Pennsylvania Department of Health
EMBASSY OF SAXONBURG
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF SAXONBURG
Inspection Results For:

There are 133 surveys for this facility. Please select a date to view the survey results.

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


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

Initial comments:Based on an Abbreviated Survey in response to nine complaints, completed on June 30, 2026, it was determined that the Embassy of Saxonburg was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

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

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

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

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

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

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

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

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

Plan of Correction - To be completed: 07/15/2026

1. Interim Director of Nursing is no longer present at the facility.

2. Regional Director of Operations and Regional Director of Clinical Services held meetings with staff members to ensure they know they have the right to call Department of Health, they will not be retaliated against for voicing their concerns, internally or to external agencies, and that the culture in the facility is going to shift.

3. Agency staff were deployed to the facility to assist with staffing needs. Recruitment efforts to hire qualified nursing staff have increased.

4. Nursing Home Administrator and Director of Nursing will be educated by the Director of Operations on following the facility handbook and discipline policy, retaliation, and grounds for termination, including that the Regional Human Resources is to be consulted prior to any terminations for review of documentation and approval of termination.

5. Nursing Home Administrator, Director of Nursing, and Social Services Director will be educated on not interrupting surveyor while in the facility, respecting the privacy of employee/surveyor interview process.

6. Monthly staffing meetings will be held with all staff, facilitated by the Nursing Home Administrator and Director of Nursing, to ensure staff have an open platform to express concerns or suggestions.

7. Audits will be completed by Regional Human Resources via interviewing five employees per week for one month to ensure staff feel they are able to voice concerns without fear of retaliation.

8. Audits will be reviewed during facility QAPI meetings for further actions, suggestions, and recommendations.

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

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

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

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

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

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

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

Observations: Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to make certain that medical records on each resident are completely and accurately documented. Findings Include: Review of the "Medication Administration Audit Report" for 6/11/26, indicated Licensed Practical Nurse (LPN) Employee E2 provided the following medications and treatments between 2:00 p.m. and 4:00 p.m. -83 oral medications -2 topical medications -7 injected medications -1 intravenous medication -6 inhaled medications -4 ophthalmic medications -4 blood sugar assessments -8 nutritional supplements provided -1 tuberculosis test assessed -29 pain assessments -6 skilled nursing assessments -3 whole body skin assessments -2 vital sign assessments -1 weight assessment During an interview on 6/25/26, at 12:50 p.m. LPN Employee E1 confirmed she did not provide all of the medications and treatments. LPN Employee E2 stated LPN Employee E3 had also provided some of the medications and treatments. LPN Employee E2 stated that she was told by the former Director of Nursing to "just sign off on them since they were given." LPN Employee E2 stated, "I did what I was told to do. Who am I to question the Director of Nursing?" During an interview on 6/25826, at 10:06 a.m. the Medical Director confirmed that she was not notified by facility staff about medications not being received on 6/11/26. During an interview on 6/25/26, at approximately 1:30 p.m. the Nursing Home Administrator and the Regional Director of Operations confirmed that the facility failed to make certain that medical records on each resident are completely and accurately documented. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Plan of Correction - To be completed: 07/15/2026

1. The facility cannot retroactively correct this deficiency.

2. An audit using the Medication Administration Report will be completed on the last seven days to identify concerns with Medication Administration and documentation.

3. Education will be completed with licensed nurses by the Director of Nursing, or designee, on the five rights of medication administration with emphasis on proper documentation.

4. MAR reports will be run five days per week for two weeks, then twice per week for two weeks by the Director of Nursing, or designee. Any missing documentation, refusals, will be noted on audit, followed up on, and appropriate steps will be taken including: assessment of resident, notification to physician, re-education of staff and/or progressive discipline if warranted.

5. Audits will be reviewed during facility QAPI meetings for further actions, suggestions, and recommendations.

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

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

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

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

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

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

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

Plan of Correction - To be completed: 07/15/2026

1. The facility cannot retroactively correct this deficiency.

2. An audit using the Medication Administration Report will be completed by the Director of Nursing, or designee, for the last seven days to identify concerns with Medication Administration and documentation.

3. Education will be completed by the Director of Nursing, or designee, with licensed nurses on the Medication Administration Policy, including notifying physician of missed medications and refusals.

4. MAR reports will be run five days per week for two weeks, then twice per week for two weeks by the Director of Nursing, or designee. Any missing documentation, refusals, will be noted on audit, followed up on, and appropriate steps will be taken.

5. Audits will be reviewed during facility QAPI meetings for further actions, suggestions, and recommendations.

§483.35(a)(1)(2) REQUIREMENT Sufficient 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) Sufficient Staff.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:

(i) Except when waived under paragraph (e) of this section, licensed nurses; and

(ii) Other nursing personnel, including but not limited to nurse aides.

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

Plan of Correction - To be completed: 07/15/2026

1. The facility cannot retroactively correct this deficiency.

2. The facility is making all attempts at recruiting qualified nursing staff. Onsite job fair, open interviews, and increased recruitment efforts are being made. Agency is being utilized to supplement facility staffing.

3. Education will be completed with the Nursing Home Administrator, Director of Nursing, and staff scheduler on consistent staffing, monitoring of PPD and ratios, and ensuring staff assignments are conducive to completing resident care needs.

4. Daily staffing meetings will be held by the Nursing Home Administrator and Director of Nursing. At this time, staffing will be reviewed and an action plan will be developed to fill needs. Sign in sheet for meetings will be kept.

5. Audits on staffing will be completed by using the DOH staffing calculator, to be completed by the Nursing Home Administrator five days per week, ongoing.

6. Audits will be reviewed during facility QAPI meetings for further actions, suggestions, and recommendations.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations: Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of five residents (Resident R6, R16, R26, and R44). Findings include: The facility policy "Pressure Ulcer Prevention and Management" dated 3/13/26, indicated the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Review of the clinical record indicated Resident R6 was admitted to the facility on 12/1/20. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/22/26, included diagnoses of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), multiple sclerosis (a disease that affects central nervous system), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Section M: Skin Conditions, indicated Resident R6 was at risk of pressure ulcer development, and at the time of the assessment had one Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) and two Stage III pressure ulcers (full-thickness skin and tissue loss). Review of Resident R6's Braden Scale assessments dated 4/25/26, indicated Resident R6 was at high risk for pressure ulcer development. Assessment completed on 6/5/26, indicated Resident R6 was at low risk for pressure ulcer development. Review of a wound nurse practitioner report dated 6/23/26, revealed the presence of a Stage IV pressure ulcer on the right ischium, a Stage IV pressure ulcer on the coccyx, and a Stage III pressure ulcer on the left ischium. Review of physician orders dated 4/29/26-6/2/26, 6/5/26-6/9/26, and 6/10/26, indicated for staff to cleanse and reapply a dressing to Resident R6's coccyx wound daily. Review of the Treatment Administration Record (TAR) for May and June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R6 was present in the facility for all dates, no refusals of wound care documented): 5/2/26, 5/5/26, 5/12/26, 5/19/26, 6/2/26, 6/9/26, 6/11/26, 6/13/26, 6/17/26, 6/22/26, and 6/26/26. Review of physician orders dated 4/29/26-6/2/26, 6/5/26-6/9/26, indicated for staff to cleanse and reapply a dressing to Resident R6's posterior thigh wounds daily. Orders dated 6/10/26, indicated to cleanse left thigh and reapply a dressing and to cleanse right ischium and reapply a dressing. Review of the TAR for May and June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R6 was present in the facility for all dates, no refusals of wound care documented): 5/2/26, 5/5/26, 5/12/26, 5/19/26, 6/2/26, 6/9/26, 6/11/26, 6/13/26, 6/17/26, 6/22/26, and 6/26/26. Review of the clinical record indicated Resident R16 was admitted to the facility on 5/16/26. Review of the MDS dated 5/21/26, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and muscle wasting. Review of Section M: Skin Conditions, indicated Resident R16 was at risk of pressure ulcer development, and at the time of the assessment had no pressure ulcers. Review of Resident R16's Braden Scale assessments dated 6/7/26, indicated Resident R16 was at moderate risk for pressure ulcer development. Review of a wound nurse practitioner report dated 6/23/26, revealed the presence of a facility acquired Stage III pressure ulcer on the left buttock, a Stage III facility acquired pressure ulcer on the right buttock, and an unstageable (obscured full-thickness skin and tissue loss) pressure ulcer on the coccyx. Review of physician orders dated 6/3/26-6/14/26, indicated for staff to cleanse and reapply a dressing to Resident R16's left and right buttocks wounds daily. Review of physician orders dated 6/17/26, indicated for staff to cleanse and reapply a dressing to Resident R16's left and right buttocks wounds every other day. Review of the TAR for June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R16 was present in the facility for all dates, no refusals of wound care documented): Documentation on 6/10/26, 6/11/26. 6/5/26, was coded to view the progress note. Review of the associated progress notes failed to indicate if the dressing change was completed. Review of the clinical record indicated Resident R26 was admitted to the facility on 1/15/24. Review of the MDS dated 4/21/26, included diagnoses of multiple sclerosis, high blood pressure, and neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination). Review of Section M: Skin Conditions, indicated Resident R6 was at risk of pressure ulcer development, and at the time of the assessment had one Stage IV pressure ulcer and two Stage III pressure ulcers. Review of Resident R26's Braden Scale assessments dated 5/14/26, indicated Resident R26 was at moderate risk for pressure ulcer development. Review of a wound nurse practitioner report dated 6/23/26, revealed the presence of a Stage IV pressure ulcer on the coccyx. Review of a physician order dated 4/22/26-5/14/26, indicated for staff to cleanse and reapply a dressing to Resident R6's coccyx wound daily. Review of physician orders dated 5/14/26-5/26/26, indicated for staff to cleanse and apply a wound vac dressing to Resident R6's coccyx wound daily. Review of a physician order dated 5/27/26-6/10/26, 6/10/26-6/17/26, 6/17/26-6/24/26, indicated for staff to cleanse and reapply a dressing to Resident R6's coccyx wound daily. Review of the TAR for May and June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R26 was present in the facility for all dates, no refusals of wound care documented): 5/5/26, 5/12/26, 5/14/26, 5/19/26, 5/26/26, 5/28/26, 6/1/26, 6/4/26, 6/10/26, 6/11/26, and 6/24/26. Documentation on 5/1/26, 5/16/26, 5/29/26, 6/20/26, was coded to view the progress note. Review of progress note dated 5/1/26, at 1:01 p.m. indicated Resident R26 was out for an appointment. No further notes indicated if the dressing change was completed upon her return. Review of the associated progress note dated 5/16/26, at 11:55 a.m. indicated Resident R26 was out of bed. No further notes indicated if the dressing change was completed. Review of the associated progress note dated 5/29/26, at 1:47 p.m. indicated "Not able to get to it this shift." Review of the associated progress note on 6/20/26 failed to indicate if the dressing change was completed. Review of the clinical record indicated Resident R44 was admitted to the facility on 11/17/20. Review of the MDS dated 5/5/26, included diagnoses of lymphedema (the build-up of fluid in soft body tissues), high blood pressure, and coronary artery disease (CAD, damage or disease in the heart's major blood vessels). Review of Section M: Skin Conditions, indicated Resident R6 was at risk of pressure ulcer development, and at the time of the assessment had three Stage II (Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis) pressure ulcers. Review of Resident R44's Braden Scale assessments dated 4/28/26, indicated Resident R44 was at low risk for pressure ulcer development. Review of a wound nurse practitioner report dated 6/23/26, revealed the presence of two facility acquired Stage II pressure ulcers on the right thigh. Review of physician orders dated 5/13/26-6/17/26, indicated for staff to cleanse and reapply dressings to Resident R44's left and right daily. Review of physician orders dated 6/17/26, indicated for staff to cleanse and reapply dressings to Resident R44's left and right twice daily. Review of the TAR for May and June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R44 was present in the facility for all dates, one refusal of wound care documented was documented on 6/8/26): 5/14/26, 5/21/26, 5/22/26, 5/25/26, 5/28/26, 5/29/26, 6/11/26, 6/13/26, 6/14/26, 6/15/26, 6/18/26 daylight, 6/21/26 evening, 6/22/26 evening. Documentation on 6/20/26, was coded to view the progress note. Review of the associated progress note on 6/20/26 failed to indicate if the dressing change was completed. During an interview on 6/25826, at 10:06 a.m. the Medical Director confirmed that she was not notified by facility staff about wound treatments not being completed. During an interview on 6/25/26, at approximately 1:30 p.m. the Regional Director of Operations and the Nursing Home Administrator confirmed the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of five residents. 28 Pa. Code: 211.10(c)(d) Resident Care Policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 07/15/2026

1. The facility cannot retroactively correct this deficiency.

2. An audit of treatment records for the last thirty days will be completed by the Regional Director of Clinical Services.

3. Education will be completed by the Director of Nursing, or Designee, with all licensed staff on completing treatments as ordered, notifying the physician of refusals.

4. TAR reports will be run five days per week by the Director of Nursing, or designee. Audit on these TAR reports will be completed five times per week for two weeks, then twice per week for two weeks. Any missing documentation, refusals, will be noted on audit, followed up on, and appropriate steps will be taken. Steps include reassessment of the resident, notification to physician, re-education of staff identified and/or progressive discipline of staff if warranted.

5. Audits will be reviewed during facility QAPI meetings for further actions, suggestions, and recommendations.

483.10(b)(3)-(7)(i)-(iii) REQUIREMENT Rights Exercised by Representative:

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(b)(3) In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated.
(i) The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the representative.
(ii) The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law.

§483.10(b)(4) The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law.

§483.10(b)(5) The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law.

§483.10(b)(6) If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns when and in the manner required under State law.

§483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident's behalf. The court-appointed resident representative exercises the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law.
(i) In the case of a resident representative whose decision-making authority is limited by State law or court appointment, the resident retains the right to make those decisions outside the representative's authority.
(ii) The resident's wishes and preferences must be considered in the exercise of rights by the representative.
(iii) To the extent practicable, the resident must be provided with opportunities to participate in the care planning process.

Observations: Based on review of facility provided documents, clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's legal surrogate (power of attorney) was provided access to medical records for one of two residents (Resident R51). Findings include: Review of the clinical record revealed that Resident R51 was admitted to the facility on 5/13/25. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 12/10/25, included diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), anemia (too little iron in the body causing fatigue), and history of a stroke. Review of information submitted to the state survey agency on 6/12/26, indicated that a request for patient health information was submitted on 12/19/25. "We reached out to the custodian on 12/31/2025. The custodian submitted incomplete records on 01/04/2026.From 01/21/2026 through 05/26/2026, we made multiple attempts to contact the custodian via phone calls, voicemails, and a HIPAA (Health Insurance Portability and Accountability Act of 1996) Violation Notice. Despite these efforts, the requested records remain outstanding. To date, the [facility] still has not released the records without any valid justification for such delay." Review of Resident R51's electronic medical record failed to reveal information related to the request for medical records. Review of an electronic communication dated 6/24/26, at 12:16 p.m. indicated the facility closed record failed to reveal information related to the request for medical records. During an interview on 6/25/26, at approximately 1:20 p.m. the Regional Director of Operations confirmed the request was received by a previous Nursing Home Administrator. The Regional Director of Operations confirmed the facility's legal department approved the release of information, but that the medical records had not been provided to the requestor by the facility. During an interview on 6/25/26, at approximately 1:30 p.m. the Regional Director of Operations and the Nursing Home Administrator confirmed the facility failed to ensure that a resident's legal surrogate (power of attorney) was provided access to medical records for one of two residents. 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2)(3) Management.

Plan of Correction - To be completed: 07/15/2026

1. R51 Medical Records request obtained from legal team. Records will be sent to requestor.

2. An audit will be completed by the Nursing Home Administrator, or designee, on the last 60 days to ensure any medical records requests received were followed up on.

3. Education will be completed by the Regional Director of Operations with the Nursing Home Administrator on timely completion of Medical Records Requests. Nursing Home Administrator will re-educate Social Services on filling medical records requests timely.

4. An audit on medical records requests will be completed by the Regional Director of Operations one time per week for one month to ensure requests are followed up on timely.

5. Audits will be reviewed during facility QAPI meetings for further actions, suggestions, and recommendations.

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

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§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 review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for six of 24 residents (Resident R3, R6, R27, R15, R17, R20, and R37). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, and annual MDS assessment was to be completed no later than Assessment Reference Date (ARD). Resident R3 had an admission date of 4/20/26, with an MDS completion date of 5/15/26. Resident R6 had an Annual MDS ARD of 4/22/26, with an MDS completion date of 5/13/26. Resident R15 had an Annual MDS ARD of 4/2/26, with an MDS completion date of 6/4/26. Resident R17 had an admission date of 3/20/26, with an MDS completion date of 4/3/26. Resident R20 had an Annual MDS ARD of 4/22/26, with an MDS completion date of 5/13/26. Resident R37 had an admission date of 4/6/26, with an MDS completion date of 4/21/26. During an interview on 6/23/26, at approximately 5:30 p.m. the Regional Director of Operations confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for six of 24 residents. 28 Pa. Code: 211.5(f) Clinical records.

Plan of Correction - To be completed: 07/15/2026

1. The facility cannot retroactively correct this deficiency.

2. An audit of the last thirty days of MDS's will be completed by the Regional Director of Operations to ensure MDS were submitted within the required timeframe.

3. Education will be completed by the Regional Director of Operations with IDT members on timely completion of their assessments for MDS and with the RNACs for timely submission of MDS's, within the required timeframe.

4. An audit on MDS completion and timely submission will be completed by the Regional Director of Operations weekly for one month.

5. Audits will be reviewed during facility QAPI meetings for further actions, suggestions, and recommendations.

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

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations: Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 15 of 18 days (6/4/26, 6/5/26, 6/6/26, 6/7/28, 6/10/26, 7/11/26, 6/13/26, 6/14/26, 6/15/26, 6/16/26, 6/17/26, 6/18/26, 6/19/26, and 6/21/26). Findings include: Review of the nursing schedules and census information for 6/4/26, through 6/21/26, revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates: -6/04/26, Census 58. PPD 2.99. -6/05/26, Census 58. PPD 2.93. -6/06/26, Census 57. PPD 2.69. -6/07/26, Census 57. PPD 2.96. -6/10/26, Census 59. PPD 3.07. -6/11/26, Census 59. PPD 2.93. -6/12/26, Census 56. PPD 2.74. -6/13/26, Census 56. PPD 2.82. -6/14/26, Census 56. PPD 2.88. -6/15/26, Census 56. PPD 2.75. -6/16/26, Census 56. PPD 2.91. -6/17/26, Census 58. PPD 2.71. -6/18/26, Census 58. PPD 2.79. -6/19/26, Census 58. PPD 2.78. -6/21/26, Census 58. PPD 2.99. During an electronic interview on 6/25/25, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 15 of 18 days.

Plan of Correction - To be completed: 07/15/2026

1. The facility cannot retroactively correct this deficiency.

2. The facility is making all attempts at recruiting qualified nursing staff. Onsite job fair, open interviews, and increased recruitment efforts are being made. Agency is being utilized to supplement facility staffing.

3. Education will be completed with the Nursing Home Administrator, Director of Nursing, and staff scheduler on meeting the regulatory PPD of 3.2 daily.

4. Daily staffing meetings will be held by the Nursing Home Administrator and Director of Nursing. At this time, staffing will be reviewed and an action plan will be developed to reach minimum PPD of 3.2. Sign in sheet for meetings will be kept.

5. Audits on staffing will be completed by using the DOH staffing calculator, to be completed by the Nursing Home Administrator, or designee, five days per week for two weeks then two days per week for two weeks.

6. Audits will be reviewed during facility QAPI meetings for further actions, suggestions, and recommendations.

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