Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT CAMPBELLTOWN
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT CAMPBELLTOWN
Inspection Results For:

There are 168 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.


KADIMA REHABILITATION & NURSING AT CAMPBELLTOWN - 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 January 22, 2026, it was determined that Kadima Rehabilitation and Nursing at Campbelltown 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 facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food under sanitary conditions in the kitchen.

Findings include:

Review of the facility policy entitled, "Food Preparation and Sanitation," last reviewed July 21, 2025, revealed that all staff were to practice proper hand hygiene and glove use. Hands were to be washed and gloves were to be changed in between switching tasks and after touching potentially contaminated surfaces.

Observations in the kitchen on January 20, 2026, at 10:15 a.m., revealed the following:

In the walk-in refrigerator, there was an open jar of fruit salad dated December 29, 2025, with a use by date of January 3, 2026.

The inside of the microwave oven was soiled with yellow and brown colored substances. There was an accumulation of food particles and grease on top and on the side of the ovens. The outside of the toaster was soiled with a brown colored substance and had an accumulation of food particles on the rolling rack. There was a plastic container of flour that was not labeled.

In the food preparation area: There was an opened bottle of ground ginger dated July 11, 2024, with a use by date of May 3, 2025. There was an opened bottle of thyme leaves dated July 11, 2024, with a use by date of November 1, 2025. There was an opened bottle of ground basil dated July 15, 2024, with a use by date of May 3, 2025. There was an opened bottle of parsley flakes dated June 27, 2024, with a use by date of December 27, 2024.

Observation of the tray line service on January 20, 2026, at 12:18 p.m. revealed the following:

Dietary Aide (DA) 1, was observed using gloved hands while assembling resident meals on tray line. DA 1 then left the tray line while wearing the same gloves, obtained cheese from the compact mini refrigerator located below the tray line, and prepared a cheeseburger for a resident tray. DA 1 then returned to the tray line and continued to assemble resident meal trays. DA 1 did not change gloves or perform hand hygiene between tasks.

In an interview on January 21, 2026, at 12:00 p.m., the Food Manager confirmed that DA 1 should have changed gloves between tasks.

CFR 483.60(i) Food Safety Requirement
Previously cited 6/6/25

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

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

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

1.The facility immediately discarded all expired and improperly labeled food items identified in the kitchen, walk-in refrigerator, and food preparation areas. All food contact surfaces, equipment, and appliances (including microwave, ovens, and toaster) were cleaned and sanitized. The dietary aide observed not following proper hand hygiene and glove use was reeducated.

2. A baseline audit of all food storage areas, refrigeration units, and food preparation spaces was completed to identify expired items, improper labeling, and sanitation concerns.

3. Dietary staff were re-educated on the facility's Food Preparation and Sanitation policy, including proper hand hygiene, glove use, changing gloves between tasks, food labeling, and sanitation of equipment and surfaces.

4. Random audits of dietary food storage areas, food preparation spaces, and proper hand hygiene with use of gloves will be completed weekly for four (4) weeks and then monthly for two (2) months to ensure sustained compliance. Audit results will be documented and reviewed through the facility's QAPI process.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:

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) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.

Observations:
Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (showering) for three of 13 sampled residents. (Residents 6, 14, 46)

Findings include:

Clinical record review revealed that Resident 6 had diagnoses that included depression and anxiety. Review of the Minimum Data Set (MDS) assessment dated November 11, 2025, revealed that the resident had no cognitive impairment. Review of nurse aide documentation revealed that Resident 6 was to receive a shower every Monday on evening shift and staff were to notify the nurse if the resident refused. Review of the care plan revealed Resident 6 required assistance with hygiene and had an intervention for staff to assist with showers. In an interview on January 20, 2026, at 12:05 p.m., Resident 6 stated, "You are lucky if you even get a shower around here." There was no documented evidence that Resident 6 received, was offered, or refused a shower during the previous 30 days.

Clinical record review revealed that Resident 14 had diagnoses that included osteomyelitis (bone infection) and anxiety. Review of the MDS assessment dated December 24, 2025, revealed that the resident had no cognitive impairment. Review of nurse aide documentation revealed that Resident 14 was to receive a shower every Wednesday on evening shift and staff were to notify the nurse if the resident refused. Review of the care plan revealed Resident 14 required assistance with personal hygiene and had an intervention for staff to assist with showers. In an interview on January 21, 2026, at 10:40 a.m., Resident 14 stated he had not had a shower in two weeks. There was no documented evidence that Resident 14 received, was offered, or refused a shower during the previous 30 days.

Clinical record review revealed that Resident 46 had diagnoses that included hemiplegia and hemiparesis (paralysis) and depression. Review of the MDS assessment dated October 24, 2025, revealed that the resident had no cognitive impairment. Review of the care plan revealed that Resident 46 had a self care deficit with an intervention for staff to assist with bathing. In an interview on January 21, 2026, at 10:39 a.m., Resident 46 stated staff often skip giving residents showers. There was no documented evidence that Resident 46 received, was offered, or refused a shower during the previous 30 days.

In an interview on January 22, 2026, at 9:43 a.m., the Director of Nursing confirmed that there was no documented evidence that showers were offered or provided to Residents 6, 14, and 46.

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

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

1. R6, R14, and R46 have been offered and given showers.

2. All current residents were audited for: bathing tasks in Point of Care. Any resident who missed a shower has now been offered and given a shower.

3. Education with the nursing staff has been completed regarding shower schedules and importance of showers.

4. DON or designee will audit shower completion for 5 random residents weekly x 4 then 5 random residents monthly x 2. Findings will be discussed at QAPI.

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

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

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

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

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

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess the nutritional status for three of 13 sampled residents. (Residents 3, 4, 14)

Findings include:

Review of the facility policy entitled, "Resident Weights," last reviewed July 21, 2025, revealed that re-weights would be obtained within 72 hours if a change was greater than three percent. If the weight change was validated the physician and dietitian would be notified. The licensed nurse would notify the interdisciplinary team for further assessment if the weight change was significant (five percent in one month), and the family would be notified.

Review of the facility policy entitled, "Nutrition Assessment," last reviewed July 21, 2025, revealed that nutrition assessments would be reviewed quarterly.

Clinical record review revealed that Resident 3 had diagnoses that included spinal stenosis and end stage renal disease. Review of the Minimum Data Set (MDS) assessment dated November 24, 2025, revealed that the resident had cognitive impairment. Review of the care plan revealed Resident 3 was at nutritional risk with an intervention for dietitian consultations. Review of the clinical record revealed that Resident 3 was last assessed by a dietitian on August 26, 2025. There was no documented evidence that Resident 3 had a nutrition assessment conducted or reviewed quarterly by the dietitian per the resident's care plan and facility policy.

Clinical record review revealed that Resident 4 had diagnoses that included cerebral palsy, malnutrition, and dysphagia (difficulty swallowing). On October 7, 2025, the resident weighed 102.0 pounds (lbs.). On November 2, 2025, the resident weighed 95.0 lbs., which reflected a 6.86 percent weight loss from the prior weight. There was no documented evidence that a second weight was obtained within 72 hours or that the dietitian was notified of the weight loss, in accordance with the policy. There was no documented evidence that the resident was assessed for the weight loss until November 19, 2025.

In an interview on January 22, 2026, at 12:37 p.m., the Director of Nursing confirmed that there was no documented evidence that a second weight was obtained within 72 hours or that the dietitian was notified per the policy.

Clinical record review revealed that Resident 14 had diagnoses that included osteomyelitis (bone infection) and diabetes. Review of the care plan revealed Resident 14 had a nutritional risk with an intervention for dietitian consultations. Resident 14 weighed 150.5 pounds (lbs) on October 30, 2025, 151.2 lbs. on November 6, 2025, and 136 lbs. on November 7, 2025, which reflected a significant loss of 10.05 percent. On November 12, 2025, Resident 14 weighted 135.2 lbs. There was no documented evidence that Resident 14 was reweighed within 72 hours of the identified weight loss on November 7, 2025, per facility policy. There was no documented evidence that the physician, family, or dietitian were aware of the significant loss until January 21, 2026, over two months after the initial loss.

In an interview on January 22, 2026, at 10:02 a.m., the Director of Nursing confirmed that there was no evidence that the residents' reweighs were obtained per policy, nutritional assessments were reviewed quarterly per policy, or that Resident 14's significant change was addressed in a timely manner.

CFR 483.25(g)(1) Maintain acceptable parameters of nutritional status.
Previously cited 8/13/25

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

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

1. Residents 3, 4, and 14 were reviewed. Dietitian assessments were completed, current weights were obtained, and significant weight changes were addressed. Physicians and families were notified as indicated, and care plans were updated.

2. A facility-wide audit was completed to ensure quarterly nutrition assessments were current, significant weight changes were identified, reweighs were obtained within 72 hours, and required physician, dietitian, and family notifications were completed per policy.

3. Licensed nurses and the dietitian were re-educated on the Resident Weights and Nutrition Assessment policies, including requirements for timely reweighs, dietitian referrals, quarterly assessments, and proper notification of the physician, IDT, and family for significant weight changes.

4. The DON or designee will complete weekly audits of at least 10% of resident weight records and nutrition assessments x4 weeks, then monthly x2 months. Results will be reviewed through QAPI to ensure sustained compliance.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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(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, it was determined that the facility failed to provide a safe, clean, and comfortable environment on the nursing unit.

Findings include:

Observations on January 20, 2026, from 11:00 a.m. through 1:30 p.m. and January 21, 2026, from 9:30 a.m. through 10:30 a.m., revealed the following:

In room 14, there was a dried brown substance on the base of the tube feeding pump and the floor by the pump at bed B.

In room 26, bed B, one of the closet doors was missing.

In room 27, there were crumbs and trash on the floor and on the fall mats around beds A and B. The door to the bedside cabinet by bed B was hanging by one hinge.

In room 29, the wall by bed A had dried black spots on it, the door of the bedside cabinet by bed B was missing, and the wall across from bed B was damaged, exposing concrete/drywall. There were empty food wrappers, crumbs, and an extinguished cigarette butt on the floor.

CFR: 483.10(i) Safe Environment

Previously cited 7/30/25.

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

28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

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

1. The facility addressed the identified environmental concerns. All affected rooms (Rooms 14, 26, 27, and 29) were cleaned and sanitized. Debris, food wrappers, cigarette butt, and residue were removed. Maintenance repaired or replaced damaged or missing bedside cabinets and closet doors, and damaged wall surfaces were repaired to ensure a safe and comfortable environment.

2.A baseline audit of resident closet doors, bedside tables, and overall room cleanliness will be completed to identify damaged furniture, cleanliness concerns, and potential safety hazards.

3.The NHA or designee will monitor compliance through routine environmental audits using a standardized checklist. All applicable staff will be re-educated on environmental cleanliness standards, identification of damaged furniture, and timely reporting of safety hazards.

4.Random audits of at least 10% of resident rooms will be completed weekly for four (4) weeks and then monthly for two (2) months to ensure sustained compliance. Audit results will be documented and reviewed through the facility's QAPI process.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

§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 that the Minimum Data Set (MDS) assessment was completed to accurately reflect each resident's status for one of 13 sampled residents. (Resident 5)

Findings include:

Clinical record review revealed that Resident 5 had diagnoses that included Parkinsonism and muscle weakness. The MDS assessment dated November 21, 2025, incorrectly indicated in Section H (Bladder and Bowel) that the resident had frequent urinary incontinence. There was no documentation in the clinical record that indicated Resident 5 had frequent urinary incontinence.

In an interview on January 22, 2026, at 9:55 a.m., the Director of Nursing confirmed that the MDS assessment did not accurately reflect the bladder status of Resident 5.

CFR: 483.20(g) Accuracy of Assessments

Previously cited 6/6/25.

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

1. The facility completed a review of the Minimum Data Set (MDS) assessment for Resident 5 to validate coding accuracy. The assessment was reviewed against the Resident Assessment Instrument (RAI) Manual and available clinical documentation. Based on this review, no modifications were warranted. Ongoing auditing of MDS assessments will be conducted to ensure continued compliance.

2. A baseline audit of all current residents' MDS assessments will be completed to ensure accurate coding of section H Bladder and Bowel per RAI guidelines.

3. Nursing will be re-educated by MDS nurse/designee on accurate MDS coding requirements of section H Bladder and Bowel per the RAI manual.

4. RNAC will monitor coding of LPN MDS nurse on 5 MDS weekly for four (4) weeks and then monthly for two (2) months to ensure 100% accuracy of section H Bladder and Bowel. Outcomes will be reported at QAPI for review and recommendations.

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 clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 13 sampled residents. (Resident 4)

Findings include:

Clinical record review revealed that Resident 4 was admitted to the facility on May 22, 2017, and had diagnoses that included cerebral palsy and dysphagia (difficulty swallowing). The Minimum Data Set assessment and Care Area Assessment summary dated November 18, 2025, noted that the resident's dental problems related to missing teeth were to be addressed in the care plan. There was no documented evidence that interventions to address Resident 4's dental problems related to missing teeth were included in the care plan.

In an interview on January 22, 2026, at 9:52 a.m., the Director of Nursing confirmed there was no documented evidence that the resident's dental problems were addressed in the care plan.

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

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

1. R4 now has interventions in care plan related to dental problems.

2. An audit has been completed for residents with oral/dental issues and all care plans are up to date.

3. Education with nursing staff has been completed regarding the need for care planned interventions for dental issues.

4. DON or designee will audit 5 random care plans for appropriate dental interventions weekly x 4, then 5 random care plans will be audited monthly x 2. Findings will be discussed at QAPI.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement safety interventions for one of 13 sampled residents. (Resident 7)

Findings include:

Clinical record review revealed that Resident 30 was admitted to the facility on July 18, 2020, and had diagnoses that included dementia, difficulty in walking, and a history of falling. On August 28, 2023, a physician ordered that staff place fall mats to both sides of the resident's bed every shift. The Minimum Data Set assessment dated November 2, 2025, revealed that Resident 7 was cognitively impaired and was dependent on staff for bed mobility and transfers. Review of the care plan revealed that the resident was at risk for falls and staff were to place mats on the floor on both sides of the bed.

Observations on January 20, 2026, between 11:40 a.m. and 1:30 p.m., and on January 21, 2026, between 9:10 a.m. and 11:30 a.m., revealed that Resident 7 was in bed with only one fall mat on one side of the bed.

In an interview on January 22, 2026, at 9:36 a.m., the Director of Nursing confirmed that there should have been fall mats on both sides of the bed.

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

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

1. R7 has bilateral fall mats in place at this time.

2. An audit has been completed for all residents with fall mat orders and fall mats are in place as ordered.

3. Education with nursing staff has been completed regarding following physician orders for fall mats to prevent accidents/incidents.

4. DON or designee will audit 5 random rooms weekly for appropriate fall mat placement weekly x 4, then 5 random rooms monthly x 2. Findings will be discussed at QAPI.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§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 facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a medication room or cart on one of two nursing units.

Findings include:

Review of the facility policy entitled, "Medication Storage in the Facility," last reviewed on July 21, 2025, revealed that medications and biologicals were to be stored safely, securely, and properly, that the supply was accessible only to licensed nursing personnel or staff members lawfully authorized to administer medications, and that supplies were locked in a medication room or cart, or attended by persons with authorized access.

Clinical record review revealed that a physician's order dated November 17, 2025, directed staff to administer 30 milliliters of liquid protein two times a day and a physician's order dated January 7, 2026, directed staff to apply calcium alginate with silver (a topical dressing that is used for wound healing) to a left heel pressure wound every day. Observation on January 20, 2026, at 11:00 a.m., in Resident 33's room, revealed a plastic medicine cup with a dark yellow liquid sitting on the resident's tray table. The resident confirmed that it was his liquid protein that the nurse brought in while he was eating breakfast. Observations on January 20, 2026, at 11:00 a.m., and on January 21, 2026, at 10:10 a.m., revealed that two unopened boxes and six individual packages of calcium alginate were in the top drawer of the resident's dresser. The drawer was not locked. There was a lack of documentation to support that assessments for medication self-administration or bedside storage of medications had been completed.

In an interview on January 22, 2026, at 9:55 a.m., the Director of Nursing confirmed that the resident was not assessed for medication self-administration or bedside storage of medications and the dark yellow liquid, and the calcium alginate dressings were not securely stored.

CFR: 483.45(g) Labeling of Drugs and Biologicalscited 6/6/25.

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

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

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

1. R33 no longer has liquid protein at the bedside. A self administration assessment has been completed for R33 and all treatment supplies are now being kept in a locked drawer per policy.

2. Residents receiving liquid protein and residents with treatment orders have been audited for self administration as appropriate and any resident unable to self administer no longer has medications/supplies at bedside.

3. Education with nursing staff has been completed regarding self administration assessments and facility policy regarding storage of medications and treatment supplies at bedside.

4. DON or designee will audit 5 random rooms for medications/treatment supplies weekly x 4, then 5 random rooms monthly x 2 months. Findings will be discussed at QAPI.

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

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

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 13 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from November 20 through 26, 2025, December 18 through 24, 2025, and January 15 through 21, 2026, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on November 22 and 23, 2025, and December 18, 20, 22, and 23, 2025.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on November 20, 22, 23, 24, and 26, 2025, December 20, 2025, and January 15, 17, and 19, 2026.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on December 20, 2025, and January 18, 2026.

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

1. The facility is unable to retroactively correct the deficient practice related to nurse aide staffing ratios for the identified dates and shifts. The facility has reviewed current staffing patterns and adjusted schedules to ensure nurse aide staffing meets or exceeds required minimum NA-to-resident ratios on all shifts going forward.

2. A baseline review of nurse aide staffing coverage was completed to ensure compliance with required NA-to-resident ratios for day, evening, and night shifts.

3. Nursing leadership and scheduling staff were re-educated on required nurse aide staffing ratios and the importance of maintaining minimum staffing levels on all shifts.

4. Random audits of nurse aide staffing schedules will be completed weekly for four (4) weeks and then monthly for two (2) months to ensure sustained compliance with minimum staffing ratios. Audit results will be documented and reviewed through the facility's QAPI process.

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

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

Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratio for one of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from November 20 through 26, 2025, December 18 through 24, 2025, and January 15 through 21, 2026, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day shift (7:00 a.m. to 3:00 p.m.) on January 17, 2026.

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

1. The facility is unable to retroactively correct the deficient practice related to the licensed practical nurse (LPN) staffing ratio for the identified date and shift. The facility reviewed current staffing patterns and adjusted schedules to ensure LPN staffing meets or exceeds the required minimum LPN-to-resident ratios on all shifts.

2. A baseline review of licensed nursing staffing coverage was completed to ensure compliance with required LPN-to-resident ratios on all shifts.

3. Nursing leadership and scheduling staff were re-educated on required licensed nurse staffing ratios and regulatory requirements.

4. Random audits of licensed nurse staffing schedules will be completed weekly for four (4) weeks and then monthly for two (2) months to ensure sustained compliance with minimum LPN staffing ratios. Audit results will be documented and reviewed through the facility's QAPI process.

§ 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 a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for four of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from November 20 through 26, 2025, December 18 through 24, 2025, and January 15 through 21, 2026, revealed the following total nursing care hours below minimum requirements:

November 22, 2025: 2.95 care hours per resident.

November 23, 2025: 2.95 care hours per resident.

December 20, 2025: 2.90 care hours per resident.

January 19, 2026: 3.17 care hours per resident.

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

1. The facility is unable to retroactively correct the deficient practice related to not meeting the minimum 3.2 hours of direct care per resident for the identified dates. The facility reviewed current staffing patterns and adjusted schedules to ensure total nursing care hours meet or exceed the required minimum of 3.2 hours of direct care per resident on all shifts.

2. A baseline review of nursing care hours per resident day PPD was completed to ensure compliance with the minimum direct care hour requirements.

3. Nursing leadership and scheduling staff were re-educated on the minimum 3.2 hours of direct care requirement and the importance of maintaining compliance based on census and acuity.

4. Random audits of nursing care hours per resident day will be completed weekly for four (4) weeks and then monthly for two (2) months to ensure sustained compliance with minimum direct care hour requirements. Audit results will be documented and reviewed through the facility's QAPI process.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement