Pennsylvania Department of Health
WESBURY UNITED METHODIST COMM
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WESBURY UNITED METHODIST COMM
Inspection Results For:

There are 119 surveys for this facility. Please select a date to view the survey results.

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WESBURY UNITED METHODIST COMM - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on July 23, 2026, it was determined that Wesbury United Methodist Community was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25 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 review of the hospice/facility agreement and clinical records, and staff interview, it was determined that the facility failed to maintain current information related to Hospice services for three of 28 residents reviewed (Residents R27, R77, and R122).

Findings include:

The "Skilled Nursing Facility Inpatient Care Services Agreement" dated 3/21/23, revealed that:
"Article II section 2.2 Plan of Care indicated the plan of care should be maintained in consultation with Skill Nursing Facility (SNF) representatives during the period the patient is admitted to the SNF, hospice shall communicate to the SNF any changes in the condition of patient which require updating the Plan of Care for each patient, and provide SNF with the updated Plan of Care; section 2.4 Manner of Communication all communication between the Hospice and SNF pertaining to the care and services provided to the patient shall be documented in the patient's clinical record."
"Article III section 3.2 Coordination of Services indicated that the SNF will obtain the most recent hospice Plan of Care specific to each patient. "

Resident R27's clinical record revealed an admission date of 6/08/20, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), difficulty swallowing, difficulty walking, and aphasia (language disorder that affects how you speak and understand language. A physician's order dated 5/22/26, indicated he/she was admitted to hospice services effective 11/17/2025.

Further review of Resident R27's clinical record revealed that the most recent hospice staff visit notes were dated 6/18/26, and that the hospice plan of care ended on 7/14/26.

Interviews on 7/22/26, at 2:13 p.m. with Licensed Practical Nurse (LPN) Employees E3 and E5, confirmed that Resident R27's hospice care plan was not current and that the clinical record lacked recent hospice staff visit notes.

Resident R77's clinical record revealed an admission date of 9/17/25, with diagnoses that included adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), Parkinsonism (clinical syndrome characterized by the four motor signs that are found in Parkinson's disease: tremor, bradykinesia (slowed movements), rigidity, and postural instability.), aphasia, and stroke. A physician's order dated 5/22/26, indicated he/she was admitted to hospice services effective 10/03/25.

Further review of Resident R77's clinical record revealed that the most recent hospice staff visit notes were dated 7/01/26, and that the hospice plan of care ended on 5/29/26.

Resident R122's clinical record revealed an admission date of 3/16/22, with diagnoses that included psychosis (loss of contact with reality that affects the mind and causes delusions, hallucinations, and other symptoms), difficulty swallowing, Alzheimer's Disease, and Barrett's Esophagus (condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach (esophagus) becomes damaged by acid reflux, which causes the lining to thicken and become red). A physician's order dated 5/22/26, indicated that he/she was admitted to hospice service effective 1/24/24.

Further review of Resident R122's clinical record revealed that the most recent hospice staff visit notes were dated 6/20/26.

During an interview on 7/21/26, at 1:57 p.m. LPN Employee E2 confirmed that Resident R77's hospice care plan was not current and that the clinical record lacked recent hospice staff visit notes, and that Resident R122's clinical record lacked recent hospice staff visit notes.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.5(f)(iii) Medical records

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

Plan of Correction - To be completed: 09/11/2026

Resident R27's, visit notes and updated plan of care were immediately received from the Hospice provider.
Resident R77's visit notes and updated plan of care were immediately received from the Hospice provider.
Resident R122's visit notes were immediately received from the Hospice provider. Care plans for all three residents were updated as necessary.
The Director of Nursing and/or designee conducted an audit of all residents currently receiving hospice services to ensure the current hospice plans of care were current in the medical record, hospice notes were maintained and up to date, and hospice recommendations were reviewed. Any missing documentation was obtained by the hospice provider and filed in the resident's medical record. Care plans were updated as necessary.
The facility revised its process for receiving, reviewing and filing hospice documentation. The Licensed staff, social services, medical records and MDS coordinator were educated on the requirement to ensure that hospice visit notes and current hospice plans of care are received promptly, maintained in the medical record, reviewed by the Interdisciplinary Care and updates are reflected in the resident's comprehensive care plan when appropriate. The Nursing Home Administrator has communicated with the Hospice provider to establish a consistent process for timely receipt of documentation.
The Director of Nursing and/or designee will audit all of the medical records of residents receiving hospice care weekly to ensure the information in the record is current for 4 weeks and then monthly thereafter to ensure compliance. Results will be taken to the Quality Assurance and Performance Improvement committee for review and further recommendations.

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

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policy and clinical records, observations, and staff interviews it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during the care of a wound for one resident (Resident R11), maintaining sanitary respiratory equipment for two residents (Residents R58 and R114) and implement infection prevention measures for one of 28 residents (Resident R129).

Findings include:

A facility policy entitled "Wound Care Procedure for Wounds" dated 5/01/26, indicated to remove the soiled dressing; remove gloves and discard in the bag; wash your hands, put on clean gloves, and clean the wound; place soiled gauze used for cleaning in the bag; remove your gloves and place in the bag; wash your hands, put on new gloves; and apply clean dressing.

A facility policy entitled "Enhanced Barrier Precautions" dated 5/01/26, indicated that personal protection equipment (PPE [gloves, gowns, etc.]) for enhanced barrier precautions (EBP) is only necessary when performing high-contact care activities and include transferring, providing hygiene, and assisting with toileting.

Resident R11's clinical record revealed an admission date of 4/15/26, with diagnoses that included hyperosmolality (occurs when the blood contains an unusually high concentration of dissolved particles) and hypernatremia (high sodium in the blood, often stems from losing too much water or gaining too much sodium, leading to an imbalance in your body), urine retention, and difficulty swallowing.

Observation of wound care on 7/22/26, at 9:38 a.m. revealed that LPN Employee E6 removed the soiled wound dressing from Resident R144's lower back, changed his/her gloves and failed to perform hand hygiene.

Further observation of wound care on 7/22/26, at 9:47 a.m. revealed that LPN Employee E6 removed the soiled wound dressing from Resident R144's right ear, failed to perform hand hygiene and change his/her gloves, dated the tape of the new dressing, cleansed the right ear wound, and applied the new dressing.

During an interview on 7/22/26, at 10:00 a.m. LPN Employee E6 confirmed that he/she should have performed hand hygiene and changed gloves when discarding the soiled dressings.

Resident R58'a clinical record revealed an admission date of 5/19/26, with diagnoses that included stroke, ataxia (difficulty walking), COPD, dependence on supplemental oxygen (oxygen provided by nasal cannula from an oxygen tank or concentrator [medical device that provides supplemental oxygen by taking in room air, removing nitrogen, and delivering oxygen-enriched gas to the patient] to ensure a person's oxygen levels are sufficient]), and long-term respiratory failure with hypoxia (low levels of oxygen in your body tissues that can lead to symptoms like confusion, restlessness, difficulty breathing, rapid heart rate and bluish skin).

Resident R58's physician orders revealed an order dated 5/19/26, for oxygen at 1-2 liters per minute (LPM) via nasal cannula every shift (QS), and an order dated 5/19/26 for Ipratropium 0.5 mg Albuterol 3mg (milligrams) /3ml (milliliter) nebulization solution via HHN (a medical device that turns liquid medication into mist and is inhaled by a face mask or holding a plastic pipe) as needed every 6 hours.

Observation on 7/20/26, at 2:30 p.m. Resident R58's oxygen tubing with a nasal cannula was lying on top of Resident R58's unmade bed, and his/her HHN was observed hanging by the elastic strap over the door of the nebulizer machine and were not in zip lock type bags. There were also two empty zip lock type bags taped to the nightstand and on the oxygen concentrator casing, and the concentrator was turned on.

Further observation at 3:11 p.m. Resident R58's oxygen tubing with a nasal cannula was lying on top of Resident R58's made bed, and his/her HHN was observed hanging by the elastic strap over the door of the nebulizer machine and were not in zip lock type bags. There were also two empty zip lock type bags taped to the nightstand and on the oxygen concentrator casing, and the concentrator was turned on.

During an interview at that time, Licensed Practical Nurse (LPN) Employee E3 confirmed that Resident R58's oxygen tubing and HHN should be placed in plastic bags when not in use.

Resident R114's clinical record revealed and admission date of 5/26/23, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), chronic obstructive pulmonary disease (COPD - when your lungs do not have adequate air flow), dependence on supplemental oxygen, and long-term respiratory failure with hypoxia.

Resident R114's physician's orders revealed an order dated 1/03/24, for oxygen at three LPM via nasal cannula QS [every shift].

Observation on 7/20/26, at 3:10 p.m. revealed that Resident R114 was self-propelling in his/her wheelchair through the unit common area, proceeded through the unit activity room and his/her oxygen tubing connected to the portable oxygen tank attached to the wheelchair was dragging on the floor, and the portable oxygen tank was turned on. At that time Nurse Aide (NA) Employee E4 picked up the nasal cannula portion of the oxygen tubing and placed it against the resident's face to reapply it to his/her nose. At the time of the observation, NA Employee E4 confirmed that the nasal cannula should be cleansed before reapplying and draped the oxygen tubing over the handle of Resident R114's wheelchair and walked away.

During an observation and interview on 7/20/26, at 3:16 p.m. LPN Employee E3 confirmed the position of the oxygen tubing on Resident R114's wheelchair handle and that the oxygen tubing should be replaced.

Resident R122's clinical record revealed an admission date of 3/16/22, with diagnoses that included psychosis (loss of contact with reality that affects the mind and causes delusions, hallucinations, and other symptoms), difficulty swallowing, Alzheimer's Disease, and Barrett's Esophagus (condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach (esophagus) becomes damaged by acid reflux, which causes the lining to thicken and become red).

Resident R122's physician's orders revealed an order dated 5/21/26, for oxygen at two LPM via nasal cannula as needed.

Observation on 7/21/26, at 8:30 a.m. revealed Resident R122's oxygen tubing lying on the floor next to his/her oxygen concentrator, and an empty zip lock type bag was taped to the top of the oxygen concentrator casing.

During an interview on 7/21/26, at 9:09 a.m. LPN Employee E2 confirmed that the oxygen tubing was lying on the floor and should have been stored in the zip lock type bag.

Resident R129's clinical record revealed an admission date of 7/22/24, with diagnoses that included non-Hodgkin lymphoma (type of cancer that affects the lymphatic system), stroke with left-sided hemiplegia (condition that causes paralysis on one side of the body due to brain or spinal cord damage), and COPD.

Resident R129's' physician's order' revealed an order dated 12/08/25, for EBP every shift.

Resident R129's care plan entitled "infection" included an intervention dated 7/06/26, for staff to wear PPE as appropriate.

Observation on 7/21/26, at 9:06 a.m. revealed signage on the outside doorframe to his/her room indicated to implement EBP to provide high-contact resident care, and an equipment storage hanging on the back of Resident R129's door included gowns, masks, gloves, etc.

Observation on 7/21/26, at 9:07 a.m. of medication administration with LPN Employee E2, Resident R129 was being assisted to his/her chair by NA Employee E1 after assisting him/her in the bathroom, and NA Employee E1 was not wearing EBP.

During an interview at that time NA Employee E1 confirmed he/she did not wear a gown to take resident to the bathroom did know that he/she needed to, and that there is "usually stuff hanging on the door." NA Employee E1 then confirmed the presence of PPE hanging on the back of Resident R129's room door.

Observation confirmed at that time by LPN Employee E2 that NA Employee E1 did not implement EBP by not wearing appropriate PPE during high-contact care for Resident R129 and that staff are required to wear gloves and a gown when assisting Resident R129 in the bathroom.

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

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: 09/11/2026

The facility immediately assessed residents R11, R58, R114 and R 129 and implemented appropriate infection prevention interventions based on the identified concern. The resident's condition, treatment needs, and infection prevention measures were reviewed by the Infection Preventionist.
The Director of Nursing and Infection Preventionist completed a review of residents who many have been affected by the same practice concern.
All nursing staff were educated to infection prevention practices which include but not limited to proper hygiene practices before and after care, appropriate use of PPE, following transmission-based precautions when indicated, proper cleaning, disinfection and storage of equipment, safe resident care practices to prevent the spread of infection and prompt reporting and management of signs and symptoms of infection.
The Infection Preventionist and/or designee will observe a minimum of 5 wound-care treatments weekly for 4 weeks , followed by 5 observations monthly for 2 months to ensure appropriate hand hygiene, glove changes, disposal of contaminated materials, clean-glove application, wound cleansing and prevention of cross-contamination.
All residents receiving oxygen therapy and/or nebulizer treatments will be audited weekly for 4 weeks, followed by monthly audits for 2 months, to verify the tubing, nasal cannulas and nebulizer equipment are appropriately handled, clean and stored off the floor and according to policy. Five high-contact care activities will be observed weekly for 4 weeks, followed by 5 observations monthly for 2 month, involving resident requiring Enhance Barrier precautions to ensure the appropriate use of Personal Protective Equipment. Results will be taken to the Quality Assurance and Performance Improvement Committee for review and further recommendations.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Plan of Correction - To be completed: 09/11/2026

Resident R2 now has a physician order to change the oxygen tubing and documentation of that change in the clinical record.
Resident R12 nasal cannula was changed and documented in the clinical record.
Resident R81's Hand Held Nebulizer has been changed, placed in a zip lock type bag and documented in the clinical record.
Resident R92's Hand Held Nebulizer has been changed and documented in the clinical record.
Resident R133 nasal cannula was changed and documented in the clinical record.
Resident R138 now has a physician order to change the oxygen tubing and documentation of that change in the clinical record.
The facility policy has been updated to ensure the documentation includes the month, day and year. The Director of Nursing and/or designee completed an audit of all residents receiving oxygen therapy and hand held nebulizers to ensure orders for oxygen and/or treatment, documentation of O2 saturations, equipment stored in zip lock type bags, nasal canula tubing, mask, extension tubing and zip lock style bags have a physician order to be changed weekly, the weekly change is documented in the clinical record with the date to include the month, day and year and the care plan addresses current respiratory needs.
All licensed staff will be inservice to include but not limited the policies and procedures for Oxygen Therapy and Equipment, Hand Held Nebulizers, Hand hygiene and appropriate use of personal protective equipment (PPE).
The Director of Nursing and/or designee will monitor residents receiving oxygen therapy and hand held nebulizers to ensure orders for oxygen and/or treatment, documentation of O2 saturations, equipment stored in zip lock type bags, nasal canula tubing, mask, extension tubing and zip lock style bags have a physician order to be changed weekly, the weekly change is documented in the clinical record with the date to include the month, day and year and the care plan addresses current respiratory needs weekly for 4 weeks and 5 residents receiving oxygen therapy and/or hand held nebulizers monthly thereafter to ensure compliance. The results will be taken to the Quality Assurance and Performance Improvement committee for review and further recommendations.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) REQUIREMENT Discharge Process:

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

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

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

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

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

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

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

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

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

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

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

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer, and failed to ensure that the necessary resident information was communicated to the receiving health care provider for one of 28 residents reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed an admission date of 9/22/22, with diagnoses that included left femur fracture (fracture of the longest bone in the body connecting hip and knee), muscle weakness, difficulty in walking, and encounter for orthopedic aftercare (care for fracture of bone). Resident R1 was transferred to the hospital on 4/20/26.

The clinical record lacked documentation that Resident R1 and/or their representative were provided with a copy of the facility bed-hold policy, and/or that the necessary resident information was communicated to the receiving hospital.

During an interview on 7/23/26, at 9:00 a.m. the Director of Nursing (DON) confirmed that Resident R1 and/or their representative were not provided with a copy of the facility bed-hold policy when transferred to the hospital on 4/20/26, but should have been provided to further explain how long his/her bed could be held during a leave of absence and the cost per day. The DON further confirmed that Resident R1's clinical record lacked evidence that necessary resident information was communicated to the receiving health care provider when Resident R1 was transferred to the hospital on 4/20/26.

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

Plan of Correction - To be completed: 09/11/2026

The facility notified the responsible party for resident R1 that the facility failed to provide the Transfer bed hold policy when Resident R1 was transferred to the hospital on 4/20/2026. The resident did not lose the bed and in fact had a 15-day paid bed hold.
The Director of Nursing and/or designee completed an audit of all residents transferred to the hospital within the last 30 days to ensure the discharge notices were provided, documentation of the notices provided were in the medical record, the receiving provider received transfer information as well as, the resident representative and physician notifications were documented.
The Director of Nursing and/or designee inserviced the licensed nursing staff and ward clerks to include but not limited to the Bed Hold policy as well as the necessary resident information the needs communicated to the receiving hospital. This policy includes but not limited to the transferring nurse is responsible providing the Bed Hold notice at the time of transfer with a written nurses note in the medical record indicating the completion. The ward clerks will audit each resident transfer to ensure a nurse's note reflects the bed hold was issued. If such notice was not issued the Business Office Manager and/or Administrator will be notified to ensure the resident/responsible party is notified within 24 hours of the transfer.
The Director of Nursing and/or designee will monitor all of the transfers and discharges to ensure the bed hold notification as well as the transfer of information was completed daily for 4 weeks and then 10 discharges/transfers monthly for 2 months. The results will be taken to the Quality Assurance and Performance Improvement (QAPI) committee for review and recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current necessary care and services for one of 28 residents reviewed (Resident R95).

Findings include:

Review of a facility policy entitled, "Care Plans (Plans of Service)" dated 5/01/26, indicated that care plans are updated whenever a change is necessitated by a resident's change in condition, physician, or when scheduled by the minimum data set (MDS [a standardized tool used in nursing homes to evaluate residents' health, functional status, and care needs] team for a quarterly, change in condition, or annual review.

A facility policy entitled "Incident/Accident Management Program" dated 5/01/26, indicated that when a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and put into place an intervention to prevent this from happening again.

Review of Resident R95's clinical record revealed a current admission date of 3/17/26, with diagnoses that included heart disease, muscle weakness, vascular dementia (type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues), and altered mental status, age-related debility (distinct medical condition that goes beyond normal aging, characterized by a general decline in strength, mobility, and resilience).

Resident R95's clinical record revealed that he/she experienced an unwitnessed fall on 4/12/26, at 10:15 p.m. and that continued diagnostic testing on 4/15/26, identified a fractured right clavicle (collar bone).

Review of the facility's fall investigation dated 4/12/26, indicated that Resident R95's care plan was updated, and lacked documentation of what items were updated.

A care plan entitled "Falls" included interventions dated 3/17/26, and a goal date of 6/15/26. The care plan lacked evidence that the care plan was updated in reference to Resident R95's fall with major injury on 4/12/26.

During an interview on 7/23/26, at 12:40 p.m. the Nursing Home Administrator confirmed that Resident R95's falls care plan did not reflect updates related to the fall with major injury from 4/12/26, and that the goal date for the falls care plan was 6/15/26.

28 Pa. Code 211.5(f)(ix) Medical records

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: 09/11/2026

The Interdisciplinary Team (IDT) reviewed and updated resident R95's care plan to ensure the care plan accurately reflected the resident's current condition, goals and interventions which includes but not limited to the fall. The attending physician, resident, and/or resident responsible party were involved in the care planning process as appropriate, and the revised care plan was communicated to the employees responsible for the resident's care.
The Director of Nursing and/or designee completed an audit of all falls within the past 30 days to ensure the care plans were developed, revised and accurately reflected current needs.
All licensed staff and members of the interdisciplinary team were re-educated to the policy Care Plans (Plans of Service) as well as the Incident/Accident Management Program which includes but not limited to the nurse working at the time updating the care plan when the resident has a change in condition and/or a fall. New admissions, readmissions, and significant changes residents will be reviewed Monday through Friday by the interdisciplinary team during the daily clinical meeting to ensure care plan revisions are reviewed and updated as needed.
The Director of Nursing and/or designee will monitor new admissions, readmissions, significant changes to ensure the care plans were developed, revised and accurately reflected current needs weekly for 4 weeks and 10 resident records per month for two months to ensure compliance. The results will be taken to the Quality Assurance and Process Improvement (QAPI) committee for review and further recommendations.

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 review of clinical records and facility policies, and staff interviews, it was determined that the facility failed to completely investigate an unwitnessed fall for one of 28 residents (Resident R95).

Findings include:

A policy entitled "Resident Incident Reporting" dated 5/0/26, indicated that the charge nurse will complete a Resident Incident Report which will include all documentation related to interviews or resident, staff members, and any other witnesses.

A facility policy entitled "Incident/Accident Management Program indicated after evaluating and treating the resident immediately, the registered nurse will investigate the circumstances of the incident and look for all possible causes; the registered nurse should talk with the nursing assistants, residents, and any other witnesses.

Review of Resident R95's clinical record revealed a current admission date of 3/17/26, with diagnoses including heart disease, muscle weakness, vascular dementia (type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues), and altered mental status, age-related debility (distinct medical condition that goes beyond normal aging, characterized by a general decline in strength, mobility, and resilience).

Resident R95's clinical record revealed that he/she experienced an unwitnessed fall on 4/12/26, at 10:15 p.m. and that continued diagnostic testing on 4/15/26, identified a fractured right clavicle (collar bone).

Review of the facility investigation related to Resident R95's unwitnessed fall on 4/12/26, lacked evidence of resident, staff and other witness interviews.

During an interview on 7/23/26, at 12:40 p.m. the Nursing Home Administrator confirmed there was no additional documentation to support that Resident R95's fall was thoroughly investigated.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.12(d)(1)(5) Resident care policies

Plan of Correction - To be completed: 09/11/2026

The Director of Nursing and the Interdisciplinary team reviewed the incident involving resident R95. A post-incident investigation was completed to the extent possible. The resident's fall risk assessment and care plan were reviewed and revised as indicated based on the findings of the investigation and the resident's current condition. The physician and responsible party were notified as appropriate.
The Director of Nursing and/or designee reviewed the accident investigations completed during the past 30 days to include but not limited to ensuring a root cause was determined and intervention in place, the resident incident report was completed which includes all documentation related to the interview of resident, staff members and any other witnesses, a nurses noted completed regarding the incident as well as physician and responsible party notification.
Licensed nurses and department supervisors will be inserviced to the policy and procedure for Resident Incident Reporting. All incident reports will be reviewed Monday through Friday by the Interdisciplinary team during the daily clinical meeting to ensure a root cause was determined and intervention in place, the resident incident report was completed which includes all documentation related to the interview of resident, staff members and any other witnesses, a nurses noted completed regarding the incident as well as physician and responsible party notification.
The Director of Nursing and/or designee will monitor resident incidents weekly to ensure to ensuring a root cause was determined and intervention in place, the resident incident report was completed which includes all documentation related to the interview of resident, staff members and any other witnesses, a nurses noted completed regarding the incident as well as physician and responsible party notification for 4 weeks and monthly thereafter to ensure compliance. The results will be taken to the Quality Assurance and Performance Improvement committee for review and further recommendations.

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

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

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

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

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

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

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

Observations:

Based on review of clinical records, and staff interviews, it was determined that the facility failed to have complete, accurate, and systematically organized documentation regarding ensuring that additional water ordered for tube feeding is administered per orders for one of 28 residents reviewed (Resident R11).

Findings include:

Resident R11's clinical record revealed an admission date of 4/15/26, with diagnoses including hyperosmolality (occurs when the blood contains an unusually high concentration of dissolved particles) and hypernatremia (high sodium in the blood, often stems from losing too much water or gaining too much sodium, leading to an imbalance in your body), urine retention, and difficulty swallowing.

Resident R11's physician's orders regarding tube feedings and flushes included:
4/15/26, fluid intake mL[milliliters] provided by nursing each shift for hydration.
4/16/26, irrigate with 30 mL water before and after medications.
4/21/26, flush with 100 mL water every shift for nursing instruction with medications.
4/21/26, flush with 100 mL water four times per day for nursing instruction.
5/02/26, Jevity 1.5 Cal 0.06 gram-1.5kcal/mL oral liquid at 50 mL per hour enteral tube feeding. Spike and hang bottle at 11:00 a.m. Do not take down until bottle is empty daily regardless of time.

Review of Resident R11's Medication Administration Record (MAR) revealed nursing staff documented administration of 100 mL water every shift and four times per day; 30 mL water before and after medication administration; and Jevity infused starting at 11:00 a.m. daily.

Review of Resident R11's MAR documentation for fluid intake (mL) provided by nursing each shift lacked direction for staff to include or exclude the 100 mL water flushes every shift and four times per day, Jevity feeding infusion, and 30 mL flushes before and after medication administration resulting in inaccurate and inconsistent documentation of fluid intake provided by nursing staff each shift.

Review of Fluid Management Report dated 7/12/26, to 7/21/26, provided by the facility on 7/23/26, indicated Resident R11's 24-hour fluid intake totals ranged between 910 mL to 2340 mL.

During an interview on 7/23/26, at 10:30 a.m. the Director of Nursing confirmed 24-hour fluid intake parameters are not clearly written on the MAR, and there is a wide gap in the documentation of the water intake, and that the orders need to be clearer to ensure that Resident R11 is receiving the appropriate amount of water flushes.

28 Pa. Code 211.5(f)(viii)(x) Medical records

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

Plan of Correction - To be completed: 09/11/2026

Resident R 11's MAR now includes parameters to document the fluid intake, including oral fluids and water flushes provided through the enteral feed tubes. The care plan and nursing documentation were reviewed and updated as necessary to reflect the resident's hydration needs, interventions, and monitoring requirements.
An audit of all enteral tube feedings was completed to ensure all residents have parameters in place to document the fluid intake, including oral fluids and water flushes provided through the enteral tube.
All licensed staff will be inserviced to include but not limited to documenting the fluid intake which includes oral fluids and water flushes provided through the enteral feed tubes.
The Director of Nursing and/or designee will monitor all residents to ensure they have parameters in place to document the fluid intake, including oral fluids and water flushes provided through the enteral tube weekly for 4 weeks and monthly thereafter. Results will be taken to the Quality Assurance and Performance Improvement committee for review and further recommendations.

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