Pennsylvania Department of Health
CHESTNUT HILL LODGE HEALTH AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CHESTNUT HILL LODGE HEALTH AND REHABILITATION CENTER
Inspection Results For:

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CHESTNUT HILL LODGE HEALTH AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a reportable incident completed on January 5, 2026, it was determined that Chestnut Hill Lodge Health and Rehab Center, was not in compliance with the requirements of 42 CFR part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

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.

�483.24(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 review of clinical records, facility schedules, staff interviews, and observations, it was determined that the facility failed to ensure residents were provided bathing and showering services in accordance with their assessed needs and physician orders for six of eight residents reviewed. (Residents R33, R43, R174, R164, R185, R180) Findings include: Review of facility policy titled "ADL Care Bathing (shower, tub, bed, perineal) last reviewed March of 2025, revealed that the facility requires residents be offered bathing or showering at least weekly, based on resident preference and care plan orders. The policy further requires that refusals, missed care, or barriers to providing ADL services be documented and reported to licensed nursing staff. The facility failed to follow its own policy by not offering scheduled showers, inaccurately reporting resident refusals, and failing to document missed care or resident preferences. Review of facility shower schedules and ADL (activities of daily living) documentation for the CD Nursing Unit revealed multiple residents were scheduled to receive showers during the 7:00 a.m. to 3:00 p.m. shift on December 29, 2025, including Residents R172, R43, R174, R164, R185, R69, and R180. Documentation did not reflect that showers were completed as scheduled, nor did it contain documented refusals or clinical justifications for missed care. Observation of the CD Nursing Unit shower room at approximately 11:45 a.m. on December 29, 2025, revealed the shower room was completely dry and being used for storage of floor lifts. There was no evidence that the shower room had been used for resident bathing on that date. During an interview conducted with the Licensed nurse Unit Manager E9, on December 29, 2025, at approximately 11:50 a.m., the surveyor was provided with the shower schedule indicating residents were assigned to receive showers that morning on the 7:00 a.m. to 3:00 p.m. shift. Interview with Nurse aide, Employee E10 on December 29, 2025 at approximately 12:05 p.m. revealed she was preparing to provide Resident R174 with a bed bath at the time of interview and the other residents declined a shower today. Interview with Nursing Aide, Employee E11 at 12:10 p.m. revealed all residents refused showers, and that one resident could not be showered due to having a PICC (central venous) line. Resident interviews contradicted staff statements as follows: Interview with Resident R33 on December 29, 2025, at approximately 11:00 a.m. revealed the resident had not received a shower since admission to the facility three weeks prior.Interview with Resident R43 revealed the resident wanted a shower, had not refused, and stated she was never asked or offered a shower.Interview with Resident R174 revealed the resident wanted to be bathed; during the interview, a CNA was preparing to provide a bed bath.Interview with Resident R164 revealed the resident wanted a shower and stated she had never received one since admission.Interview with Resident R185 revealed the resident wished to receive a shower.Interview with Resident R180 revealed the resident wanted a shower and stated she was never asked or offered one. The resident reported washing herself with wipes due to not being provided shower assistance. 28 Pa. Code 201.20 (a)(5)(6)(b) Staff development 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

483.35(a)(3)(4)(d) REQUIREMENT Competent Nursing Staff:

�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 personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required licensure and certifications for three of three employees reviewed. (Employee E13, Employee E14, Employee E15) Findings include: Review of Facility contract with nursing staffing agency, titled "Schedule A Statement of work ("SOW") #1" dated November 28, 2022, under section 1. Services " d. It is understood and agreed by Facility [nursing staffing agency] only refers candidates for consideration and that the hiring decisions and determinations of suitability, employment eligibility verification and conditions of employment are ultimately the responsibility of Facility." Review of Employee E13's personnel file revealed that Employee E13 was agency employee, hire date of December 16, 2024, working as a Supervisor Registered Nurse. Review of facility investigation revealed on September 14, 2025, it was reported to facility leadership that Employee E13's nursing license was suspended on July 30, 2025. Interview with Employee E2, Director of Nursing confirmed that upon checking the license verification system on September 14, 2025, it was confirmed that Employee E13's registered nursing license was suspended on July 30, 2025. Further interview with Employee E2, Director of Nursing, confirmed that Employee E13 worked 19 shifts between July 30, 2025 and September 14, 2025 in the role of Supervisor Registered Nurse. Interview with Employee E2, Director of Nursing on December 30, 2025 at 10:25am revealed that nurses and staff accepted to work in facility nursing staffing agency have all required documentation (license, background checks, etc) loaded into a portal for facility to review and if a nurse unknown to the facility then Director of Nursing will "usually" confirm license verification via the State Licensing online system. Interview with Employee E1, Nursing Home Administrator on December 20, 2025 at 10:30am revealed that prior to referenced incident, employee licenses and certifications were audited annually as a part of the mock survey process. After referenced incident, facility started new policy for HR Director to maintain a file with a 3 month look ahead with license/ certification expiration dates. However, it did not include agency staff. There was no documented evidence that facility independently verified Employee E13's registered nursing license. Review of Employee E14's personnel file revealed that the employee was full-time employee, hire date of May 22, 2024, working as a nursing Aide. Review of facility investigation revealed that Employee E14, nurse aide certification expired on June 15, 2025. Interview with Employee E1, Nursing Home Administrator on December 20, 2025 at 10:30am confirmed that Employee E14 remained fulltime in facility between June 15, 2025 and October 9, 2025. Review of Employee E15's personnel file revealed that the employee was full-time employee, hire date of February 7, 2024, working as a Nurse aide. Review of facility investigation revealed that Employee E15, nursing assistant certification expired on May 3, 2025. Interview with Employee E15, Nursing Home Administrator on December 20, 2025 at 10:30am confirmed that Employee E15 remained fulltime in facility between May 3, 2025 and October 9, 2025. 28 Pa. Code 201.19(7) Personnel records

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

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Employee E13, E14, E15 have had their licenses updated and/or no longer work at the facility.
2. All residents are risk when licensed/certified staff work without a valid license.
3. Human resources will create a file of license/certification expiration dates for all licensed/certified staff and will review it monthly to identify any staff whose license/certification is due to expire. Staff will be immediately removed from work schedules if the facility does not have a c copy current license/certification by the date of expiration of their license. Numan Resources will work with agencies to ensure the agency staff coming to the facility all have valid licenses/certifications.
4. Human Resource Director will conduct audits monthly x 3 months of the license/certification book to ensure all staff, facility staff, or agency staff, have valid licenses. Results of audits will be reviewed at QAPI.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations: Based on observations, review of facility policy, as well as interview with staff and residents, it was determined that facility did not ensure to honor residents' preferences related to fresh air breaks and activities for two of 33 residents reviewed (Resident R58 and Resident R16). Findings inclide: Review of facility policy 'Activity Programs,' reviewed on April 2025, indicates that "activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident."Further review of policy indicates that "activities offered are based on the comprehensive resident-centered assessment and the interest and preferences of each resident." Interview with Resident R58 on Monday, December 29, 2025, at 11:45 am, revealed that the only residents who are accommodated with fresh air breaks are the ones who smoke. Further interview with R58 revealed that she is non-smoker, and when she attempts to bring up fresh air break times during resident council meetings, the staff who hold meeting do not address her preference. Interview with facility's activities director, employee E3, on Tuesday, December 30, 2025 at 3:00 pm, revealed that facility currently does not offer fresh air breaks to non-smoking residents' due to weather conditions. Review of Resident R16's clinical record revealed resident admitted to facility on February 27, 2020 with diagnosis of TBI (Traumatic Brain Injury), Major Depressive Disorder and Schizophrenia. Review of Resident R16's BIMS (Brief Interview for Mental Status) assessment dated December 30, 2025, resident scored 11, indicating resident is moderately impaired. Interview with Resident R16 on December 29, 2025 at 12:00pm, "We just don't get fresh air unless you are smoking. I feel locked up when I can't go outside, it's terrible. I want to go outside sometimes and they just don't let us." Further interview revealed that resident has expressed this on multiple occasions and "no one listens." 28 Pa Code 211.18(b)(1) Management

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

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1.] Facility is unable to retroactively correct residents R58 and R16 being told they cannot go outside.
2.] All resident's have the possibility to be affected by not being allowed to go outside.
3.]
A.] Activity Staff will be educated on the facility's policy of allowing residents to go outside.
B.] Supervised Fresh Air Breaks will be scheduled for 10:00AM, 1:30PM, and 4:30PM and will be supervised by the Recreation Department.
C.] Resident's will be notified of the Fresh Air Break Times by, notice on the daily activity calendar each resident receives in the room as well as on the monthly activities calendar that is posted on nursing units.

4.] Activities Director, or designee will conduct random audits, weekly x4 weeks then monthly x 2 months of residents to ensure they are being allowed to go outside of the building. Results will be reviewed at the monthly QAPI Meeting.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

�483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

�483.10(f)(6) The resident has a right to participate in family groups.

�483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

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

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1.] A Resident Council Meeting was held to get a current list of resident concerns.
2.] All residents are at risk to be affected if concerns raised in resident council are not documented and followed through the facility grievance process.
3.] NHA will educate Activities Director on how to take proper minutes for resident council and how to ensure concerns raised during resident council are followed up on and documented through the grievance process and noted in the resident council meeting minutes.
4.] NHA or designee will conduct audits, monthly x 3 months, of Resident Council Meeting Minutes to ensure that all concerns are addressed and documented through the grievance process. Results of audits will be reported at the monthly QAPI meeting

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

�483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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

Observations: Based on clinical record review, staff interviews, and incident/accident documentation, the facility failed to demonstrate that it conducted a thorough, timely, and documented investigation into an allegation of misappropriation of resident property, for one of 33 residents reviewed. (Resident R70) Findings include: Review of the facility's policy titled "Incident Reporting and Investigation of Accident Hazards, Supervision, Assistive Devices" last reviewed October 2025 revealed the facility requires that all incidents and adverse occurrences be fully, timely, and thoroughly investigated until a clear conclusion is reached. An investigation is considered incomplete if required information, documentation, analysis, or approvals are missing. Key points related to incomplete investigations include: Immediate initiation is mandatory: All incidents involving injury, abuse, neglect, mistreatment, or unknown origin must be reported immediately to the DON and Administrator, and an investigation must begin without delay.Comprehensive data collection is required: Incomplete investigations may result from missing incident reports, unsigned or unreviewed witness statements, lack of resident assessments, missing timelines, or failure to identify all parties involved. The policy requires collection of factual witness statements, environmental observations, resident assessments, and supporting documentation.Required review and oversight: Incident reports and investigations must be reviewed by supervisory staff (Unit Manager, DON, ADON, NHA). Failure to obtain required reviews, signatures, or approvals (including regional or executive approval for reportable events) renders the investigation incomplete.Analysis and conclusions must be documented: An investigation is not complete unless it includes documented conclusions addressing:How the incident occurredWhy it occurred (if determinable)Whether it was preventableRoot cause analysis, when possibleFollow-up actions are required: Immediate corrective actions, care plan revisions, and prevention measures must be documented. Missing or unimplemented corrective actions indicate an incomplete investigation.Additional investigation when needed: If facts are insufficient, abuse is suspected, or reasonable cause cannot be established, the policy requires continued investigation, additional statements, and escalation to the DON, Administrator, and appropriate agencies.Final review and closure: Investigations must be finalized, signed, logged, and trended. Incomplete investigations may occur if documentation is not returned for final review, not forwarded for required signatures, or not included in tracking and QAPI review.Review of documentation reported to the State Survey Agency relate to Resident R70 misappropriation of resident property, revealed that the resident contacted social services on December 8, 2025 and notified the Social Service Director that on November 24, 2025, someone came into a room claiming to be a social worker and took her debit card an ID and had her sign some forms. Resident R33 reported that she received a notification on November 26, 2025 from her bank stating that they suspected fraudulent activity. Resident claims $400 was spent out of her account. In conclusion, the bank has reimbursed the money to her account and issued her new card, an investigation was started, the police and Protective Services were contacted. Continued review of reported incident revealed Resident R70 could not identify the person that came into a room only that it was a female and wore a business suit. The Nursing Home Administrator (NHA), Employee E1 instructed staff who do not dress in scrubs to visit this resident while rounding on December 9, 2025 and December 10, 2025. The resident did not recognize any of the employees. Review of the facility's investigation included a police report, the statement of Resident R33 to Social Services, and the Social Services initial assessment of Resident R70, which indicated the resident scored 15 on the BIMS (brief interview of mental status), reflecting intact cognition. The facility concluded that the NHA, Employee E1 was unable to substantiate that the purchase on the resident's card resulted from someone taking it while at the facility, noting that the resident could not provide a description of the alleged individual or identify anyone involved. The investigationdid not include interview with other potential witnesses. Interview with NHA, Employee E1, on January 5, 2025, at approximately 9:00 a.m., acknowledged that the resident reported money missing and initially alleged that an individual presenting as a facility employee entered her room and took her funds. Employee E1 stated that the resident's account changed multiple times, including claims that the withdrawals occurred outside the facility, possibly related to a motel stay prior to admission, and later speculation that the individual may not have been a facility employee. NHA, Employee E1 further stated that the facility did not have further involvement because law enforcement and the bank would not release additional information without a subpoena. He believed the incident did not occur within the facility. Based on the resident's changing descriptions, he informally showed the resident several staff members who might match her description but stated the resident was unable to identify anyone. He acknowledged that the resident could not consistently describe the alleged individual and that no staff member matched the description provided. Employee E1 confirmed that while he spoke generally with staff and followed up with the resident, there was no clear documentation of a comprehensive internal investigation, including: A documented timeline of events,Review of staff schedules and sign-in logs,Interviews with other residents on the unit,Identification of potential witnesses,Documentation of investigative findings and conclusions.28 Pa. Code 201.18(b)(3) Management

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:

�483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

�483.20(b) Comprehensive Assessments
�483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

�483.20(b)(2) When required. Subject to the timeframes prescribed in �413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in �413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.

Observations: Based on observation, clinical record review, and staff interview, the facility failed to ensure a comprehensive assessment was completed upon admission for one of eight residents reviewed. (Resident R 175) Findings include: Review of Resident R175's admission Minimum Data Set (MDS- assessment of resident care needs) dated December 17, 2025, revealed that the resident entered the facility on December 11, 2025, with diagnosis including orthopedic conditions, malnutrition, diabetes (failure of the body to produce insulin), and respiratory failure. Resident R175's functional abilities were assessed as independent with supervision and the use of a wheelchair and a walker. The resident's brief interview of mental status (BIMs) was 14 indicating intact cognition and the resident is noted to have severely impaired vision with no corrected lenses. Interview with resident on December 29, 2025, approximately 11:00 AM revealed resident has concerns of not being cared for (her/his) blindness stating that there's no interventions for (her/his) blindness. The resident stated that (she/he) was independent but cannot see and had difficulty and needed some assistance. The nurses leave the medications on the overside bed tray and (she/he) can't see them. Review of Resident R 175's clinical record primary diagnosis did not include any visual deficit or legal blindness. Interview with Registered Nurse Assessment Coordinator, Employee E5 confirm that Resident R175 was legally blind and confirmed that it was not coded on the diagnosis list of the MDS. 28 Pa. Code 211.12(d)(1)(5) Nursing services

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

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident 175 had her assessment completed to reflect legal blindness.
2. RNAC department has conducted an audit of all residents that have been admitted within the last 30 days diagnosed with legal blindness, to ensure a complete assessment was completed to reflect the diagnosis.
3. RNAC's will be educated on making sure that residents diagnosed with legal blindness have their assessments completed to reflect their diagnosis on admission.
4. DON or designee will conduct audits weekly x4 weeks then monthly by 2 months of all newly admitted residents to ensure that those residents with a diagnosis of legal blindness have their assessments completed to reflect the diagnosis. Results will be reviewed at the QAPI meetings.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

�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 review of clinical records, review of facility policy and interview with staff and residents, it was determined that facility failed to develop and implement a comprehensive resident centered care plan for three of 33 residents reviewed. (Residents R69, and R175) Findings include: Review of the facility policy titled "Care Planning Process and Care Conference," last reviewed May2025, revealed the facility is required to develop and implement a comprehensive, resident-centered interdisciplinary care plan based on each resident's assessed needs, diagnoses, and functional limitations. The policy requires the care plan to be initiated upon admission and updated following completion of the comprehensive assessment, with revisions made for any change in the resident's condition. The policy further requires the facility to identify and care plan for each resident's diagnoses and impairments, including visual deficits or blindness, and to develop individualized, measurable goals with specific interventions. Each identified care plan problem must include assigned responsible disciplines, target dates, and interventions designed to promote resident safety, independence, and quality of life. An interdisciplinary team must develop the comprehensive care plan within 21 days of admission, and all staff are required to provide care in accordance with the care plan. Failure to assess, develop, implement, or revise care plans to address identified diagnoses, such as visual impairment or blindness, is inconsistent with facility policy and the requirements. Review of Resident R175's clinical record revealed that the resident was admitted to the facility on December 11, 2025, with diagnosis including orthopedic conditions, malnutrition, diabetes (failure of the body to produce insulin), and respiratory failure. Resident R175's functional abilities were assessed as independent with supervision and the use of a wheelchair and a walker. The resident's brief interview of mental status (BIMs) was 14 indicating intact cognition and the resident is noted to have severely impaired vision with no corrected lenses. Interview with resident on December 29, 2025, approximately 11:00 AM revealed resident has concerns of not being cared for (her/his) blindness stating that there's no interventions for (her/his) blindness. The resident stated that (she/he) was independent but cannot see and had difficulty and needed some assistance. The nurses leave the medications on the overside bed tray and (she/he) can't see them. Review of Resident R175's care plan did not include a specific problem, goal, or individualized interventions addressing legal blindness. Interview with the Unit Manager Nurse, Employee E9 on January 4, 2026, confirmed the resident is legally blind and confirmed the care plan does not specifically address the resident's visual impairment or include interventions to improve safety and comfort related to blindness. Review of Resident R69's clinical record revealed medical diagnosis of cerebral infarction (stroke), hemiplegia (paralysis) affecting right nondominant side, need for assistance with personal care. Observations of Resident R69 on December 29, 2025, at 10:30 am, revealed resident laying on his right side with right arm underneath him. Interview with facility's Rehabilitation Director, Employee R4, on Friday, January 2, 2026 at 11:30 am, revealed that Resident R69 was to have pillow prop up in bed under right upper extremity. Review of occupational therapy notes, dated December 3, 2025, indicated that "Clinician provided education regarding wearing R (right) sling when in therapy or out of bed for increased comfort." Review of R69's care plan revealed no evidence of interventions related to pillow and sling provision for resident's comfort. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12 (c) (d)(1)(3)(5) Nursing services

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

This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident 69 care plan was completed to reflect right arm paralysis.
2. DON has conducted an audit of all residents with Arm paralysis to ensure they have care plans in place.
3. Nursing staff will be educated on implementing appropriate care plans on admission/readmission/change in status.
4. DON or designee will conduct audits weekly x4 weeks then monthly x2 months of all newly admitted residents that have arm paralysis to ensure they have care plans implemented timely. Results will be reviewed at the QAPI meetings.

1 Resident 175 had her care plan completed to reflect legal blindness.
2 DON has conducted an audit of all residents with a diagnosis of blindness to ensure they have care plans in place.
3 Nursing staff will be educated on facility policy for implementing care plans.
4 DON or designee will conduct audits weekly x4 weeks then monthly x2 months of all newly admitted residents with a diagnosis of Legal Blindness to ensure that they have care plans implemented timely. Results will be reviewed at the QAPI meetings.

483.25 REQUIREMENT Quality of Care:

� 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.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

�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 facility provided documentation, review of clinical records and interview with staff, it was determined facility did not ensure to complete medication regimen reviews according to professional standards of practice for two of five residents reviewed (Residents R3, and R8) Findings include: Review of facility policy 'Medication Regimen Review,' reviewed in May 2025, indicates that "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." Review of facility provided 'Consultant Pharmacist's Medication Regimen Review,' for recommendations created between August 1, 2025, and August 6, 2025, revealed that dose reduction was recommended for Resident R3 related to Abilify prescription. Further review of 'Consultant Pharmacist's Medication Regimen Review,' revealed no evidence of physician rationale for Resident R3. Review of Consultant Pharmacist's Medication Review Regimen, for recommendations created between July 1, 2025, and July 16, 2025, revealed recommendation for Resident R8, stating " Federal Guidelines necessitate review and possible attempts at psychoactive dose reduction. Please review this resident's Lexapro order considering if the resident is a candidate for decrease in dose. Possible responses to circle: 1. After review and assessment the benefit to the resident outweighs any observed risk. No reduction at this time. 2. The resident's condition warrants the following dosage reduction (see order below). 3. The resident's current condition warrants further increase or change in therapy (see order below). Further review of this "Consultant Pharmacist's Medication Review Regimen" revealed Physician/ Prescriber disagreed with recommendation, however provided no rationale. Review of Consultant Pharmacist's Medication Review Regimen, for recommendations created between August 1, 2025, and August 6, 2025, revealed recommendation for Resident R8, stating " Federal Guidelines necessitate review and possible attempts at psychoactive dose reduction. Please review this resident's Risperdal order considering if the resident is a candidate for decrease in dose. Possible responses to circle: 1. After review and assessment the benefit to the resident outweighs any observed risk. No reduction at this time. 2. The resident's condition warrants the following dosage reduction (see order below). 3. The resident's current condition warrants further increase or change in therapy (see order below). Further review of this "Consultant Pharmacist's Medication Review Regimen" revealed Physician/ Prescriber disagreed with recommendation, however provided no rationale. Interview with Employee E7, Medical Director confirmed findings. 28 Pa Code 211.9(k) Pharmacy services 28 Pa Code 211.12(d)(3) nursing services

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

�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 observation, review of facility policy and procedures and interviews with residents and staff, it was determined that the facility failed to maintain an effective infection control program related to water cup distribution for three of 33 residents observed. (Resident R8, Resident R121 and Resident R18) Findings include: Review of "Water Pitcher Pass/ cleaning" review date April 2025, revealed that "Styrofoam cups will be replaced nightly on 11-7 shift. Cups should be labeled with date of placement." Continued review revealed "Nursing staff will fill water pitchers/Styrofoam cups with ice and fresh water placing them at bedside." Interview with Resident R8 on December 29, 2025, at 10:30am, revealed resident doesn't feel like she gets offered enough water and they always use the same cup and fill it at the bathroom sink. Observation of Resident R8's Styrofoam water cup on bedside table on December 29, 2025, at 10:30am, revealed that cup was labeled with a date of December 18, 2025, 11p-7a. Interview with Resident R121 on December 29, 2025, at 10:30am, revealed that cups get filled in the bathroom sink when requesting water and cups do not get replaced often. Observation of Resident R121's Styrofoam water cup on bedside table on December 29, 2025, at 10:35am, revealed that cup was labeled with a date of December 26, 2025, 11p-7a. Interview with Employee E12, Nursing Assistant on December 29, 2025, at 10:45am, confirmed findings and stated, "I don't know what happened, I am agency, but I think cups are supposed to be changed every night shift." Interview with Resident R18 on December 29, 2025, at 10:55am, revealed concerns related to water cups filled in bathroom sink of shared resident bathroom and that resident was disgusted by this. 28 Pa Code 211.12 (d)(1)(5) Nursing services

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