Pennsylvania Department of Health
KINGSTON COURT 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

KINGSTON COURT SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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KINGSTON COURT 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, State Licensure, Civil Rights, and Complaint survey which ended on September 3, 2026, it was determined that Kingston Court Skilled Nursing and Rehabilitation 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, and Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

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.

�483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

�483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

�483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident the right to formulate an advance directive for two of eight residents reviewed for advanced directives (Residents 3 and 7); and failed to ensure each resident the right to formulate an advance directive by utilization of only the POLST (Pennsylvania orders for Life-Sustaining Treatment) for two of eight residents reviewed for advanced directives (Residents 6 and 63).

Findings Include:

An "Advance directive" is "a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated."

Review of the facility's policy, titled "Healthcare Decision Making," recently reviewed ... reads, in part, "It is the right of all patients/residents (hereinafter "patient") to participate in their own health care decision-making, including the right to decide whether they wish to request, accept, refuse, or discontinue treatment, and to formulate or not formulate an advance directive." Also, "If the patient does not have an advance directive: 1.2.1 Inform the patient/patient representative of their rights under state law regarding health care decision making, including the right to prepare advance directives. 1.2.2 Ask whether the patient wishes to formulate an advanced directive. 1.2.3 Provide advance directive information.1.2.4 Document that information has been provided to the patient/patient representative. 1.2.5 Offer assistance with the formulation of an advance directive."

The policy continued, "Throughout the stay, advance care planning conversations will be conducted as part of the care plan process and with significant change in condition to identify, clarify, and review existing advance directives and/or portable medical orders and determine whether the patient wishes to change or continue these instructions."

The definition of a POLST form consists of a set of medical orders that applies to a limited population of patients and addresses a limited number of critical medical decisions. The form is intended as a complement to advance directives in that it serves as a translational tool and a continuity of care assurance. In contrast, an advance directive is a form in which an individual: (1) appoints a person or persons to make health care decisions for the individual if and when the individual loses the capacity to make health care decision (typically called a "health care power of attorney"); and/or (2) provides guidance or instructions for making health care decisions, typically in end-of-life care situations (often called a "living will"). An advance directive is a direction from the patient, not a medical order.

Review of Resident 3's clinical record revealed an admission date to the facility on February 14, 2020, and diagnoses that included hypertension (elevated blood pressure) and multiple sclerosis (an autoimmune disease that affects the central nervous system, leading to damage to the myelin sheath that protects nerve fibers resulting in a range of physical and cognitive symptoms).

Review of Resident 3's most recent Brief Interview for Mental Status (BIMS- a cognitive examination performed periodically and at any change in condition) revealed a score of 14/15 (indicating the resident is cognitively intact).

Review of Resident 3's physician orders revealed the Resident wished to receive cardiopulmonary resuscitation (CPR- life saving procedures performed when the heart stops beating or when a person ceases to breathe) in the event of an emergency.

Further review of Resident 3's clinical record revealed no documentation of the facility offering Resident 3 the opportunity to formulate an advanced directive in the event of incapacity or during end-of-life treatment.

Review of Resident 6's clinical record revealed an admission date to the facility on June 29, 2021, and diagnoses that included arthritis (condition that causes pain, swelling, and stiffness in one or more joints) and hypertension (elevated blood pressure).

Review of Resident 6's most recent Brief Interview for Mental Status (BIMS- a cognitive examination performed periodically and at any change in condition) revealed a score of 15/15 (indicating the resident is cognitively intact).

Review of Resident 6's clinical record revealed a current POLST form signed by the Resident on admission to the facility in 2021 to be a full code status (CPR-cardio-pulmonary resuscitation, full treatment, the use of antibiotics if life can be prolonged, a trial period of artificial hydration and nutrition by tube to be decided at that time and was discussed with the resident). There was no documentation to show that Resident 6 was offered the opportunity to formulate an advance directive.

On August 13, 2026, at the most recent care plan meeting, Resident 6 chose to remain Full Code status. Facility documented they confirmed code status on the orders, care plan, and POLST. There was no documentation to show that Resident 6 was offered the opportunity to formulate an advanced directive.

Review of Resident 7's clinical record revealed an admission to the facility on March 8, 2024, and diagnoses that included Diabetes Mellitus Type II (a condition that affects how the body uses insulin and sugar) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood properly over time).

Review of Resident 7's most recent BIMS examination, revealed a score of 15/15.

Review of Resident 7's physician orders revealed the Resident's wishes to receive CPR in the event of an emergency.

Further review of Resident 7's clinical record revealed no documentation of the facility offering Resident 7 the opportunity to formulate an advanced directive in the event of incapacity or during end-of-life treatment.

Review of Resident 63's clinical record revealed an admission to the facility on December 5, 2025, and diagnoses that included Alzheimer's Disease (progressive brain disorder) and hospice status (end of life).

Review of Resident 63's most recent BIMS examination, revealed a score of 8/15, indicating resident has moderate cognitive impairment.

Review of Resident 63's clinical record revealed a current POLST form signed by the resident on admission to the facility in 2025 to be a do-not-resuscitate code status (DNR-do not perform cardio-pulmonary resuscitation). There was no documentation to show that Resident 63 was offered the opportunity to formulate an advanced directive.

On March 19, 2026, the facility documented they confirmed code status on the orders, care plan, and POLST. There was no documentation to show that Resident 63 was offered the opportunity to formulate an advanced directive.

During an interview with Employee 1 (Regional Director of Social Work) she stated the facility identified they were not offering its residents the opportunity to formulate an advanced directive and are currently addressing the issue with new admissions and the issue with its long-term care residents at their quarterly care plan meetings.

28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 211.12 (d) (2) (5) Nursing services

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

�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 observation, review of facility policies, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance withprofessional standards for food safety in the kitchen, prep area, two of three nourishment pantries and two of three reach-in refrigerators

Findings include:

Review of facility policy, titled Food Handling, revised May 15, 2026, read, in part, tray line holding food temperature are taken and recorded on the Production Worksheets at the beginning of each meal service. Foods in dry storage and room temperature food are in closed, labeled, and dated containers; no open boxes or bags. For product that have been opened but not fully used, a "use by" date is included on the label.

Review of facility policy, titled Personal Hygiene, revised March 20, 2026, read, in part, facial hair coverings are used to cover all facial hair.

Observation in the dry storeroom on August 31, 2026, at 9:30 AM, the following items weren't date marked: 4 bags corn bread mix, 1 bag white cake mix, 1 box of pasta, and 2 bags Rice Krispies. The lid on the bin containing corn flakes was broken, item not securely closed. At that time, interview with Employee 3 (Registered Dietitian) revealed the items should be date marked and the cereal should be securely closed.

Observation in the reach-in refrigerator outside the dry storeroom on August 31, 2026, at 9:35 AM, revealed 1 carton mild thick lemon water wasn't date marked with an open or "use by date." At that time, interview with Employee 3 revealed the lemon water should contain an open and "use by" date.

Observation in the reach-in refrigerator to the right of the grill on August 31, 2026, at 9:36 AM, revealed 1 container of cheese had a broken lid; item not securely closed.

Observation of the storage shelf in kitchen to right of ice machine on August 31, 2026, at 9:42 AM, revealed 1 box cream of wheat cereal, 1 bag grits, and 1 box lasagna noodles were open and not securely closed. Under the prep table, the bulk sugar container lid was not securely closed. At that time, interview with Employee 3 revealed the items should be securely closed.

Observation of the food temperature logs on August 31, 2026, at 9:54 AM, revealed food temperatures weren't recorded for the following meals: August 26th, 2026, breakfast and lunch; August 27th, 2026, breakfast, lunch, and dinner; and August 30th, 2026, breakfast and lunch. At that time, interview with Employee 3 revealed food temperatures are to be recorded on the production sheets for each meal.

Observation in the A/C - station pantry on August 31, 2026, at 9:59 AM, revealed the grate over the ice chest area of the ice machine was missing; and there was no air gap (pipe from the ice machine was below floor level inside the floor drain) over the floor drain. At that time, Employee 3 stated she would inform maintenance.

Observation in the A/C - station pantry with Employee 2 (Maintenance Director) on September 1, 2026, at 11:45 AM, revealed the pipe from the ice machine and the pipe under the floor were connected to each other with a coupler. At that time, Employee 2 said he would disconnect the pipes and utilize a funnel to ensure the pipe remained above the drain.

Observation in the Heritage pantry on August 31, 2026, at 10:03 AM, revealed the following: 1- 4 oz orange and 1- 4 oz apple juice containers were thawed without a use by date; product should be used within 10 days of thawing. At that time, Employee 3 stated that the juice was sent as a labeled snack and the snack label shouldn't have been removed; the label contains a date.

Observation of tray line service on September 1, 2026, at 11:50 AM, Employee 4 (Dietary Aide) was serving at the end of tray line. Employee 4 had a short beard and wasn't wearing a facial covering. At that time, interview with Employee 3 revealed Employee 4 should be wearing a beard net.

Interview with the Nursing Home Administrator on September 2, 2026, at 1:30 PM, it was revealed that food temperatures should be documented, food should cover, labeled and dated appropriately, the grate in the ice machine was replaces and the air gap is being fixed, and facial covering should be worn as needed.

28 Pa code 211.6(f) - Dietary Services

Plan of Correction - To be completed: 10/06/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1.Areas identified during the survey as needing to be discarded were corrected at that time. Containers that were broken have been removed from service and new ones were purchased to replace them. There was no negative outcome from food temperatures not being documented. The grate over the ice chest area of the ice machine and the air gap on the A\C station have been replaced. Employee #4 was instructed to put on a facial covering.
2.An initial audit will be conducted by the facility Nursing Home Administrator or designee of the facility freezers, refrigerators and dry storage areas for proper dating and storage of food items as well as each of the facility ice machines for grates and air gaps. An initial audit of the last 24 hours of food temperature logs will be conducted by the facility Nursing Home Administrator or designee for accuracy. Corrections will be made as needed.
3.Education will be provided to the facility's Dietician and facility kitchen staff on proper storage of food, how to take and document food temperatures and the proper wearing of hair and facial hair coverings. Maintenance staff will be educated on the need for ice machine grates and air gaps.
4.An audit will be conducted by the facility Nursing Home Administrator or designee of the facility freezers, refrigerators and dry storage areas for proper dating and storage of food items as well as each of the facility ice machines for grates and air gaps, food temperature logs for completion of food temperature monitoring and appropriate wearing of hair and facial hair coverings weekly x four and monthly x three.

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

�483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
�483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

�483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

�483.10(i)(3) Clean bed and bath linens that are in good condition;

�483.10(i)(4) Private closet space in each resident room, as specified in �483.90 (e)(2)(iv);

�483.10(i)(5) Adequate and comfortable lighting levels in all areas;

�483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81�F; and

�483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in three of five nursing units (B, C, and Heritage Units).

Findings include:

Review of facility policy, titled Safe and Homelike Environment, last reviewed June 17, 2026, read, in part, "The Center must provide: A safe, clean, comfortable, and homelike environment, allowing the patient to use his/her personal belongings to the extent possible. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior."

Interview with Resident 12 on August 31, 2026, at 12:20 PM, it was revealed thatthe privacy curtain around Resident 12's bed contained four dried red spots on the outside of the curtain.

Observation in Resident 29's room on August 31, 2026, at 1:27 PM, revealed the privacy curtain contained dried light tan stains. The PTAC unit filters contained a substantial amount of grey fuzzy substance.

Observation in Resident 70's room on August 31, 2026, at 1:16 PM, revealed the PTAC unit contained a substantial amount of grey fuzzy substance on the front of the unit and both filters, and a black substance on the top of the unit.

Observation in Resident 135's room on August 31, 2026, at 1:10 PM, revealed the PTAC unit filters contained a substantial amount of grey fuzzy substance, and the bathroom floor contained a five inches brownish red ring around the toilet.

Interview and observation with the Nursing Home Administrator (NHA) on August 31, 2026, at 1:17 PM, revealed the units are to be cleaned quarterly, and the unit looked like it needed to be cleaned. She also stated that she has maintenance doing a full house sweep to clean all the units in the facility. NHA contacted housekeeping to clean Resident 135's bathroom floor and stated the floor may be stained.

Interview with the Employee 4 (Director of Maintenance) on September 1, 2026, at 11:20 AM, revealed the PTAC units were due to be cleaned during the month of August 2026, and the facility hadn't completed the task prior to September 1,2026. Prior to that the units were cleaned in April 2026.

Interview with Employee 5 (Director of Housekeeping) on September 1, 2026, at 11:25 AM, it was revealed that he checks the privacy curtains on one unit per week and if they need to be laundered, they are taken down and laundered.

The following schedule was provided: Heritage unit the 1st week, B station the 2nd week, A and C stations the 3rd week and Medbridge the 4th week of the month.

Interview with the NHA on September 1, 2026, at 1:47 PM, revealed that any staff member should request that a privacy curtain be replaced when they notice it isn't clean. It was also revealed that the PTAC units should be clean, and housekeeping should wipe down the outside of the units and maintenance would clean the filters.

During a group interview with Residents 42, 60, and 86 on September 2, 2026, at 11:32 AM, they revealed their bathrooms are not cleaned often enough, and the vents are covered with dust.

Observation in Resident 86's bathroom on September 2, 2026, at 11:44 AM, revealed a fuzzy grey substance completely covering her bathroom vent.

Observation in Resident 42's bathroom on September 2, 2026, at 11:47 AM, revealed a fuzzy grey substance completely covering her bathroom vent.

Observation in Resident 60's bathroom on September 2, 2026, at 11:49 AM, revealed a fuzzy grey substance covering his bathroom vent.

During an interview with the NHA on September 3, 2026, at 11:06 AM, she revealed she would expect the facility to maintain a safe, clean, comfortable and home-like environment.

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

Plan of Correction - To be completed: 10/06/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1.Residents #12 and #29's privacy curtains were replaced during the survey. Resident #29, #70 and #135's PTAC unit filters were cleaned during the survey. Resident #135's bathroom floor was cleaned during the survey. The bathrooms and vents for Residents #42, #60, #86 were cleaned during the survey.
2.An initial audit will be conducted by the facility Nursing Home Administrator or designee of the facility resident's privacy curtains, PTAC unit filters, bathrooms and vents to ensure each is clean. Corrections will be made as needed.
3.Education will be provided to facility environmental and maintenance staff on Policy OPS200 Safe and Homelike Environment regarding ensuring each resident room is safe, clean, comfortable and home-like.
4.Ten random audits of the facility resident rooms will be conducted weekly x four and then monthly x three by the facility Nursing Home Administrator or designee to ensure resident rooms are safe, clean, comfortable and home-like with clean privacy curtains, PTAC unit filters, bathrooms and vents. Corrections will be made as necessary and results of audits will be reported at the Quality Assurance Performance Improvement meetings.
Date of compliance 10 / 6 /2026

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in �483.10(g)(17)(i)(A) and (B) of this section.

�483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations:

Based on document review and staff interview, it was determined that the facility failed to ensure each Medicare Beneficiary is provide the Notice of Non- Medicare Coverage(NOMNC, Form CMS-10123)at least two days before the end of a Medicare covered Part A stay in order to be informed the right to an expedited review by a Quality Improvement Organization for one of three residents reviewed (Resident 35).

Findings Include:

Review of Resident 35's clinical record revealed a most recent admission date to the facility on January 23, 2026, and a discharge home dated June 23, 2026, with a last covered day of Medicare A benefits dated June 22, 2026.

A review of Resident 35's NOMNC form revealed that the Resident's Responsible Party (RP) was given notice of the end of Resident 35's Medicare A covered via telephone on June 22, 2026. Therefore, Resident 35, nor his RP, was provided with the required 48-hour notice of the end of services, dated June 22, 2026, which was the same date of the end of the services.

An interview with the Nursing Home Administrator on September 1, 2026, at 8:57 AM, confirmed that Resident 35's notice was given only 24 hours instead of the required 48 hours notice.

28 Pa. Code 201.14 Responsibility of licensee

Plan of Correction - To be completed: 10/06/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1.Resident #35 was provided with his Notice of Non-Medicare Coverage (NOMNC) and transitioned to a long-term care resident.
2.An initial audit will be conducted by the facility Nursing Home Administrator or designee of the past 48 hours of current facility residents to ensure each received a timely NOMNC. Assistance will be offered as needed to ensure a review by a Quality Improvement Organization (QIO) is conducted.
3.Education will be provided to the facility Minimum Data Set Coordinators and the Interdisciplinary Team regarding ensuring each Medicare Part A Beneficiary is provided the NOMNC at least two days prior to the end of a Medicare covered Part A stay in order to be informed of the right to an expedited review by a Quality Improvement Organization.
4.Daily audits of the facility residents on Medicare Part A will be conducted by the facility Nursing Home Administrator or designee for four weeks to ensure each resident whose coverage is ending has been given the NOMNC at least two days prior to ensure he\she is informed of the right to an expedited review by a Quality Improvement Organization. Corrections will be made as necessary and results of audits will be reported at the Quality Assurance Performance Improvement meetings.
Date of Compliance 10 / 6 /2026

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:

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

�483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

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

Observations:

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that all staff members are aware of the requirements to report alleged violations of abuse, as evidence by one Nursing Assistant neglected to notify the Nursing Supervisor that a dependent Resident alleged a Nursing Assistant, on the previous shift, moved her call bell out of her reach intentionally (Resident 142).

Findings include:

Review of facility policy, titled Abuse Prohibition Policy and Procedure, last reviewed June 17, 2026, read, in part, staff will identify events that may constitute abuse and report the incident to his/her supervisor immediately.

On May 3, 2026, 11:00 PM, Resident 142 reported to Employee 9 (Dayshift Nursing Assistant [NA]) on May 4th, 2026, that her call light was taken from her by Employee 6 (Night shift NA). The report of the alleged abuse was not reported until May 7th, 2026.

Review of Resident 142's clinical record documented she was cognitively intact, was very particular about her care and would refuse care and services at times, and required maximum assistance for activities of daily living (dressing, washing hands and face, and toileting) and mobility related to bilateral weakness and general debility.

Progress noted dated May 7, 2026, documented "The resident stated that on Sunday, 5/3/2026, during night shift, she activated her call light for assistance. According to the resident, the NA assigned to her and her roommate entered the room, noticed the resident's call light was on, and turned it off without asking what the resident needed. The resident reported that she turned the call light back on. She stated that the NA then walked to the resident's bedside, snatched the call-bell cord out behind the headboard, and the button portion struck the resident's face. When the resident asked why the NA did that, the NA allegedly walked away without responding. The resident further reported that the NA took her call bell away from her at approximately 2:00 AM and that she did not have access to it for the remainder of the night until morning-shift staff arrived. The resident stated she informed NA, about the incident. The writer did skin assessments and no visible skin injury was noted."

Review of facility investigation and incident report initiated on May 7th, 2026, documented Registered Nurse assessment revealed vital signs were within normal limits and no injury was noted. The primary care provider was notified and there were no new orders. A statement wasn't obtained from Employee 6 due to not returning phone calls; she was terminated.

Employee 9 received Abuse training upon hire and was re-educated on May 7th, 2026, to report allegations of abuse immediately.

Interview with the Director of Nursing on September 2, 2026, at 12:41 PM, it was revealed that Resident 142 reported the abuse allegation to Employee 9 on May 4th, 2026. And Employee 9 didn't report the abuse allegation until May 7th, 2026; at which time the investigation was initiated and the Resident was assessed. It was revealed that if the call light cord was removed from the wall, the light would remain on and couldn't be turned off until the cord was replaced.

Interview with the Nursing Home Administrator on September 2, 2026, at 1:30 PM, it was revealed that Employee 9 should've reported the allegation immediately.

28 Pa code 211.11(b)(1) - Management

Plan of Correction - To be completed: 10/06/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1.Employee #6 no longer works at the facility. Employee #9 was re-educated on abuse reporting at the time of the incident. Resident #142 has had no negative outcomes from the May 7, 2026 incident.
2.An initial audit will be conducted of the past 30 days of abuse allegations by the facility Nursing Home Administrator or designee to ensure timeliness of supervisor notification occurred. Follow-up re-education with staff member(s) will be completed as needed.
3.Education will be provided to facility staff regarding identification of events that may constitute abuse and reporting the incident to his\her supervisor immediately.
4.Audits of allegations of abuse will be conducted weekly x four and then monthly x three by the facility Nursing Home Administrator or designee to ensure timeliness of supervisor notification occurred. Follow-up re-education with staff member(s) will be completed as necessary and results of audits will be reported at the Quality Assurance Performance Improvement meetings.
Date of compliance: 10 / 6 /2026

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 observation, policy review, clinical record review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure interventions in place to prevent accident/hazards for its residents in one resident hallway observed (200 Hall) and also per the resident's person-centered care plan for one of three residents reviewed for falls (Resident 13).

Findings include:

Review of facility policy, titled "Falls Management" last reviewed June 17, 2026, read, in part, "Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Purpose: To ensure the patient-centered care plan is reviewed and revised according to the patient's fall risk status. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care."

Review of Resident 13's clinical record revealed diagnoses that included multiple fractures of ribs, left side, muscle weakness, and difficulty in walking.

Review of Resident 13's clinical record revealed she sustained a fall on June 20, 2026.

Review of Resident 13's fall report from June 20, 2026, read, in part, Resident was found lying on her back in bathroom. She was lying diagonal in the open floor with the door closed. Her walker was on top of her. Resident Description: "I went to the bathroom, stood up from the toilet, turned around and fell." When asked why she didn't put her call light for help, she replied "I thought I could do it myself." The intervention in response to the fall revealed: "Signs hung on bedside table and walker reminding her to ask for help before getting up."

Review of Resident 13's care plan revealed a focus area "At risk forfalls due to impaired balance/poor coordination ...actual fall with rib fractures" last revised June 20, 2026, with an intervention for "Signs on bedside table and walker to remind patient to ask for help before getting up," with an initiated date of June 20, 2026.

Observation in Resident 13's room on September 1, 2026, at 9:25 AM; and September 2, 2026, at 11:46 AM; failed to reveal a sign on her bedside table or walker to remind her to ask for help before getting up.

During an interview with Employee 8 (Licensed Practical Nurse/Unit Manager) on September 2, 2026, at 12:46 PM, she revealed she could not locate any signs in Resident 13's room, including on her walker and bedside table, but she had signs in her bathroom to remind her to call of assistance.

Observation in Resident 13's room on September 3, 2026, at 9:39 AM, revealed she had a sign on the wall across from her bed and a sign on her closet door that stated, "please ask staff for assistance."

Review of Resident 13's comprehensive care plan revealed her fall intervention for the signs had been updated to "signs posted [on] the wall and by the closet door to remind [Resident 13] to ask for assistance" with a start date of September 2, 2026.

During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on September 2, 2026, at 11:06 AM, the DON revealed the signs went missing at a certain point but staff weren't able to report exactly when, but the Resident was particular about her walker and table and probably removed them herself. Therefore, where they are now is most appropriate. The NHA revealed she would expect fall interventions to be in place or updated as appropriate.

During an observation on September 3, 2026, at approximately 8:30 AM, in the 200 Hall, a white round object was found on the floor near the nurses' cart directly outside of one resident room.

An immediate interview with Employee 9 (Licensed Practical Nurse) revealed that the object was a white pill, however, the type would need to be identified.

Upon further investigation, the pill was determined to be a 20 MG Lexapro tablet.

Lexapro is a prescription antidepressant and anxiolytic classified as an SSRI. It increases serotonin availability in the brain by inhibiting its reuptake, which helps regulate mood and anxiety.

A follow up interview with the NHA and the DON at 11:14 AM, confirmed the knowledge of the Lexapro tablet found on the floor and agreed prescription resident medications should not be on the floor in high trafficked resident and visitor areas or elsewhere. The medication was subsequently destroyed and, according to the DON, an audit of resident medication administration was underway.

201.14(a) Responsibility of licensee
201.18(b)(1) Management
211.10(d) Resident care policies
211.12(d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 10/06/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1.Resident #13's care plan intervention of signs on her bedside table and walker were put into place during the survey. The pill found on the floor during the survey was disposed of in the drug buster. The Director of Nursing was unable to determine who's Lexapro it was.
2.An initial audit will be conducted by the Director of Nursing or designee of current facility residents' fall care plans for an intervention for signage and ensure the sign(s) is in place. An initial audit will be completed of the facility hallways by the Director of Nursing or designee for any medications laying on the floor. Corrections will be made as needed.
3.Education will be provided to the facility nursing staff on policy NSG215 Falls management section of interventions to reduce risk and minimize injury will be implemented as appropriate to ensure fall care plan interventions of signage are in place. Education will be completed with the facility licensed nursing staff regarding how to handle a dropped medication.
4.Five random audits by the Director of Nursing or designee will be conducted of current facility residents' fall care plans for an intervention for signage and ensure the sign(s) is in place. A weekly audit x four weeks will be completed of the facility hallways by the Director of Nursing or designee for any medications laying on the floor. Corrections will be made as necessary and results of audits will be reported at the Quality Assurance Performance Improvement meetings.
Date of compliance 10/06 /2026

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

�483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

�483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Observations:

Based on observation, clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of 29 residents reviewed (Resident 16).

Findings include:

Review of the facility policy, titled "Enteral Management," last reviewed June 17, 2026, stated, "use infection control precautions and related techniques to minimize the risk of contamination."

Review of the clinical record for Resident 16 revealed clinical diagnoses that included gastrostomy tube (an opening into the stomach, from the abdominal wall, for introduction of food) and dysphagia, pharyngeal phase (persistent difficulty or discomfort when swallowing foods, liquids, or even saliva).

Observation of Resident 16 on August 31, 2063, at 10:16 AM, revealed Jevity 1.5 calorie/milliliter (tube feeding formula) with 250 milliliters of formula remaining, hanging in the room that was not dated. Further observation revealed the bottle of Jevity was connected to tubing that was not dated. The piston syringe utilized for flushing the gastrostomy tube was dated August 28, 2026.

Review of Resident 16's current physician orders included an order to change the feeding tube syringe every day shift and to date and time the syringe.

During an interview with the Director of Nursing (DON) on August 31, 2026, at approximately 11:00 AM, the DON was requested to enter Resident 16's room and confirmed the tubing and formula was not dated, and the piston syringe that was dated August 28, 2026. The DON left the room for a few minutes then returned and discarded the formula, tubing and syringe.

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

Plan of Correction - To be completed: 10/06/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1.The enteral tube feeding formula, tubing and piston syringe for Resident #16 were changed to a new set-up with the current date during the survey.
2.An initial audit will be conducted of facility residents with orders for enteral tube feeding formula will be conducted by the Director of Nursing or designee to ensure the formula bottle and tubing have an appropriate administration date and time label as well as the correct date for the piston syringe. Corrections will be made as needed.
3.Education will be provided to the facility licensed nursing staff on the facility policy NSG213 Enteral Management and labeling the enteral tube feeding solution and tubing at time of administration.
4.Audits of facility residents with orders for enteral tube feeding solutions will be conducted weekly x four and then monthly x three by the facility Director of Nursing or designee to ensure the formula bottle and tubing have an appropriate administration date and time label as well as the correct date for the piston syringe. Corrections will be made as needed and results of audits will be reported at the Quality Assurance Performance Improvement meetings.
Date of compliance 10/06/2026

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

�483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

�483.45(h) Storage of Drugs and Biologicals

�483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

�483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on observation, facility policy, product packaging, and staff interview, it was determined that the facility failed to store and label medication in accordance with manufacture guidelines for two of three medication carts reviewed (A-Station medication cart and Heritage long hall medication cart).

Findings Include:

Review of facility provided policy, titled Medication Storage, revised January 2026, revealed, "Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in refrigerator or at room temperature. Opened insulin pens should be stored at room temperature."

Observation of the A-Station medication cart on September 3, 2026, at 9:41 AM, revealed two Lantus Insulin pens (diabetic medication) opened and in use, and not labeled with a date that they were opened or removed from refrigeration.

Observation of the Heritage long hall medication cart on August 3, 2026, at 10:00 AM, revealed one Humalog insulin pen (diabetic medication) being stored at room temperature in the medication cart. This pen was not in use and was not labeled with the date that it was removed from refrigeration.

Review of Lantus product packaging on February 26, 2025, revealed when opened or removed from refrigeration, Lantus should be discarded after 28 days.

Review of Humalog product packaging, revised August 14, 2017, revealed unopened medication should be stored in a refrigerator at a temperature between 36 to 46 degrees Fahrenheit and should be discarded 28 days after removed from refrigeration.

Interview with the Nursing Home Administrator on September 3, 2026, at 10:35 AM, revealed an expectation that the product instructions would be followed, and the medication would be stored properly.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1) Pharmacy services

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

�483.60(c) Menus and nutritional adequacy.
Menus must-

�483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

�483.60(c)(2) Be prepared in advance;

�483.60(c)(3) Be followed;

�483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

�483.60(c)(5) Be updated periodically;

�483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

�483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations:

Based on observations, select document review, and staff interviews, it was determined that the facility failed to provide a nutritionally adequate menu substitution for one of one meal observed (September 1, 2026, lunch meal).

Findings include:

Review of facility provided Consistency Census Reported, printed September 1, 2026, documented 12 residents were ordered and documented on printed tray tickets for that day a puree diet.

Review of the Diet Guide Sheet (document that specifies what food items and texture each diet should receive) for September 1, 2026, lunch documented that residents on a puree diet should've received puree chicken taco, pureed creamed corn, cream of rice and vanilla pudding.

Review of the Production Counts Sheet (document that specified the number of portions required for each menu and extension sheet item) for September 1, 2026, documented the number of puree servings as follows: chicken taco - 12, creamed corn - 13 (11- 1/2 cup servings and 2- 1 cup servings), cream of rice - no documented number of servings.

Observation of tray line service on September 1, 2026, at 11:50 AM, revealed residents who were served a puree diet were provided with puree chicken and mashed potatoes; puree creamed corn or an alternate puree vegetable wasn't provided. It was also noted that there wasn't a puree vegetable available on the steam table. By that time, five food carts had already left the kitchen (2 for Medbridge and 3 for Heritage). Residents 17, 27, 52, 71, 103, 109, and 120 were to receive a puree vegetable and didn't.

At 12:11 PM, the surveyor alerted Employee 3 (Registered Dietitian) that a puree vegetable wasn't served per the extension sheet. At that time, Employee 3 confirmed that a puree vegetable should've been served; puree corn was made and was served on tray line as of 12:14 PM, starting with C station cart.

Upon returning to the kitchen at 12:45 PM, it was observed that the last food cart was being served (A-station) no puree corn was available on the tray line and a resident ordered a puree diet wasn't served a puree vegetable; only puree taco and mashed potatoes.

At that time, the surveyor alerted Employee 3 that a puree vegetable wasn't served. Puree corn was made and the two residents on that cart were served puree corn.

Interview with the Nursing Home Administrator on September 2, 2026, at 1:30 PM, it was revealed that a puree vegetable should've been served.

28 Pa. Code 201.14. Responsibility of licensee
Pa code 211.6 - Dietary Services

Plan of Correction - To be completed: 10/06/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1.Residents #17, #27, #52, #71, #103, #109 and #120 had no negative outcome due to not being served a pureed vegetable during one day of the survey.
2.An initial audit will be conducted by the facility Nursing Home Administrator or designee of the number of current residents with pureed diet orders to ensure amounts of pureed food prepared by dietary staff is sufficient for the number of residents with a pureed diet. Corrections will be made as needed.
3.Education will be provided to the facility's Dietitian and facility kitchen staff on ensuring there is an appropriate amount of pureed food prepared to feed each resident with a pureed diet order.
4.Five random audits will be conducted by the facility Nursing Home Administrator or designee of the tray line for residents with pureed food to ensure each resident has each listed food group\item on his\her plate\tray weekly x four and monthly x three. Corrections will be made as needed and results of audits will be reported at the Quality Assurance Performance Improvement meetings.
Date of compliance 10 /06 /2026

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

�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 review of select food service committee meeting minutes, resident and staff interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures.

Findings include:

Review of the Food Committee Meeting minutes dated May 7, 2026, documented "a few residents are saying the coffee is cold."

Review of facility Food and Nutrition Services Test Tray Evaluation form, not date marked, read, in part, hot entrstarch, vegetable, and coffee temperature range greater than 140 degrees Fahrenheit (F); and cold beverage and dessert less than 55 degrees F.

Resident interviews (Residents 1, 6, 12, 13, and 86) revealed the quality of food purchased could be better, food is just warm, dislikes the food, and the food is too salty.

A test tray completed on September 1, 2026, revealed adequate portions size and the food was palatable for taste and texture for a regular diet, however, the temperature of the chicken taco, rice, coffee, and apple juice weren't palatable for temperature. The test tray was placed on a meal cart and delivered to C-station with other trays being delivered at that time; 13 minutes had elapsed between the time the test tray was prepared from the service line and presented for evaluation.

Employee 3 (Registered Dietitian) took temperatures of the food items at the time the test tray was served for evaluation. The following were the recorded highest temperatures:
Chicken taco - 118 degrees F
rice - 120 degrees F
corn- 130 degrees F
pudding - 63 degrees F
Apple juice- 64 degrees F
Coffee- 118 degrees F

Interview with Employee 3 at the time of the test tray evaluation revealed that a taco is difficult to maintain temperature, the pudding was served at room temperature, and the coffee could've been warmer.

Interview with the Nursing Home Administrator on September 2, 2026, at 1:30 PM, it was revealed that food should be served at palatable temperatures.

28 Pa. Code 201.14. Responsibility of licensee
28 Pa code 211.6 - Dietary Services

Plan of Correction - To be completed: 10/06/2026

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

1.Residents #1, #6, #12, #13, and #86 will be provided with an invitation to the monthly food committee meeting to include the dates and times for meetings through the end of the year.
2.Current facility residents will be provided with an invitation to the monthly food committee meeting to include the dates and times for meetings through the end of the year. An initial audit will be done for one meal on each unit for the temperatures of the first and last tray delivered from the meal cart.
3.Education will be provided to the facility's Dietician and facility kitchen staff on ensuring food is served at temperatures appropriate for food safety and palatability. Education will be provided to the facility nursing staff regarding passing of resident food trays when meal carts arrive on the unit.
4.Five random audits will be conducted by the facility Nursing Home Administrator or designee of residents weekly x four and monthly x three for his\her response to recent food temperatures and palatability. Five random audits will be conducted by the facility Nursing Home Administrator or designee of tray line temperature logs and for one meal on each unit for the temperatures of the first and last tray delivered from the meal cart weekly x four and monthly x three. Corrections will be made as needed and results of audits will be reported at the Quality Assurance Performance Improvement meetings.
Date of compliance 10/06/2026

� 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview and review of the facility's Infection Control Meeting attendance records, the facility failed to ensure two of the required nine multidisciplinary members were present at the Infection Control meetings (laboratory personnel and community member).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the Medical Care Availability and Reduction of Error (Mcare) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include...a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members include Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, a community member, laboratory personnel, pharmacy staff, and infection control team members.

Review of the facility's infection control meeting attendee list from November 2025 through August 2026, failed to reveal laboratory personnel or a community member participated in any of the meetings.

During an interview with the Director of Nursing (DON) on September 3, 2026, at approximately 11:50 AM, the DON confirmed the absence of laboratory personnel and a community member.

� 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 staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 10 residents on the day shift for one of 21 days reviewed (May 31, 2026), and one NA per 15 residents on the night shift for three of 21 days reviewed (February 26, 2026; March 1, 2026; and May 29, 2026) as calculated by full time equivalent (FTE - number of staff required calculated by determining the required number of hours of full time shifts worked to meet the minimum staff to resident ratio).

Findings include:

Review of staffing information for the day shift of May 31, 2024, revealed a resident census of 138, which resulted in a minimum NA FTE of 13.80; submitted information revealed the facility provided 12.93.

Review of staffing information for the night shift of February 26, 2026, revealed a resident census of 141, which resulted in a minimum NA FTE of 9.40; submitted information revealed the facility provided 9.00.

Review of staffing information for the night shift of March 1, 2026, revealed a resident census of 137, which resulted in a minimum NA FTE of 9.13; submitted information revealed the facility provided 8.00.

Review of staffing information for the night shift of May 29, 2026, revealed a resident census of 138, which resulted in a minimum NA FTE of 9.20; submitted information revealed the facility provided 9.00.

During an interview with the Nursing Home Administrator on September 3, 2026, at 11:00 AM, she acknowledged that the facility did not have staff scheduled this way, but experienced call outs and were not able to fill all open slots.

� 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 staffing documents and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24-hour period met the required minimum of 3.20 hours of direct care per resident for two of 21 days reviewed (March 1, 2026, and May 31, 2026).

Findings include:

Review of three weeks of facility staffing hours that included February 25, 2026, through March 3, 2026; May 25 through 31, 2026; and August 27, 2026, through September 3, 2026, revealed that the facility provided only 3.18 hours of direct care per resident on March 1, 2026, and 3.12 hours of direct care per resident on May 31, 2026.

During an interview with the Nursing Home Administrator (NHA) on September 3, 2026, at 11:00 AM, the NHA revealed that he was aware of the staffing issues and that the facility is working to correct this going forward.

35 P. S. � 448.809b LICENSURE Photo Id Reg:

Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.

Observations:

Based on observation, policy review, and staff interviews, it was determined that the facility failed to ensure its staff wear identification badges while performing work duties for one of one nurse aide staff observed (Employee 7).

Findings include:

Review of the facility's policy, titled "Identification Badges," recently reviewed January 2026, read, in part, "All employees of [Facility] and its affiliates (collectively "Company") are required to wear an identification badge while on duty. The identification ("ID") badge will display the legal surname of the employee or affiliate."

During an observation of Employee 7 on September 3, 2026, at 9:45 AM, revealed her to be passing ice water to residents in resident rooms, and revealed an identification badge affixed to her uniform that did not display her photo identification, her legal name including surname.

An interview with Employee 7 revealed she was provided the current identification badge, and she has been employed with the facility for approximately "2 months."

An interview with the Nursing Home Administrator on September 3, 2026, at 11:09 AM, confirmed that Employee 7 was hired on June 17, 2026, and confirmed that she was not provided or wearing the facility's appropriate identification badge while performing nurse aide duties.

28 Pa. Code 201.14 Responsibility of licensee
28 Pa. Code 211. C Nursing services

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