will be completed to validate that residents with active skin conditions have appropriate treatment orders in place. A review of current residents will be completed to validate that the resident's wishes are accurately reflected on their POLST or advanced directive. Corrective action will be taken if needed.

3. Education will be provided to licensed nurses related to the identification of skin conditions and proper actions to take to obtain appropriate treatment. Education will be provided to licensed nurses and the Interdisciplinary team related to the proper completion and review of advanced directives.

4. Audits will be conducted by the Director of Nursing/designee to validate that residents receive treatment and care in accordance with professional standards of practice. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical . . . restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
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)(2) Ensure that the resident is free from physical . . . restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations: Based on clinical record review, review of select facility policies and procedures, and staff and responsible party interview, it was determined that the facility failed to obtain appropriate documentation for a device used as a physical restraint for one of one resident reviewed for restraint use (Resident 6). Findings include: The policy entitled "Physical Restraints," last reviewed without changes September 9, 2025, reveled physical restraints are only used when they are used appropriately to treat a resident's medical symptoms and to promote an optimal level of function for the resident. If an adaptive device is being used an Adaptive Equipment assessment will be completed by a licensed nurse or therapist to determine if the device is limiting the resident's freedom of movement or normal access to one's body. If device is found to be limiting movement, the Restraint Assessment will be completed. The least restrictive device should be used with documentation of all other alternatives tried prior to the implementation of a restraint. An order for the use of restraint will be received from the physician which includes medical symptoms for use, frequency of use, type of restraint, release protocols, and a plan for reduction. Notification to the residents and/or family of the risks of physical restraints and documentation of informed consent/education on use must be obtained anytime there is a restraint applied. The resident's care plan will be updated with the use of a restraint. A restraint review should be completed at least quarterly with updates if applicable. Clinical record review revealed the facility admitted Resident 6 on September 4, 2021, with diagnoses including cerebral palsy. Review of Resident 6's most recent quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated December 30, 2025, revealed staff assessed Resident 6 using a trunk restraint daily. Review of previous MDS assessments dated November 2, and August 25, 2025, revealed nursing staff also assessed Resident 6 as utilizing a trunk restraint daily. Review of Resident 6's clinical record revealed a Restraint Use/ Assessment dated January 23, 2026, noting staff assessed Resident 6 for the use of a harness and seatbelt for use in her wheelchair. The assessment revealed Resident 6 is at a significant risk of serious or fatal injury if a fall should occur out of chair due to her diagnosis of cerebral palsy, epilepsy, and having an extrapyramidal movement disorder and severe cognitive impairment. The only previous restraint assessment was completed February 26, 2025. Interview with Resident 6's family on February 10, 2026, at 2:20 PM revealed that staff utilize the seat belt/harness restraint when they are feeding Resident 6. Resident 6's family explained when staff feed Resident 6 her wheelchair is in the upright position and her restraint is utilized, and when she is seated in the hallway her wheelchair is tilted/reclined. Further review of Resident 6's clinical record revealed there was no physician order, or plan of care addressing Resident 6's restraint. These findings were reviewed with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:38 PM. Further interview with the Nursing Home Administrator and Director of Nursing on February 11, 2026, at 9:38 AM confirmed there was no documentation of monthly assessments, a physician order, or a plan of care addressing Resident 6's restraint until after surveyor questioning. 28 Pa. Code: 211.8(e) Use of restraints. 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: 03/31/2026

1. A physician order has been obtained for Resident 6's use of a harness and seatbelt restraint. Resident 6's care plan will be updated to address the use of the restraint and ongoing re-evaluation of the device will occur as required.

2. A review will be completed for any residents utilizing a physical restraint to validate that the use of restraints is indicated with a physician order in place, the facility is using the least restrictive alternative for the least amount of time, ongoing re-evaluation of the need for restraints is completed and the use of the restraint is included in the residents' plan of care. Corrective action will be taken as required.

3. Education will be completed with licensed nurses and the Interdisciplinary Team regarding restraint policy and procedures.

4. Audits will be conducted by the Director of Nursing/designee to validate that when the use of restraints is indicated, the facility policy is followed. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI (Quality Assurance Performance Improvement) Committee for review.

5. Date of compliance: 03/31/2026
483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations: Based on clinical record review, review of select facility policies and procedures, and resident and staff interview, it was determined that the facility failed to determine a resident's capability to self-administer their medications for one of 19 residents reviewed (Resident 22). Findings include: The facility policy entitled "Medication Self Administration," last reviewed without changes September 9, 2025, revealed the resident shall have a screen completed by a licensed nurse to determine factors that may impact the safe administration of medications. Residents who have been deemed appropriate to self-administer medications independently or with supervision/cueing or after set-up, shall have a physician order to do so. The screen will be re-evaluated quarterly and more frequently as clinically indicated. Medications to be self-administered shall be secure in a locked area in the resident's room or stored in the medication cart for provision to the resident to self-administer. Any significant change in the resident's condition will be promptly reported to the Director of Nursing and/or the resident's attending physician with rescreening for self-administration performed to ensure self-administration of medications is still safe. The resident will be provided with a medication administration record to document the self-administration medications. Proper documentation of self-administration will be reviewed and used as a factor to determine continued self-administration at the next review. The self-administration of medications will be care planned with interventions specific to the individual resident. Clinical record review revealed the facility admitted Resident 22 on January 5, 2026. Review of Resident 22's physician orders revealed the following orders: Dialysis Monday, Wednesday, Friday, with a chair time of 11:00 AM, transported by Step van, and dietary to provide lunch, initiated on January 9, 2026. Renvela (medication used to control high phosphorus levels in adults with chronic kidney disease on dialysis) tablet 800 milligrams (mg), three tablets by mouth three times a day, initiated on January 8, 2026. Interview with Resident 22 on February 8, 2026, at 1:47 PM revealed that she goes out of the facility to dialysis three days a week. Resident 22 stated that she takes her lunch and a "large white pill to take" with her to dialysis. Review of Resident 22's clinical record on February 8, 2026, revealed no evidence of a Self-Administration Screen, or physician order for Resident 22 to self-administer her Renvela. The facility did not complete a Self-Administration Screen until February 9, 2026, after the surveyor's questioning. The facility did not get an order for Resident 22 to self-administer her Renvela medication on dialysis days until February 9, 2026, after the surveyor's questioning. The above findings for Resident 22 were reviewed during a meeting with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:30 PM. The Nursing Home Administrator confirmed that Resident 22 was not assessed to self-administer her medication until after surveyor questioning. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
 Plan of Correction - To be completed: 03/31/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1. Resident 22 had a self-administration assessment completed on 2/9/26. She was deemed appropriate to self-administer the medication, Renvela. A physician order was obtained on 2/9/26 for self-administration of the medication. Resident 22 has been discharged from the facility and no further corrective action can be taken for this resident.

2. A review of additional residents receiving dialysis services will be completed to identify residents who are self-administering medications while at the dialysis clinic. The review will validate that the facility policy for "Medication Self Administration" is being followed. Corrective action will be taken as necessary.

3. Facility licensed nurses will be re-educated on the policy for medication self-administration if required for dialysis residents.

4. Audits will be conducted by the Director of Nursing/designee to validate that the interdisciplinary team has determined that residents who are self-administering medications are clinically appropriate to do so. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI (Quality Assurance Performance Improvement) Committee for review.

5. Date of Compliance: 3/31/2026
483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.71 and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations: Based on a review of employee personnel and education records and staff interviews, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of three nurse aides reviewed (Employee 1). Findings include: Review of Employee 1's, nurse aide, personnel record revealed that the facility hired her on September 21, 2022. The surveyor requested training records for Employee 1 during an interview with the Nursing Home Administrator and the Director of Nursing on February 9, 2026, at 2:38 PM. Review of training records provided by the facility for Employee 1 on February 10, 2026, revealed that Employee 1 completed only 3.35 hours of in-service education in the last year. Interview with the Director of Nursing and the Nursing Home Administrator on February 11, 2026, at 9:44 AM confirmed the above findings for Employee 1, and were unable to provide any further documentation indicating Employee 1 received 12 hours of in-service training annually. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development
 Plan of Correction - To be completed: 03/31/2026

1. Employee 1 will complete 12 hours of in-service training annually as required.

2. A review will be completed of facility nurse aides to validate that 12 hours of in-service training have been completed annually as required. Corrective action will be taken as necessary.

3. Education will be completed with the Director of Nursing and Nurse Educator related to the regulated requirements for nurse aides.

4. Audits will be conducted by the Nursing Home Administrator/designee to ensure facility nurse aides receive at least 12 hours of in-service training annually. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 a review of select facility policies and procedures, observation, and staff and resident interviews, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of eight residents reviewed for infection control (Resident 22). Findings include: The facility policy entitled "Isolation Precautions," last reviewed without changes September 9, 2025, revealed contact precautions will be implemented for residents suspected or confirmed to be infected with a communicable disease/infection that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces/equipment in the resident's environment. Residents should be placed in a private room when available. Prior to entering the isolation room, the following steps are required: perform hand hygiene and apply gloves and gown prior to entering room, while providing direct resident care, wear gloves and wash hands after coming into contact with infectious material, remove gloves and perform hand hygiene before leaving room. Clinical record review revealed the facility admitted Resident 22 on January 5, 2026. Interview with Resident 22 on February 8, 2026, at 12:35 PM revealed that she came to the facility from the hospital due to Clostridioides difficile (c-diff, a bacterium that causes diarrhea and inflammation of the colon). Review of Resident 22's physician's orders revealed an order for contact precautions for c-diff initiated January 5, 2026. Observation of Resident 22 on February 8, 2026, at 1:20 PM revealed Employee 11 (laundry aide) entered Resident 22's room to put Resident 22's laundry away. Employee 11 wore gloves but did not don (put on) a gown. Observation of Resident 22 on February 8, 2026, at 1:25 PM revealed Employee 10 (licensed practical nurse) entered Resident 22's room and administered Resident 22 her medications. Employee 10 wore gloves but did not don a gown. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 3:07 PM, who confirmed staff are to wear gloves and gowns when entering a resident's room on contact precautions. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control Previously cited deficiency 1/24/25 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services
 Plan of Correction - To be completed: 03/31/2026

1. Resident 22 has been discharged from the facility. No further corrective action can be taken for this resident.

2. A review will be completed for current residents requiring transmission-based precautions to prevent the spread of infection to validate that proper PPE (Personal Protective Equipment) is in place.

3. Education will be completed with nursing and housekeeping staff related to the requirements associated with transmission-based precautions.

4. Audits will be conducted by the Director of Nursing/designee to ensure an environment free from the potential spread of infection. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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.
§483.45(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations: Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent on one of four nursing units (North Nursing Unit; Residents 75 and 94). Findings include: The facility's medication error rate was 11.54 percent based on 26 medication opportunities with three medication errors. Review of Resident 75's current physician orders revealed an order dated September 24, 2025, for Potassium Chloride (potassium supplement) ER (extended release) oral tablet 20 mEq (milliequivalent); give 1 tablet by mouth two times a day, dissolve in small amount of fluid for slurry. Observation of Resident 75's medication administration on February 8, 2026, at 8:37 AM revealed that Employee 10, licensed practical nurse, crushed the Potassium Chloride ER tablet and placed it in pudding with additional crushed medications to administer to Resident 75. Employee 10 did not prepare the Potassium Chloride ER as ordered. Drugs.com (an online comprehensive source of drug information) states do not chew, break, or crush the medication. Review of Resident 75's current physician orders revealed an order dated March 25, 2025, for Calcium 600 plus D plus Minerals (a calcium and vitamin supplement) oral tablet chewable 600-400 mg (milligrams) - unit (international units) (calcium carbonate-vitamin D with minerals); give 1 tablet by mouth one time a day for supplement. Observation of Resident 75's medication administration on February 10, 2026, at 8:35 AM revealed that Employee 8, licensed practical nurse, prepared the medications prior to administration. This preparation included one Calcium 600 plus Vit D3 (a house stock medication containing Calcium 600 mg and Vitamin D 5 mcg (micrograms). Five mcg is the equivalent of 200 units of Vitamin D which was not the concentration of the medication ordered for the resident. Employee 8 then proceeded to administer the medication to Resident 75. Resident 75's medication administration concerns were reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. Review of Resident 94's current physician orders revealed an order dated August 28, 2023, for Calcium 600 plus D plus minerals oral tablet 600-400 milligrams-unit (calcium carbonate vitamin D with minerals); give one tablet by mouth two times a day for calcium deficiency. Observation of Resident 94's medication administration pass on February 11, 2026, at 8:10 AM revealed that Employee 8, licensed practical nurse, prepared the medications prior to administration. This preparation included one Calcium 600 plus Vit D3 (a house stock medication containing Calcium 600 mg and Vitamin D 5 mcg). The medication only contained 200 units of Vitamin D and not the 400 units ordered. Employee 8 then proceeded to administer the medication to Resident 94. An interview with Employee 8 on February 11, 2026, at 11:00 AM confirmed that the Vitamin D dose in the house stock medication did not match the dose specified in the physician order for Resident 94. The Nursing Home Administrator and Director of Nursing were notified of the findings for Resident 94 on February 11, 2026, at 11:03 AM. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services
 Plan of Correction - To be completed: 03/31/2026

1. Residents 94 and 75 will have their calcium supplement dosing orders clarified by their attending provider. There were no negative outcomes as a result of Resident 75's Potassium being crushed.

2. A review of current residents receiving Calcium supplements will be completed to validate that correct dosing is available and being administered. A review of current residents receiving Potassium Chloride will be completed to validate that directions indicate that the medication should not be crushed. Corrective actions will be taken as necessary.

3. Education will be completed with facility licensed nurses regarding administering medications at the correct dose per physician order and only crushing medications which are suitable to be crushed.

4. Audits will be conducted by the Director of Nursing/designee to validate that medications are administered without errors. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(h)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations: Based on observations and staff interview, it was determined that the facility failed to ensure residents' rights to secure confidential personal and medical information in the facility's main lobby, one of four nursing units (North Hall Nursing Unit) and three of 19 residents reviewed (Residents 11, 53, and 60). Findings include: Observation of hallway in the area located in front of Nurse Station 1 at the end of the North Hall Nursing Unit on February 8, 2026, at 12:10 PM revealed a facility binder on the wall titled Pennsylvania Department of Health Survey Book. The binder contained the results of recent surveys of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Observation of the facility's main lobby area on February 8, 2026, at 1:38 PM revealed a facility binder on the wall titled Pennsylvania Department of Health Survey Book. The binder contained the results of recent surveys of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Review of the contents of these binders revealed that the facility placed the full health survey letters and complaint deficiency letters (letters sent to administration after a survey) into the binder. Further review of the binders revealed a deficiency letter and associated Statement of Deficiencies (Form CMS-2567) for a survey on February 16, 2024. The letter noted the full name and associated specific resident identifiers for Residents 11 and 60. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on February 8, 2026, at 1:40 PM. Observation of a medication pass with Employee 8, licensed practical nurse, on the North Hall Nursing Unit on February 11, 2026, at 8:12 AM revealed a medication cart with a plastic garbage receptacle attached to the side. The garbage receptacle contained an empty medication card with a prescription label attached containing Resident 53's name, and dosing instructions for mycophenolate mofetil oral capsules (a medication used to prevent organ rejection after transplant and treatment of autoimmune diseases). An interview with Employee 8 on February 11, 2026, at 8:12 AM revealed that the medication card with the attached identifying information for Resident 53 should not be thrown away in the regular trash. Employee 8 informed that the resident identifiers on the medication card should be torn off and placed in the shredder bin located near the nurse station. The above information for Resident 53 was reviewed in a meeting on February 11, 2026, at 9:47 AM. The facility failed to ensure the right to privacy of their personal and medical information for Residents 11, 53, and 60. 28 Pa. Code: 201.18(e)(1) Management
 Plan of Correction - To be completed: 03/31/2026

1. The full health survey letters and complaint deficiency letters (letters sent to administration after a survey) containing Residents 11, 52 and 60's personal information were removed from the facility binders on 2/8/26. Resident 53's empty medication card with a prescription label attached containing Resident 53's name, and dosing instructions for mycophenolate mofetil oral capsules was removed from the medication cart and placed in the shredder bin on 2/11/26.

2. The facility binders containing the results of recent surveys conducted by Federal or State surveyors will be reviewed to validate that all confidential personal and medical information has been removed. A review of all medication carts will be completed to validate that no confidential personal or medical information is located in the garbage receptacles. Corrective action will be taken as necessary.

3. Licensed Nurses and members of the facility IDT (Interdisciplinary Team) will receive education related to requirements to ensure the right to privacy of residents' personal and medical information.

4. Audits will be conducted by the Administrator/designee to validate that the interdisciplinary team has determined that the facility has ensured the right to privacy of residents' personal and medical information. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI (Quality Assurance Performance Improvement) Committee for review.

5. Date of compliance: 3/31/2026
483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process: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.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

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

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

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

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

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

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

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

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

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

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
Observations: Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of six residents reviewed for hospitalizations (Residents 3, 6, and 36). Findings include: Review of Resident 3's clinical record revealed they were transferred to the hospital on November 5, 2025, December 13, 2025, and January 30, 2026. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 3's transfer to the hospital on November 5, 2025, December 13, 2025, or January 30, 2026. Review of Resident 6's clinical record revealed that the facility transferred her to the hospital from December 23 to 26, 2025. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 6's transfer to the hospital on December 23, 2025. Review of Resident 36's clinical record revealed they were transferred to the hospital on November 6, 2025, and November 22, 2025. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 36's transfer to the hospital on November 6, 2025, or November 22, 2025. Interview with the Nursing Home Administrator and Director of Nursing on February 11, 2026, at 10:04 AM confirmed the above findings for Resident 3, 6, and 36. The facility failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for Residents 3, 6, and 36. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights
 Plan of Correction - To be completed: 03/31/2026

1. The Office of the State Long-Term Care Ombudsman will be updated regarding the transfers to the hospital for Residents 3, 6 and 36.

2. A review will be conducted of facility residents who have transferred to the hospital within the past 30 days to ensure The Office of the State Long-Term Care Ombudsman was notified. Corrections will be made as needed.

3. Education will be provided to the facility interdisciplinary team on the requirement to notify The Office of the State Long-Term Care Ombudsman when a resident is transferred to the hospital.

4. Audits will be conducted by the facility Nursing Home Administrator / designee monthly for three months to validate The Office of the State Long-Term Care Ombudsman was notified when a resident is transferred to the hospital. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.
Observations: Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for 3 of 19 residents reviewed (Residents 29, 70, and 22). Findings include: Clinical record review for Resident 29 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 9, 2026, that indicated section C of the assessment (cognitive patterns) was documented with dashes indicating Resident 29 was not assessed for cognitive status. Further clinical record review for Resident 29 revealed a quarterly MDS assessment dated October 5, 2025, that indicated she was assessed as having no cognitive impairment with a BIMS (Brief Interview for Mental Status) of 15, (a score of 13-15 is intact cognition). Interview with Resident 29 on February 9, 2026, at 11:45 AM revealed her to be alert and oriented with no noticeable cognitive deficits. Interview with the Nursing Home Administrator on February 9, 2026, at 2:00 PM confirmed that Resident 29 was cognitively intact. She indicated that the social service director who is responsible for completing section C of the MDS went out on leave and they did not realize Resident 29's section C assessment was not done until the assessment reference date had passed, so they had to code Resident 29's cognitive status as "not assessed" The facility failed to accurately assess Resident 29's cognitive pattern for the MDS assessment as noted above. Clinical record review for Resident 70 revealed a quarterly MDS dated January 16, 2026, that indicated Section C of the assessment (cognitive patterns) was documented in all areas as "not assessed." Further clinical record review for Resident 70 revealed a Discharge Return Anticipated MDS assessment dated January 10, 2026, that indicated multiple areas of Section C documented by staff as "not assessed." Further clinical record review for Resident 70 revealed a quarterly MDS assessment dated December 24, 2025, that indicated the resident was assessed as having a BIMS of 13. Interview with Resident 70 on February 9, 2026, at 10:35 AM revealed the resident to be alert and with no noticeable cognitive deficits and answered questions appropriately. The above information for Resident 70 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:10 PM. The Nursing Home Administrator revealed that the staff member responsible for completing section C of the MDS went on leave and the facility did not realize Resident 70's Section C assessment was not completed until the assessment reference date had passed, so the facility had to code Resident 70's cognitive status as "not assessed." The facility failed to accurately assess Resident 70's cognitive pattern for the MDS assessments as noted above. Clinical record review for Resident 22 revealed an admission MDS dated January 11, 2026, that indicated section C of the assessment (cognitive patterns) was documented with dashes indicating Resident 22 was not assessed for cognitive status. Interview with Resident 22 on February 8, 2026, at 11:45 AM revealed her to be alert and oriented with no noticeable cognitive deficits. The above findings for Resident 22 were reviewed with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:28 PM. The facility failed to accurately assess Resident 22's cognitive pattern for the MDS assessments as noted above. 483.20(g), F641, Accuracy of Assessments Previously cited 1/24/25 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/31/2026

1. Resident 22 has been discharged from the facility. No further corrective action can be taken for this resident. Cognitive assessments for Residents 29 and 70 will be completed.

2. A review will be completed of current residents to validate that cognitive patterns were accurately assessed with MDS assessments completed in the past 90 days. Corrective action will be taken as required.

3. Education will be completed with the Social Service Director, RNAC (Registered Nurse Assessment Coordinator) and Assistant Administrator regarding the timely completion of cognitive assessments.

4. Audits will be conducted by the Nursing Home Administrator/designee to validate that cognitive patterns are assessed timely in correlation with MDS assessments. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations: Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan regarding a diagnosis for PTSD (Post-Traumatic Stress Disorder, a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) for one of 19 residents reviewed (Resident 9). Findings Include: During an interview with Resident 9 on February 8, 2026, at 1:38 PM, the resident stated he was diagnosed with PTSD related to a history of childhood sexual trauma. Clinical record review for Resident 9 revealed that the resident was diagnosed with PTSD on March 8, 2025. Review of Resident 9's current comprehensive plan of care (a summary of a resident's personal health, nursing, and psychological well-being needs and how they can be met) included two stated goals; "I will remain comfortable and safe in my environment," and "I will not have episodes of crisis." There were two listed interventions including, "Discuss feelings of anger with resident," and "I want to stay in contact with my friends/family." The care plan did not describe what individualized interventions would assist Resident 9 to remain comfortable within their environment. The care plan did not describe what an episode of crisis looks like for the resident or how to address these episodes with the resident to achieve these stated goals. The above information regarding the care plan was reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. 28 Pa. Code 211.10. (a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/31/2026

1 Resident 9's care plan will be updated to describe individualized interventions to assist resident in relation to his diagnosis of PTSD.

2. A review will be completed of current residents with a diagnosis of PTSD to validate that individualized interventions are identified on care plans to achieve the stated goals.

3. Education will be provided to the facility Interdisciplinary Team regarding ensuring residents with mental health conditions have comprehensive, person-centered care plans in place.

4. Audits will be conducted by the Nursing Home Administrator/designee to validate that residents with mental health conditions have a comprehensive, person-centered care plan in place. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations: Based on observation, clinical record review, and resident family and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of four residents reviewed (Resident 11). Findings include: Observation of Resident 11 on February 8, 2026, at 12:58 PM revealed he was sleeping in bed and his hair appeared long (shoulder length) and disheveled. Interview with Resident 11 on February 9, 2026, at 1:52 PM revealed that he wished to have his hair cut. Concurrent interview with Resident 11 on February 10, 2026, at 10:15 AM revealed Resident 11 again stated a desire to have his hair cut, indicating he was not sure why it was taking so long. The findings for Resident 11 were reviewed with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:30 PM. They were unable to provide an explanation as to why Resident 11 has not received a haircut for an extended period. Review of social service documentation dated February 9, 2026, at 6:00 PM revealed social worker asked Resident 11 if he would like a haircut, and Resident 11 voiced "yes." There was no evidence that the facility offered, or Resident 11 refused to have his hair cut. 483.24(a)(2) ADL Care Provided for Dependent Residents Previously cited deficiency 1/24/25 28 Pa. Code 211.12(d)(1)(5) Nursing services
 Plan of Correction - To be completed: 03/31/2026

1. Resident 11 has received a haircut.

2. A review of current residents will be completed to determine resident preferences as it relates to beautician services. Corrective action will be taken as warranted.

3. Licensed nurses and the Interdisciplinary team will receive education related to obtaining resident preferences in relation to beautician services. Upon admission and with resident care conferences, resident preference for beautician services will be reviewed

4. Audits will be conducted by the Director of Nursing/designee to validate that residents are provided services to maintain adequate grooming and personal hygiene. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations: Based on clinical record review, observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services for a resident who is fed by enteral (feeding tube) means to prevent potential complications for one of one resident reviewed for tube feeding concerns (Resident 36). Findings include: Review of facility policy titled "Policy &; Procedure Tube Feeding: Continuous Tube Feeding" last reviewed on September 9, 2025, states under step 7 of the procedure to "elevate the head of the bed at least 30 degrees during feeding and for 30 to 60 minutes after feeding unless contraindicated." Observation of Resident 36 on February 8, 2026, at 12:20 PM revealed the presence of a feeding tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications; also known as a PEG tube) connected to a feeding pump (a mechanical device used to pump fluids and a specialized liquid nutrition source referred to as feed, through a G-tube at a pre-set rate). A concurrent observation of the feeding pump revealed that the feeding pump was actively administering feed through the residents feeding tube while Resident 36 was in bed, with the bed laying in a flat position. Observation of Resident 36 on February 9, 2026, at 9:10 AM revealed that the feeding pump was actively administering feed through the residents feeding tube while Resident 36 was in bed, with the bed laying in a flat position. Clinical record review revealed that Resident 36 had an active physician's order dated March 3, 2024, to elevate the residents HOB (head of bed) while the tube feed is running and for one hour after the feed is completed every shift for preventing aspiration (food or liquid entering the airway/lungs). The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:25 PM. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing service
 Plan of Correction - To be completed: 03/31/2026

1. The head of bed for Resident 36 is being elevated while her tube feeding is infusing.

2. A review of additional residents receiving tube feedings will be completed to validate that the residents' care plans, orders and resident kardexes are reflective of the need to maintain the head of bed in an elevated position while tube feeds are running.

3. Nursing staff will be educated regarding the need to elevate the head of bed as per order and/or policy when tube feedings are infusing.

4. Audits will be conducted by the Director of Nursing/designee to validate that appropriate treatment and services are being provided to residents who are being fed by enteral means. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations: Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store respiratory care equipment in a sanitary manner on one of four nursing units (South, Resident 33) and provide respiratory care consistent with professional standards of practice for one of two residents reviewed for respiratory concerns (Resident 4). Findings include: Observation of Resident 33's bedside table on February 8, 2026, at 12:24 PM revealed a nebulizer machine (a compressor device that converts liquid medication into a fine mist, allowing for easier inhalation into the lungs) with nebulizer tubing (a removable, flexible hose that connects the nebulizer machine to the liquid medication cup, allowing air to flow through and convert liquid medication into a mist for inhalation) and a nebulizer mask with a medicine cup (a breathing mask worn over the nose and mouth connected to the medicine cup, which ensures that the aerosolized medicine is adequately inhaled) on the table. The mask appeared to be coated in a slightly opaque white colored film, and the medicine cup had dried droplets of liquid noted to the inside of the medicine cup. Observation of Resident 33's bedside table on February 9, 2026, at 12:10 PM again revealed a nebulizer machine with attached nebulizer tubing and a nebulizer mask and medicine cup on the table. The mask continued to appear to be coated in a slightly opaque white colored film, but the medicine cup was noted with droplets of liquid to the inside of the medicine cup. Concurrent observation of the bedside table revealed food debris/crumbs, a dried drop of a red liquid, and a spoon that appeared to have been previously used. The above findings regarding the condition of Resident 33's nebulizer machine was discussed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. Clinical record review revealed the facility admitted Resident 4 on January 21, 2022, with diagnosis of chronic obstructive pulmonary disease (COPD). A diagnosis of chronic respiratory failure with hypoxia (insufficient oxygen supply) was added April 25, 2025. A physician's order initiated on July 1, 2024, instructed staff to administer Resident 4 continuous oxygen at two liters per minute (LPM) by nasal cannula (medical tubing that delivers supplemental oxygen directly to the nose). Observation of Resident 4 on February 8, 2026, at 10:52 AM and 2:51 PM revealed she was seated in her wheelchair with her oxygen being administered at three LPM. Observation of Resident 4 on February 10, 2026, at 9:49 AM revealed she was seated in her wheelchair with her oxygen being administered at one LPM. The above information for Resident 4 was reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:30 PM. 483.25(i) Respiratory Care Previously cited 1/24/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/31/2026

1. Resident 33's bedside table was cleaned and his nebulizer tubing and mask were replaced. Resident 4 is currently receiving oxygen as ordered.

2. A review of residents receiving nebulizer treatments will be completed to validate that nebulizer equipment is cleaned and stored appropriately. Current residents who are receiving oxygen will be reviewed to validate oxygen is being administered per physician order.

3. Education will be completed with licensed nurses related to proper cleaning and storage of nebulizer equipment and proper administration of oxygen in accordance with physician orders.

4. Audits will be conducted by the Director of Nursing/designee to validate oxygen is being administered per physician order and that nebulizer equipment is cleaned and stored appropriately. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.35(a)(3)(4)(d) REQUIREMENT Competent Nursing Staff: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.
§483.35 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)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(d) Proficiency of nurse aides.

The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations: Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with wound vacs for four of four employees reviewed (Employees 4, 5, 6, and 7). Findings include: Clinical record review revealed the facility admitted Resident 3 on November 20, 2025. A physician order dated January 13, 2026, revealed nursing staff are to apply a wound vac (a therapy that uses a device to decrease air pressure on a wound) to Resident 3's sacral area wound using black foam and setting to 125 mmhg (millimeters of mercury). A request for nursing staff competencies for Resident 3's wound vac revealed the facility was unable to provide any competencies related to wound vacs for Employees 4 and 5 (licensed practical nurses) and Employees 6 and 7 (registered nurses). The findings were reviewed with the Nursing Home Administrator and Director of Nursing on February 11, 2026, at 9:44 AM. They confirmed the facility could provide no documentation that ensured Employees 4, 5, 6, and 7 had specific competencies and skill sets to care for Resident 3's needs listed above. 483.35(a)(3)(4)(d) Competent Nursing Staff Previously cited deficiency 1/24/25 28 Pa. Code 201.20 (a) Staff Development
 Plan of Correction - To be completed: 03/31/2026

1. Competencies for wound vacs will be completed with Employees 4,5,6 and 7.

2. Competencies for wound vacs will be completed with all licensed nursing staff.

3. Education will be provided to the facility's Director of Nursing, Assistant Director of Nursing and Nurse Educator related to the requirement of annual competencies for licensed nurses.

4. Audits will be conducted by the Nursing Home Administrator/designee to validate that annual competencies are completed with licensed nurses. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

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

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

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

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

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations: Based on clinical record review and staff interview, it was determined that the facility failed to obtain and provide medications for one of 19 residents reviewed (Resident 20). Findings include: Clinical record review for Resident 20 revealed that the facility admitted her on June 16, 2017. Further clinical record review revealed that she had diagnoses of bipolar disorder (a mental health disorder characterized by intense mood swings, ranging from extreme highs to deep lows), psychotic disorder with hallucinations (a loss of contact with reality, characterized by hearing voices, seeing things, or feeling sensations that are not there), restlessness and agitation, generalized anxiety disorder (a mental health condition characterized by chronic, excessive, uncontrollable worry), and vascular dementia with agitation (triggered by brain damage from reduced blood flow to the brain causing cognitive decline with behaviors of increased motor activity, restlessness, irritability, and aggression). Review of Resident 20's medication administration record (MAR) for December 2025, revealed that Resident 20 was to receive one milliliter of Lorazepam (a medication used to treat anxiety) 0.5 milligrams (mg) per milliliter (ml) gel topically two times a day. Resident 20's MAR for December 2025, revealed that the medication was not administered on December 25-26, 2025, at 8:00 AM or 8:00 PM, and it was not administered on December 27, 2025, at 8:00 AM due to the medication not being available. Clinical record review for Resident 20 revealed a progress note dated December 25, 2025, at 8:27 AM that indicated Lorazepam 0.5 mg/ml Gel was not available and they were awaiting pharmacy delivery of the medication. A progress note dated December 25, 2025, at 9:45 PM revealed that the facility was waiting on delivery of Resident 20's Lorazepam 0.5 mg/ml Gel. A progress note dated December 26, 2025, at 8:08 AM revealed that Resident 20's Lorazepam 0.5 mg/ml Gel was unavailable. The writer indicated that the medication was ordered last week and pharmacy would be called. A progress noted dated December 26, 2025, at 1:16 PM indicated that the writer called the pharmacy but was unable to get an answer as to whether the medication had been shipped. A progress note dated December 27, 2025, at 4:18 AM revealed that the pharmacy was called and the representative stated that the medication was not reordered but they would fill the medication now and send it on the next pharmacy run between 9:00 AM-12:00 PM. A pharmacy order status report dated February 10, 2026, provided by the facility revealed that the Resident 20's Lorazepam 0.5/ml Gel was reordered on December 15, 2025, but the pharmacy only sent enough for eight doses. The medication was not reordered again until December 27, 2025, after Resident 20 missed 5 doses. An email dated February 10, 2026, at 12:19 PM, provided by the pharmacy to the facility indicated that Resident 20's Lorazepam refill request was received by them on December 27, 2025, at 4:00 AM (after hours). The email indicated that the pharmacy filled and shipped the medication on December 27, 2025. An interview with the Director of Nursing and Nursing Home Administrator on February 11, 2026, at 9:30 AM confirmed the noted information related to the unavailability of Resident 20's Lorazepam 0.5 mg/ml gel. The facility failed to ensure Resident 20 received her physician ordered medications as noted above. 483.45 Pharmacy Services Previously cited June 4, 2025 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 03/31/2026

1. Resident 20 is receiving Lorazepam as ordered.

2. A review of current residents prescribed Lorazepam will be completed to validate that the medication has been available over a look-back period of 30 days. Corrective action will be taken if necessary for medications that are not currently available.

3. Licensed nurses will be educated on practices to be followed to ensure timely delivery of medication and the proper process to be followed if a medication is not available for administration.

4. Audits will be conducted by the Director of Nursing/designee to validate medications are obtained timely and administered as ordered. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations: Based on review of select facility policy and procedure and staff interview, it was determined that the facility failed to develop policies and procedures for the monthly medication regimen reviews that included time frames for the different steps in the process. Findings include: A review of the facility policy titled, "Medication Regimen Review," last reviewed September 9, 2025, revealed a purpose that the consultant pharmacist shall review the medication regimen of each resident at least monthly. Further review of the policy revealed the following (in part): the consultant pharmacist will communicate the findings and recommendations in writing on a medication regimen review report; the consultant pharmacist will contact the Director of Nursing or designees when irregularities are noted that require immediate action to protect the resident and prevent the occurrence of an adverse drug event; any irregularities will be communicated to the physician utilizing a written recommendation and report for consideration; information on the medication regimen reviews and written recommendations will be reviewed by the Director of Nursing or designee and the Director of Nursing or designee will send the medication regimen review to the appropriate provider for follow-up; providers will review the medication regimen review from the pharmacist, follow-up as applicable, and return the medication regimen review form to the Director of Nursing or designee. The policy did not contain specific time frames for the pharmacist to communicate findings and recommendations in writing on the medication regimen review report, the time frame to contact the Director of Nursing or designee when irregularities are noted that require immediate action to protect the resident and prevent the occurrence of an adverse drug event, the time frame for the pharmacist to communicate to the physician, the time frame for physician response, or the time frame for the Director of Nursing or designee to review the medication regimen report. The facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process. The above information was reviewed with the Nursing Home Administrator on February 10, 2026, at 10:05 AM. 28 Pa. Code 201.18 (d) Management
 Plan of Correction - To be completed: 03/31/2026

1. No specific residents were cited to require additional intervention.

2. A review will be completed of the facility policy "Medication Regimen Review" to determine necessary revisions required to identify time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

3. Education will be provided to the nursing management team related to the updated Medication Regimen Review Process.

4. Audits will be conducted by the Nursing Home Administrator/designee to validate that the facility policy reflects time fromes for the different steps in the Medication Regimen Review Process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Audits will be conducted monthly for three months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations: Based on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage. Findings include: Observation of the facility's main dumpsters located outside near the rear of the building with Employee 9, Dietary Director, on February 8, 2026, at 9:40 AM revealed the following: A trash dumpster had bagged garbage overflowing and a dumpster lid partially ajar due to the overflowing trash. Another dumpster lid was also open with bagged trash visible. There was debris including multiple paper towels observed discarded on the ground A recycling dumpster was overflowing with cardboard. There were three empty boxes for oatmeal creme pies on the ground adjacent to dumpster. A large construction dumpster had paper trash visible near the perimeter of the dumpster. At least two medical gloves were observed discarded on the ground adjacent to dumpster. There were wood shards, an empty beverage can, and paper products discarded adjacent to the dumpster. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:10 PM. 28 Pa. Code 201.14(a) Responsibility of licensee
 Plan of Correction - To be completed: 03/31/2026

1. The dumpsters have been emptied, and the lids are closed. The trash/debris has been removed from the ground adjacent to the dumpsters.

2. A review will be completed of the area where the dumpsters are located to validate that dumpster lids are properly closed, garbage is not overflowing, and there is no debris on the ground adjacent to the dumpsters.

3. Education will be completed with dietary and housekeeping staff related to the proper disposal of garbage and refuse.

4. Audits will be conducted by the Nursing Home Administrator/designee to validate that garbage is disposed of properly. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
§ 201.18(b)(2) LICENSURE Management.:State only Deficiency.
(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.
Observations: Based on closed clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure accurate documentation regarding the disposition of a resident's personal belongings for one of three closed records reviewed (Resident 1). Findings include: Closed clinical record review for Resident 1 revealed nursing documentation dated September 27, 2025, at 4:06 AM that noted the resident will be sent to the emergency room following a change in condition. Closed clinical record review for Resident 1 revealed the resident did not return to the facility after being sent to the emergency room. Closed clinical record review for Resident 1 revealed documentation from staff titled, "Admission Screener," dated September 22, 2025, at 2:10 PM that noted the resident had personal belongings that included clothing, ice packs, and shoes. The documentation did not specify the exact items that were present. Further clinical record review for Resident 1 revealed no documentation (such as a personal belongings inventory sheet) that was completed upon admission to the facility on September 22, 2025, or upon transfer/discharge when the resident was sent to the hospital and did not return. An interview with the Nursing Home Administrator on February 11, 2026, at 9:47 AM revealed that the facility could not find any documentation related to the disposition of Resident 1's belongings.
 Plan of Correction - To be completed: 03/31/2026

1. Resident 1 has been discharged from the facility. No further corrective action can be taken.

2. A review will be completed of residents discharged in the previous 30 days to validate that accurate documentation regarding the disposition of residents' personal belongings is present. Corrective action will be taken as necessary.

3. Education will be completed with licensed nurses related to the requirement to document disposition of resident belongings at the time of discharge.

4. Audits will be conducted by the Director of Nursing/designee to ensure documentation of disposition of personal belongings is present upon a resident's discharge. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026
§ 211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) [Reserved].
Observations: Based on closed clinical record review and staff interview, it was determined that the facility failed to document the actual disposition of medications for one of three discharged residents reviewed (Resident 97). Findings include: Closed clinical record review for Resident 97 revealed nursing documentation dated January 4, 2026, that indicated she had died. Review of Resident 97's medication administration record dated January 2026, revealed that she received the following medications at the time of her death: Metoprolol Tartrate (a medication used to treat high blood pressure) 12.5 milligrams (mg) Remeron (a medication used to treat depression) 30 mg Baclofen (a muscle relaxant) 5 mg Oxycodone (a medication used to treat moderate to severe pain) 5 mg Further closed clinical record review for Resident 97 revealed that the facility could not account for the disposition her Metoprolol Tartrate, Remeron, or Baclofen upon her death. Interview with the Director of Nursing on February 11, 2026, at 1:45 PM confirmed the above noted findings related to Resident 97's medication disposition. The facility failed to provide documentation of the disposition of Resident 97's medications that would include the quantity and method of disposition.
 Plan of Correction - To be completed: 03/31/2026

1. Resident 97 has been discharged from the facility. No further corrective action can be taken.

2. A review will be completed of residents discharged in the previous 30 days to validate that accurate documentation regarding the disposition of residents' medications is present. Corrective action will be taken as necessary.

3. Education will be completed with licensed nurses related to the requirement to document disposition of medications at the time of a resident's discharge.

4. Audits will be conducted by the Director of Nursing/designee to ensure documentation of disposition of medications is present upon a resident's discharge. Audits will be conducted weekly for four weeks and then monthly for two months. Audit results will be submitted to the facility QAPI Committee for review.

5. Date of compliance: 3/31/2026

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