Pennsylvania Department of Health
BETHLEHEM NORTH SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BETHLEHEM NORTH SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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BETHLEHEM NORTH SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to three complaints, completed February 12, 2026, it was determined that Bethlehem North Skilled Nursing and Rehabilitation Center, 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 as they relate to the Health portion of the survey.

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, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department.

Findings include:

Review of the facility policy entitled, "Use-by Dating Guidelines," dated January 15, 2026, revealed that staff were to discard prepared foods after 72 hours and frozen foods after 45 days of opening.

Review of the facility policy entitled, "Department Sanitation," dated January 15, 2026, revealed that staff were to assure that the pot and pan sink were properly filled with the sanitizing solution at the appropriate concentration.

Observations during the kitchen tour on February 10, 2026, at 10:43 a.m., revealed the following:

Inside the stockroom reach-in freezer, there was food debris on the bottom. In the reach-in cooler, there was a container of yogurt not dated and a cup of apple juice labelled use-by December 17, 2025. In the dry storage area, there were four packages of mousse mix removed from the original packaging that were not dated. There were two opened bulk containers of croutons and breadcrumbs that were not dated. There were two large bags of flour and breadcrumbs that were not sealed and were open to air. The container of breadcrumbs had breadcrumb debris covering the lid.

In reach-in cooler # 2, there was a bulk container of enhanced pudding with a use-by date of February 7, and a pan of chopped eggs dated February 3. In reach-in cooler # 3, there was an opened bag of shredded cheese that was not dated. The floor of the cooler had a dried red liquid below a tray of raw ground beef. In reach-in freezer # 4, there was an opened package of frozen corned beef that was dated October 22, 2025.

According to Dietary Manager, at the time of the observation during the kitchen tour, the pot sink required a chemical solution to sanitize the pots and pans that were soaking in the solution. When measured, the sanitizing solution did not meet the required parts per million to sanitize the pots and pans.

In an interview at 11:20 a.m., on February 10, 2026, the Dietary Manager confirmed that the previously mentioned foods were not dated and should have been, the expired food items should have been discarded and were not, and the amount of chemical solution in pot and pan sink was not properly sanitizing the items.

CFR 483.60(i) Food Safety Requirement

Previously cited 3/6/25.

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

Plan of Correction - To be completed: 03/24/2026

1) Immediate Corrective Action:
A) All undated food items were immediately discarded.
B) The Ecolab technician was contacted immediately and corrected the sanitizing system to meet the required 200 PPM.

2) Identification of Other Residents and Corrective Action:
A) The Dietary Team audited all food storage areas to identify any undated items.
B) Any undated food found was discarded.
D) All sanitizing systems were Checked to ensure they met policy standards.

3) Systemic Changes / Measures to Prevent Reoccurrence:
A) The Dietary Team was educated on proper dating and labeling of food items.
B) Signs were hung on food storage area doors as reminders regarding the dating guidelines.
C) Education was provided to the Dietary Team regarding proper sanitizing procedures.
D) Sanitizing solution will be tested weekly.
E) Twice weekly audits of all food storage areas are now in place.

4) Monitoring & Quality Assurance:

A) The NHA/designee will follow up on the twice-weekly dietary storage audits.
B) The Dietary Director/designee will conduct weekly audits to ensure the PPM is up to standard.
C) Tracking and trends will be submitted to the QAPI Committee for review and recommendations.

5) Completion Date:03/24/2026

483.25 REQUIREMENT Quality of Care:

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

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for five of 35 sampled residents. (Residents 8, 12, 16, 18, 159)

Findings include:

Review of the policy entitled, "Medication Administration General Guidelines," last reviewed January 15, 2026, revealed staff were to obtain and record vital signs, if necessary, prior to medication administration and document necessary information in the Medication Administration Record (MAR).

Clinical record review revealed that Resident 8 had diagnoses that included hypertension (high blood pressure) and heart failure. A physician's order dated December 12, 2025, directed staff to administer a medication (carvedilol) two times a day for hypertension and heart failure. Staff were not to administer the medication if the resident's blood pressure was less than 100 millimeters of mercury (mm/Hg) or if the heart rate (the number of times a heart beats in one minute) was less than 60 beats per minute (bpm). Review of Resident 8's December 2025, and January and February 2026 MARs revealed that staff administered the medication 36 times in December, 29 times in January, and eight times in February with no documentation that the blood pressure and heart rate were assessed prior to medication administration per the physician's order.

Clinical record review revealed that Resident 12 had diagnoses that included atrial fibrillation (an irregular heartbeat) and high blood pressure. A physician's order dated April 4, 2025, directed staff to administer a medication (metoprolol tartrate) two times a day for hypertension. Staff were not to administer the medication if the resident's heart rate was less than 60 bpm. Review of Resident 12's December 2025, January and February 2026 MARs revealed that staff administered the medication 30 times in December, 17 times in January, and 11 times in February with no documentation that the heart rate was assessed prior to medication administration per the physician's order.

Clinical record review revealed that Resident 16 had diagnoses that included hypertension. A physician's order dated May 9, 2025, directed staff to administer a medication (metoprolol tartrate) one time a day for hypertension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 100 mm/Hg or if the heart rate was less than 60 bpm. Review of Resident 16's December 2025 and January and February 2026 MARs revealed that staff administered the medication 27 times in December, 31 times in January, and nine times in February with no documentation that the blood pressure and heart rate were assessed prior to medication administration per the physician's order.

Clinical record review revealed that Resident 18 had diagnoses that included diabetes and end stage kidney disease. A physician's order dated January 16, 2026, directed staff to administer 12 units of a diabetic medication (insulin aspart subcutaneous solution) before meals. Staff were not to administer the medication if the blood sugar was less than 100 milligrams per deciliter (mg/dL) and were to notify the provider if the blood sugar was less than 70 mg/dL or greater than 350 mg/dL. Review of Resident 18's January 2026 MAR revealed that the resident's blood sugar was 52 mg/dL on January 21 and January 26. There was no documentation that the provider was notified of the blood sugar that was below 70 mg/dL. A physician's order dated February 2, 2026, directed staff to administer eight units of a diabetic medication (insulin aspart subcutaneous solution) before meals. Staff were not to administer the medication if the blood sugar was less than 100 mg/dL and were to notify the MD if the blood sugar was less than 70 mg/dL or greater than 350mg/dL. A review of Resident 18's February 2026 MAR revealed that the resident's blood sugar was 86 mg/dL on February 4, 2026, and he was given insulin aspart subcutaneously (an injection into the fatty tissue layer between the skin and the muscle using a short needle) when the medication was not to be given.

In interviews on February 12, 2026, at 10:40 a.m. and 3:10 p.m., the Assistant Director of Nursing confirmed that there was no documented evidence that the provider was notified of Residents 18's blood sugar being below 70 mg/dL per the physician's order and that the resident received insulin aspart when it should have been held.

Clinical record review revealed that Resident 159 had diagnoses that included heart disease, hypertension (high blood pressure), and atrial fibrillation (irregular heart rhythm). A physician's order dated February 12, 2025, directed staff to administer a medication (metoprolol tartrate) one time a day to treat hypertension. Staff were to hold the medication if the resident's heart rate was below 60 beats per minute. Review of Resident 159's December 2025 and January and February 2026 MARs revealed no documented evidence that the resident's heart rate was taken prior to the medication being administered.

In an interview on February 12, 2026, at 10:15 a.m., the Assistant Director of Nursing confirmed there was documented evidence that the blood pressure and/or heart rate were taken prior to medication administration per physicians' orders for Residents 8, 12, 16, and 159.

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

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

Plan of Correction - To be completed: 03/24/2026

1.Residents 8, 12, 16, 159 are receiving their medication according to physician ordered documented parameters. Resident 18 is receiving insulin according to physician ordered scale and physician is notified when glucose is less than 70.

2.medication administration to ensure that documentation of BP/pulse is completed and medication is administered accordingly. Current residents receiving insulin based on results of glucose testing have been reviewed and physician notified according to physician order.

3.Licensed nursing staff have been re-educated on including documentation of BP/pulse in EMAR to ensure medication administration is completed according to parameters. Licensed nursing staff have been re-educated to administer insulin according to physician orders and notify physician according to order.

4.DON/designee will audit 5 residents/week for two weeks and then 5 residents every two weeks for 4 weeks for compliance to physician orders for medication administration. Results of audits will be reported to QAPI for review and recommendations.

5.Compilation Date 03/24/2026

5.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:
Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 35 sampled residents. (Residents 18, 204)

Findings include:

Review of the facility policy entitled, "Medications: Self-Administration," last reviewed January 15, 2026, revealed that the facility was to assess and determine whether self-administration of medications was safe and clinically appropriate based on the resident's functionality and health condition. The policy also stated that a physician/advanced practice provider order was required for medication self-administration, the facility was to document in the resident's care plan that the resident was able to self-administer medication, and, if applicable, the resident was to be provided with a secure, locked area to maintain medications.

Clinical record review revealed that Resident 18 had diagnoses that included end-stage kidney disease and dependence on kidney dialysis (a procedure that cleans the blood in people with poor kidney function). Observation on February 11, 2026, at 11:30 a.m., revealed that there was a pill cup containing two pills, unsecured on Resident 18's lunch tray. At that time the resident stated that the pills were calcium acetate (a medication used to treat high phosphate levels in the blood of people on dialysis), which he was to take with meals. There was no documentation to indicate that the facility had assessed Resident 18 for the ability to self-administer the calcium acetate. The medications were not secured in his room.

Clinical record review revealed that Resident 204 had diagnoses that included high blood pressure, diabetes, and depression. Observation on February 11, 2026, at 11:40 a.m., revealed that there was a pill cup containing multiple pills, unsecured on Resident 204's tray table. At that time, the resident stated that the pills were some of her morning medications. In an interview on February 11, 2026, at 11:45 a.m., Registered Nurse (RN) 1 confirmed that the pills were vitamin C, vitamin B 12, sodium bicarbonate (baking powder), and sodium chloride (table salt). There was no documentation to indicate that the facility had assessed Resident 204 for the ability to self-administer the medications. The medications were not secured in her room.

In an interview on February 12, 2026, at 10:40 a.m., the Assistant Director of Nursing confirmed that Residents 18 and 204 were not assessed to self-administer the medications as per the facility policy.

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

Plan of Correction - To be completed: 03/24/2026

1. Resident 18 and 204 have been evaluated for Self Administration of medications.

2. Current residents have been evaluated for Self Administration of Medications and if appropriate, facility procedure completed.

3.Licensed nursing staff have been re-educated on the Medication Self Administration policy with attention to staying with resident until medications are completely administered.

4.DON/designee will audit five licensed staff medication administration passes a week for 5two weeks and five medication passes every two weeks for four weeks to ensure medication is completely administered. Results of audits will be reported to QAPI for review and recommendations.

5.Compilation Date 03/24/2026

483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization:

§483.80 Infection control
§483.80(d)(3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses.
(v) The resident or resident representative, has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision; and
(vi) The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident, or
(C) If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.
(vii) The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

Observations:
Based on facility policy review, clinical record review, staff interview, and review of the Centers for Disease Control and Prevention guidelines, it was determined that the facility failed to offer coronavirus-19 (COVID-19) vaccines in accordance with facility policy to two of five residents whose vaccines were reviewed. (Residents 1, 19)

Findings include:

Centers for Disease Control and Prevention (CDC) guidance dated November 19, 2025, stated that staying up to date and getting the 2025/2026 COVID-19 vaccine is especially important for those living in a long-term care facility.

The policy entitled "Policy for COVID-19 Vaccination," last reviewed January 15, 2026, revealed the facility was to offer the COVID-19 vaccine to healthcare workers and the residents when it became available, consents for vaccination were to be obtained and if refused a declination was to be signed. The policy also stated the facility would provide education on the risks versus benefits of the vaccine and would be responsible for documentation.

Clinical record review revealed that Resident 1 was admitted to the facility on July 3, 2025. The resident received a COVID-19 vaccine on October 30, 2021. There was no documentation to support that the resident was offered the COVID-19 vaccine since the time of her admission to the facility.

Clinical record revealed that Resident 19 was admitted to the facility on November 6, 2006. The resident received a COVID-19 vaccine on November 28, 2023. There was no documentation to support that the resident was offered the COVID-19 vaccine in 2024, 2025, or 2026.

In an interview on February 12, 2026, at 1:45 p.m., the Assistant Director of Nursing/Infection Preventionist confirmed that the residents had not been offered the COVID-19 vaccine per facility policy.

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

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

Plan of Correction - To be completed: 03/24/2026

1.Residents 1 and 19 have been offered the COVID 25-26 vaccine.

2.Current residents have been reviewed and those appropriate have been offered the COVID 25-26 vaccine.

3.Licensed nursing staff have been re-educated on the facility policy regarding offering the COVID vaccine. Residents will be reviewed within 7days of admission for offering of the COVID vaccine.

4.DON/designee will audit admissions to ensure compliance to facility policy for offering of the COVID is completed. Results of audits will be reported to QAPI Committee for review and recommendations.

5.Compilation Date 03/24/2026

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to evaluate the need to provide pneumococcal disease vaccines in accordance with facility policy for two of five residents whose vaccines were reviewed. (Residents 19, 47)

Findings include:

Review of the facility policy entitled, "Pneumococcal Vaccination," last reviewed January 15, 2026, revealed that upon admission, the facility would assess each resident to determine if they had been previously vaccinated for pneumococcal disease and offer the vaccine if the resident had not received it or was not up to date according to the Center for Disease Control's "Pneumococcal Vaccine Timing for Adults" guidelines. Staff were to document education, including benefit of vaccination, and whether the resident received the vaccination or declined in the electronic medical record.

Clinical record review revealed that Resident 19 was admitted to the facility on November 6, 2006. The resident received the pneumococcal pneumonia vaccine Prevnar 13 on December 6, 2016. There was no documented evidence that the facility reviewed the resident's vaccination status to determine if an updated vaccine needed to be offered.

Clinical record review revealed that Resident 47 was admitted to the facility on May 19, 2021. The resident received pneumococcal pneumonia vaccines PPSV23 on September 3, 2014, and Prevnar 13 on March 18, 2016. There was no documented evidence that the facility reviewed the resident's vaccination status to determine if an updated vaccine needed to be offered.

In an interview on February 12, 2026, at 1:45 p.m., the Assistant Director of Nursing confirmed that the residents' pneumococcal pneumonia vaccination status had not been reviewed to determine if an updated vaccine needed to be offered.

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

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

Plan of Correction - To be completed: 03/24/2026

1.Residents 19 and 47 have been offered the pneumococcal pneumonia vaccine.

2.Current residents have been reviewed to determine if pneumococcal pneumonia vaccine is appropriate to be offered.

3.Licensed nursing staff have been re-educated on the Pneumococcal pneumonia vaccine administration guidelines.
Residents will be reviewed within one week of admission to determine if pneumococcal pneumonia vaccine needs to be offered.

4.DON/designee will audit admissions to facility weekly to ensure pneumococcal pneumonia vaccine has been offered according to vaccine guidelines. Results of audits will be reported to QAPI for review and recommendations.

5. Compilation Date 03/24/2026

483.10(f)(10(i)(ii) REQUIREMENT Protection/Management of Personal Funds:

§483.10(f)(10) The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds.
(i) The facility must not require residents to deposit their personal funds with the facility. If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section.
(ii) Deposit of Funds.
(A) In general: Except as set out in paragraph (f)( l0)(ii)(B) of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund.
(B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interest-bearing account, or petty cash fund.

Observations:
Based on clinical record review, resident interview, facility documentation review, and staff interview, it was determined that the facility failed to obtain written authorization to manage personal funds for one of 35 sampled residents. (Resident 160)

Findings include:

Clinical record review revealed that Resident 160 was admitted January 6, 2023, and had diagnoses that included diabetes and hypertension (high blood pressure). The Minimum Data Set assessment, dated January 21, 2026, indicated that the resident was able to communicate her needs and was able to be understood.

In an interview on February 10, 2026, at 11:30 a.m., Resident 160 stated that she had received a letter from Social Security stating that she will no longer receive her money and that the facility will manage her funds. She further stated that she did not authorize the facility to become her representative payee and that the facility took her money without her permission.

A review of the representative payee authorization forms that were sent to Social Security on October 23, 2025, revealed that Resident 160 had not given authorization for funds to be managed by the facility.

A review of the Resident Fund Account revealed that on February 1, 2026, Resident 106 had funds in the account. There was no documented evidence that the facility obtained authorization from the resident to open the account.

During an interview on February 12, 2026, at 12:15 p.m., the Administrator confirmed that written authorization to manage funds for Resident 160 had not been obtained.

28 Pa. Code 201.18(b)(2) Management.

28 Pa. Code 201.29(a) Resident rights.

Plan of Correction - To be completed: 03/24/2026

1)Immediate Corrective Action:A)NHA and BOM attempted to see Resident to review her right to appeal the decision of Social Security. She did not want to see us.
B)NHA and BOM attended FEB 2026 Resident Council meeting and reviewed the cost/sharing liability for residents approved for Medical Assistance. Their requirement to pay their patient liability portion to the facility upon approval of Medicaid or jeopardize their stay at the facility.

C)BOM and NHA also explained the process of applying for Rep Payee for non-payment accounts after trying to work on payment arrangements with residents or their family.
2) Identification of Other Residents and Corrective Action:
A)BOM audited other residents who have Rep Payee.
B)BOM has since completed SSA4164 with consent and scanned into the record.

3)Systemic Changes/Implemented Measures to Prevent Reoccurrence:

A)Education and Training for the Business Office Staff of the Rep Payee Application Process and consent.

B)Location of Form SSA-4164 to be implemented with consent in all Rep Payee Applications going forward On admission.

4)Monitoring Corrective Measures & Quality Assurance:
A)The business office will keep accurate records of accounts and thoroughly follow the Rep Payee Application process for individuals who fail to pay their resident liability.

B)Tracking and trends will be submitted to the QAPI Committee for review and recommendations

5)5) Completion Date: 03/24/2026

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

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

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

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

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

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

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

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

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

Observations:
Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for two of five newly hired employees. (Employees 1, 5)

Findings include:

A review of the facility policy entitled, "Abuse Prohibition," dated January 15, 2026, revealed that the facility was to conduct screenings for potential hires.

A review of the facility policy entitled, "Hiring," dated January 15, 2026, revealed that the facility was to check references and to verify the license required for the position for all potential hires.

Employee 1 had been working in the facility as the Administrator since January 20, 2026, and an inquiry to the state licensure board was not completed until February 11, 2026.

Employee 5 had been working in the facility as a nurse aide since November 4, 2025, and a reference check was not completed until November 29, 2025.

In an interview on February 20, 2026, at 1:15 p.m., the Director of Human Resources Operations Partner confirmed there was no documented evidence that the reference check and the license verification were done prior to the start of employment.

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

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

28 Pa. Code 201.19(3) Personnel policies and procedures.

Plan of Correction - To be completed: 03/24/2026

1.Employee 1 has had license verified on 2/11/26. Employee 5 has had a reference check completed on 11/29/25.

2.Employees hired since February 1, 2026 have been reviewed to ensure license has been verified and reference checks completed according to facility policy.

3.Employees hired since February 1, 2026 have been reviewed to ensure license has been verified and reference checks completed according to facility policy.

4.NHA/designee will audit new employee files weekly for six weeks to ensure licenses have been verified and reference checks completed according to facility policy. Results of audits will be reported to QAPI for review and recommendations.

5.Compilation Date 03/24/2026

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

§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 clinical record review and staff and resident interviews, it was determined that the facility failed to provide assistance with bathing for two of 36 sampled residents. (Residents 127, 192)

Findings include:

Clinical record review revealed that Resident 127 had diagnoses that included a cerebral infarction (stroke) affecting the right side and diabetes with polyneuropathy (damage to the peripheral nerves causing burning pain, numbness, tingling, and weakness). According to two Minimum Data Set (MDS) assessment dated December 26, 2025, the resident required extensive assistance from staff for activities of daily living (ADLs) and was totally dependent on staff for bathing. A review of the care plan revealed that the resident required assistance with hygiene and that staff was to provide a shower or bed bath twice a week. Review of nurse aide documentation for January and February 2026, revealed the resident was scheduled for a bath or shower on January 15 and 17, 2026, and did not receive one. In an interview on February 10, 2026, at 1:25 p.m., Resident 127 stated that she was not always offered showers and she wanted to receive them.

Clinical record review revealed that Resident 192 had diagnoses that included cerebral infarction affecting the left side, contracture of the left and right lower legs, and protein-calorie malnutrition. According to the MDS assessment dated January 31, 2026, the resident required extensive assistance from staff for ADLs and was totally dependent on staff for bathing. Review of nurse aide documentation for January and February 2026, revealed the resident was scheduled for a bath or shower on January 21 and February 7, 2026, and did not receive one. In an interview on February 10, 2026, the resident stated that she was not always offered showers and she wanted to receive them.

In an interview on February 12, 2026, at 10:55 a.m., the Assistant Director of Nursing confirmed that Residents 127 and 192 were not offered a bath or shower on their scheduled shower dates.

CFR 483.24(a)(2) ADL Care Provided for Dependent Residents
Previously cited 3/6/25.

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

Plan of Correction - To be completed: 03/24/2026

1.Residents 127 and 192 are being offered a bath/shower on their preferred shower days.

2.Current residents have been reviewed to ensure that they are being offered a bath/shower on their preferred shower days.

3.Nursing staff have been re-educated to offer residents a bath/shower according to their individual schedule and to notify licensed nurse and document accordingly if resident refuses.

4.DON/designee will audit ten residents a week for three weeks and five residents a week for three weeks to ensure residents have been offered a bath/shower according to their schedule. Results of audits will be reported to QAPI for review and recommendations.

5.Compilation Date 03/24/2026

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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for one of four sampled residents with pressure ulcers. (Resident 1)

Findings Include:

Clinical record review revealed that Resident 1 had diagnoses that included open wound of the lower back and pelvis region (bed sore) and left heel pressure ulcer. A physician's order dated August 20, 2025, directed staff to apply a heel suspension device (a device to prevent and treat pressure sores) to the right and left heels while in bed. Review of the comprehensive care plan revealed that Resident 1 was at risk for skin breakdown. Multiple observations on February 10, 2026, and February 11, 2026, between 10:00 a.m. and 2:00 p.m., revealed Resident 1 in bed, and the heel suspension device was not applied. In an interview dated, February 11, 2026 at 12:36 p.m., Resident 1 stated sometimes the staff would apply a pillow under her heels or heel boots and that it all depended on who was working.

In an interview on February 12, 2026, at 10:45 a.m., theAssistant Director of Nursing confirmedthat the heel suspension device was not in place as ordered for Resident 1.

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

Plan of Correction - To be completed: 03/24/2026

1.Resident 1 has heel suspension device in place according to plan of care.

2.Current residents who have a plan of care for heel suspensions devices to be in place have been reviewed and device is in place according to plan of care.

3.Nursing staff have been re-educated to follow plan of care for use of heel suspension devices if indicated.

4.DON/designee will audit 5 residents/week for two weeks and 5 residents every two weeks for 4 weeks to ensure heel suspension devices are in place according to plan of care. Results of audits will be reported to QAPI for review and recommendations.

5.Compilation Date 03/24/2026

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

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

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

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

Observations:
Based on clinical record review and resident and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for two of 35 sampled residents. (Residents 4, 9)

Findings include:

Clinical record review revealed that Resident 4 had diagnoses that included muscle weakness, bladder cancer, and chronic obstructive pulmonary disorder. Review of the Minimum Data Set (MDS) assessment dated November 29, 2025, revealed that Resident 4 was cognitively intact. On January 16, 2026, the physical therapist recommended a restorative nursing program (RNP) for ambulation for Resident 4 to use a rolling walker and contact guard assistance from staff to walk 100 to 200 feet for 15 minutes daily. There was no documented evidence that the facility provided the recommended RNP. In an interview on February 12, 2026, at 10:30 a.m., Resident 4 stated that he had not been offered the RNP program for ambulation and he would not have refused it.

In an interview on February 12, 2026, at 10:22 a.m., the Assistant Director of Nursing confirmed the recommended restorative nursing program was not implemented for Resident 4. In an interview on February 12, 2026, at 10:40 a.m., the Director of Rehabilitation stated the program would be for functional maintenance of mobility.

Clinical record review revealed that Resident 9 had diagnoses that included other specified disorders of muscle, rheumatoid arthritis, and spondylosis (arthritis of the spine). The MDS assessment dated November 10, 2025, indicated that the resident had no cognitive impairment, was dependent on staff for personal hygiene, and had a loss of range of motion. Review of the care plan revealed that the resident was dependent for activities of daily living related to functional deterioration due to limited mobility. Interventions included that staff apply a splint in the morning and remove it in the evening for left hand contracture. Observations on February 10, 2026, between 10:36 a.m. and 1:35 p.m., and February 11, 2026, between 9:50 a.m. and 1:14 p.m., revealed that Resident 9 was in bed without a splint on his left hand. In an interview at that time, the resident stated that he did not refuse to wear the hand splint.

In an interview on February 12, 2026, at 10:50 a.m., the Assistant Director of Nursing confirmed that the splint was to have been in place.

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

Previously cited 3/6/25.

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

Plan of Correction - To be completed: 03/24/2026

1.Resident 4 is no longer a resident in facility. Resident 9 splint is being applied according to plan of care.

2.Current residents with plan of care for ambulation and appliance of splint have been reviewed and are being offered according to plan of care.

3.Nursing staff have been re-educated to offer restorative nursing programs to residents according to their plan of care and document results.

4.DON/designee will audit 5 residents/week for 2 weeks and 5 residents every 2 weeks for four weeks to ensure that restorative program is offered according to plan of care and documentation completed. Results of audits will be reported to QAPI for review and recommendations.

5.Compilation Date 03/24/2026

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:
Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one of 35 sampled residents. (Resident 13)

Findings include:

Review of the facility policy entitled, "Continence Management," last reviewed January 15, 2026, revealed that staff was to complete a urinary incontinence and/or bowel incontinence assessment upon admission and quarterly as part of their care planning process, and whenever there was a change in a resident's continence. The purpose was to provide appropriate treatment and services for residents with urinary and bowel incontinence and restore continence to the extent possible. The facility was to develop individualized interventions and a plan of care based on information from the assessment and voiding records.

Clinical record review revealed that Resident 13 was admitted September 25, 2025, and had diagnoses of hypertension (high blood pressure) and quadriplegia (symptoms of paralysis that affects the body from the neck down). The Minimum Data Set (MDS) assessment, dated September 25, 2025, indicated that the resident was able to communicate her needs, required no assistance from staff with toileting, was frequently incontinent of urine and continent of bowel, and was not on a toileting program. The assessment also indicated that the problem of urinary incontinence was to be addressed in the care plan. The MDS assessment dated December 30, 2025, indicated that the resident was able to communicate her needs, required some assistance from staff with toileting, was frequently incontinent of urine and occasionally incontinent of bowel, and was not on a toileting program. There was no documented evidence that an incontinence assessment was completed upon admission to assess and provide treatment and services to the resident for urinary incontinence to restore bladder continence to the extent possible. In addition, there was no documented evidence that an incontinence assessment was completed after Resident 13 had a change in bowel incontinence, and there was no care plan developed with specific interventions to address Resident 13's urinary and bowel incontinence.

In an interview on February 12, 2026, at 11:15 a.m., the Assistant Director of Nursing confirmed that there was no documented evidence that staff had completed an incontinence assessment or developed and implemented specific care planned interventions to address Resident 13's urinary and bowel incontinence.

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

Plan of Correction - To be completed: 03/24/2026

1.Resident 13 has had an incontinence assessment completed and an incontinence care plan implemented.

2.Current residents have been reviewed to ensure an incontinence care plan is in place where appropriate and assessment completed when a change in continence status occurs.

3.Licensed nursing staff have been re-educated to complete an incontinence assessment when there is a change in continence status and to implement a incontinence care plan when appropriate.

4.DON/designee will audit 5 residents/week for 2 weeks and 5 residents every two weeks for 4 weeks to ensure an incontinence assessment is completed and care plan implemented. Results of audits will be reported to the QAPI Committee for review and recommendations.

5.Compilation Date 03/24/2026

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

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

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

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

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

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess nutritional status for one of three sampled residents at risk for weight loss. (Resident 144)

Findings include:

Review of the facility policy entitled, "Weights and Heights," last reviewed January 15, 2026, revealed that if a body weight of a resident is not as expected, reweigh the resident within 24 hours. A licensed nurse would notify the registered dietitian (RD) of any significant weight changes, and the notification would be documented in a progress note.

Clinical record review revealed that Resident 144 had diagnoses that included myasthenia gravis (autoimmune disorder causing fluctuating weakness in voluntary muscles), cerebral infarction (stroke), and mild protein-calorie malnutrition. Review of the care plan revealed that the resident was at risk for malnutrition and the intervention was for staff to monitor for changes in nutritional status. On February 2, 2026, the resident weighed 188 pounds (lbs.). On February 5, 2026, the resident weighed 178.2 lbs., which reflected a significant weight loss of 9.8 lbs. (5.2%). There was a lack of evidence to support that the RD was notified of the significant weight loss. On February 6, 2026, the RD noted that the resident needed to be reweighed. Resident 144 was not weighed again until February 11, 2026. There was no documented evidence that Resident 144 was reweighed within 24 hours according to facility policy.

In an interview on February 11, 2026, at 11:47 a.m., the Registered Dietician stated that reweights are to be done within 24 hours and Resident 144 was not reweighed per request and policy.

CFR 483.25(g)(1) Maintain acceptable parameters of nutritional status.
Previously cited 3/6/25.

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

Plan of Correction - To be completed: 03/24/2026

1.Resident 144 reweight was completed.

2.Current residents who have had a significant weight change since February 13, 2026. have been reviewed and a reweight was completed within 24 hours.

3.Nursing staff have been re-educated to complete a reweight within 24 hours when a significant weight change occurred and dietician is notified of the weight according to facility policy.

4.DON/designee will audit 5 resident weights/week for two weeks and 5 resident weights every two weeks for 4 weeks to ensure a re-weight is completed within 24 hours and dietician notified according to policy

5.03/24/2026

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of 35 sampled residents. (Resident 139)

Findings include:

Clinical record review revealed that Resident 139 was admitted to the facility on August 27, 2021, with diagnoses that included PTSD, major depressive disorder, anxiety, and mood disorder. The Minimum Data Set assessment dated February 10, 2026, revealed that the resident had a diagnosis of PTSD and displayed symptoms of feeling tired, feeling hopeless, having trouble falling asleep, and feeling bad. There was a lack of documentation to support that symptoms or triggers were assessed related to the diagnosis of PTSD. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.

In an interview on February 12, 2026, at 9:08 a.m., the Social Work Director confirmed that there was no care plan developed to address Resident 139s PTSD symptoms or triggers.

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

Plan of Correction - To be completed: 03/24/2026

1)Immediate Corrective Action:
A)) The identified resident's care plan was immediately reviewed and updated to reflect PTSD related needs.

2) Identification of Other Residents and Corrective Action:
A)All residents with similar diagnoses had their care plans reviewed and updated as needed

B)A PTSD diagnosis report was generated, and all residents with PTSD were identified for care plan review.

3)Systemic Changes/Implemented Measures to Prevent Reoccurrence:
A)Social Services will complete weekly audits of residents with PTSD to ensure care plans accurately reflect needs, triggers and interventions.

B)Social Services will meet with Psychiatry weekly to review any new diagnoses or changes requiring care plan updates

4)Monitoring Corrective Measures & Quality Assurance:
A)Social Services will conduct weekly audits of PTSD care plans to ensure interventions are appropriate and all supportive services are in place.

B)Tracking and trends will be submitted to the QAPI Committee for review and recommendations

5) Completion Date: 03/24/2026

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

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.

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:
Based on facility documentation, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of four nursing units. (4th floor)

Findings include:

In a group interview on February 10, 2026, at 10:00 a.m., Residents 12, 15, 49, and 166 reported that hot food was frequently served cold.

Review of facility documentation entitled, "Food and Nutrition Services Test Tray Evaluation," revealed that the hot main entree, starch, and vegetable should be greater than 140 degrees Fahrenheit (F) at point of service to the resident.

Results of a test tray audit conducted on February 11, 2026, at 12:26 p.m., after the last resident meal tray was served from the dining cart, revealed a smothered chicken thigh was served at a temperature of 115.2 degrees F, the mashed potatoes at a temperature of 115.7 degrees F, and the mixed vegetables at a temperature of 108.5 degrees F. All the food items were cool to taste.

In separate interviews on February 11, 2026, between 12:17 p.m. and 12:34 p.m., Residents 92 and 115 received their meal trays from the same cart as the test tray and stated that the chicken and mashed potatoes were cool to taste. In an interview at 12:24 p.m., Resident 127, stated that the chicken and mashed potatoes were cool to taste.

In an interview on February 11, 2026, at 12:30 p.m., the Dietary Manager confirmed the test tray hot food temperatures did not meet policy expectations.

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

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

Plan of Correction - To be completed: 03/24/2026

1) Immediate Corrective Action
A) All heating vessels (steam table, plate warmer, heat inducer) were inspected to ensure they were functioning at maximum heat. Any issues identified were corrected.

B) Half pan lids were used during service to reduce temperature loss.

2) Identification of Other Residents and Corrective Action
B) The Dietary Director rounded to ensure food is at an adequate temperature.

C) During the Food Committee meeting, residents were asked if they had any concerns regarding food temperatures.

3) Systemic Changes / Measures to Prevent Reoccurrence
A) Units will be notified immediately when tray carts leave the Dietary Department.

B) The tray line will be monitored by the Dietary Director/designee to ensure timely service and at an adequate temperature.

4) Monitoring & Quality Assurance
A) The Dietary Director/designee will audit five (5) resident meal trays three times per week, then five (5) residents every two weeks monthly.

B) Tracking and trends will be submitted to the QAPI Committee for review and recommendations.

5) Completion Date: 03/24/2026

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations:
Based on observation, it was determined that the facility failed to dispose of trash and refuse properly.

Findings include:

Observation of the trash compactor area on February 10, 2026, at 11:15 a.m., revealed the area adjacent to the compactor had multiple pieces of plastic and paper debris. There was a wrapped, soiled feminine hygiene product, a soiled piece of gauze, multiple used plastic gloves, and a chicken drumstick on the ground in front of the compactor.

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

Plan of Correction - To be completed: 03/24/2026

F0814 – Failure to properly dispose of trash.

1) Immediate Corrective Action
A) The affected area was immediately cleaned.
B) The area was added to staff rounding rotations for ongoing monitoring.

2) Identification of Other Residents and Corrective Action
A) All trash areas were audited to ensure proper disposal.
B) A floor tech was assigned to maintain and monitor the area.

3) Systemic Changes / Measures to Prevent Reoccurrence:
A) Twice daily audits/rounds of trash areas are now implemented to ensure proper disposal.
B) The floor tech will continue to maintain and monitor these areas.

4) Monitoring & Quality Assurance
A) The Housekeeping Director/designee will audit rounding logs.
B) Tracking and trends will be submitted to the QAPI Committee for review and recommendations.

5) Completion Date: 03/24/2026

§ 211.1(a) LICENSURE Reportable diseases.:

(a) When a resident develops a reportable disease, the administrator shall report the information to the appropriate health agencies and appropriate Division of Nursing Care Facilities field office. Reportable diseases, infections and conditions are listed in § 27.21a (relating to reporting of cases by health care practitioners and health care facilities).

Observations:
Based on facility record review and staff interview, it was determined that the facility failed to inform the Division of Nursing Care Facilities (DNCF) field office of a reportable disease (influenza). (Resident 138)

Findings include:

A review of facility infection control documentation revealed Resident 138 tested positive for Influenza on December 26, 2026. There was no documented evidence that this was reported to the DNCF field office.

In an interview on February 12, 2026, at 12:49 p.m., the Assistant Director of Nursing/Infection Preventionist confirmed that the field office was not notified of the resident's positive influenza diagnosis.

Plan of Correction - To be completed: 03/24/2026

1.Resident 138 positive influenza test has been reported to DNCF.

2.Current residents who have a positive influenza test have been reported to DNCF.

3.Infection Control professional has been re-educated on reporting guidelines for influenza.

4.DON/designee will audit residents who tested positive for influenza to ensure reporting to DNCF has been completed. Results of audits will be reported to QAPI Committee for review and recommendations.

5.Compilation Date 03/24/2026

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

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

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 four of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 14 through 27, 2026, and February 5 through 11, 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 January 25 and 26, 2026, and February 11, 2026.

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 January 25, 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 January 18 and 25, 2026.

During an interview on February 12, 2026, at 8:55 a.m., the Administrator confirmed that the facility did not meet the required NA to resident ratios on the days identified.

Plan of Correction - To be completed: 03/24/2026

1,2) Nurse aide staffing ratios will be
reviewed for the last 7 days to
evaluate if nurse aide ratios are met.

3) Nursing admin and scheduler will
be re-educated on July 1 2024 nurse
staffing and PPD requirements.

4) Weekly audit of nurse aid ratios
will be conducted for 60 days by
NHA/designee to ensure nurse aid
ratios are met. Tracking and trends
to be submitted to the QAPI

5)03/24/2026

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

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

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

Findings include:

Review of nursing schedules for 21 days from January 14 through 27, 2026, and February 5 through 11, 2026 revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on January 18 and 26, 2026.

During an interview on February 12, 2026, at 8:55 a.m., the Administrator confirmed that the facility did not meet the required LPN to resident ratio on the days identified.

Plan of Correction - To be completed: 03/24/2026

1,2) LPN staffing ratios will be
reviewed for the last 7 days to
evaluate if LPN ratios are met.

3) Nursing admin and scheduler will
be re-educated on July 1 2024 nurse
staffing and PPD requirements.

4) Weekly audit of LPN ratios will be
conducted for 60 days by
NHA/designee to ensure LPN ratios
are met. Tracking and trends to be
submitted to the QAPI committee.

5)03/24/2026

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

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

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 seven of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 14 through 27, 2026, and February 5 through 11, 2026 revealed the following total nursing care hours below minimum requirements:

Sunday, January 18, 2026: 3.07 care hours per resident.

Monday, January 19, 2026: 3.00 care hours per resident.

Tuesday, January 20, 2026: 3.10 care hours per resident.

Sunday, January 25, 2026: 2.30 care hours per resident.

Monday, January 26, 2026: 2.84 care hours per resident.

Tuesday, January 27, 2026: 3.04 care hours per resident.

Wednesday, February 11, 2026: 3.07 care hours per resident.

During an interview on February 12, 2026, at 8:55 a.m., the Administrator confirmed that the facility did not meet the minimum required nursing care hours on the days identified.

Plan of Correction - To be completed: 03/24/2026

1,2) HPPD will be reviewed for the
last 7 days to evaluate if the state
minimum PPD of 3.2 is met.

3) Nursing admin and scheduler will
be re-educated on July 1 2024 nurse
staffing and PPD requirements.

4) Weekly audit of HPPD will be
conducted for 60 days by
NHA/designee to ensure minimal
HPPD is met. Tracking and trends to
be submitted to the QAPI committee.

5)03/24/2026

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