Pennsylvania Department of Health
CHAPEL MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CHAPEL MANOR
Inspection Results For:

There are 215 surveys for this facility. Please select a date to view the survey results.

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


CHAPEL MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey and an Abbreviated survey in response to three complaints, completed on December 3, 2025, it was determined that Chapel Manor, was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities related to the health portion of the survey process.

Plan of Correction:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations: Based on observation and staff interviews, it was determined that the facility failed to ensure that a resident was treated with respected during a group meeting for one of four residents reviewed (Resident 35). Findings include: On September 16, 2025, at 1:30 p.m., a resident council meeting was held with seven alert and oriented residents (R93, R78, R129, R35, R149, R52, and R13). At 1:57 p.m., during the meeting, Licensed Nurse Employee E8 entered and stated, "Excuse me, I need to give Resident R35 medication." Employee E8 then proceeded to administer three pills in a medication cup along with a cup of water. The nurse left the room immediately after. Resident R35, appeared uncomfortable and unprepared to take his medication in front of peers. At 2:06 p.m., following the meeting, Resident R35 was interviewed privately regarding the incident. Resident R35 reported: "It made me feel uncomfortable. I was surprised when the nurse came in to give me medsit caught me off guard." At 2:30 p.m., a meeting was conducted with the Administrator, Employee E1 and Director of Nursing, Employee E2. Both confirmed that it was not appropriate for the nurse to administer medication during the resident council meeting. 28 Pa Code 211.12(d)(1) Nursing services

Plan of Correction - To be completed: 12/09/2025

Social Worker provided emotional support to resident R35.
Upon notification of alleged violation employee E8 was educated on Medication Administration with a focus on dignity and respect.
NPE/designee will educate licensed nursing staff on Medication Administration Policy and Procedure with a focus on dignity and respect.
DON/designee will conduct 2 random medication passes per unit weekly x 4, then monthly X 2 to ensure Medication Administration practices are being followed with a focus on dignity and respect.
Results of audits will be reviewed with the QAPI committee monthly X 3.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

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

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§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 review of facility policy, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to conduct a complete and thorough investigation related to a resident fall for one of four residents reviewed (Resident R174). Findings Include: Review of facility policy "Abuse Prohibition" revised October 24, 2022, revealed the facility will implement an abuse prohibition program which would include investigation of incidents and accidents. Review of Resident R174's quarterly Minimum Data Set (MDS federally mandated resident assessment and care screening) dated April 1, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS -a structured interview to assess cognitive function and orientation) score of 14 (intact cognitive response). Further review of Resident R174's the MDS revealed the resident had diagnoses of muscle weakness, osteoarthritis (joint pain and stiffness), mild cognitive impairment, and polyneuropathy (condition characterized by damage to multiple peripheral nerves, leading to symptoms such as pain, weakness, and sensory loss). Review of Resident R174's comprehensive care plan revised December 30, 2024, revealed the resident was at risk for falls related to impaired mobility. Further review of Resident R174's comprehensive care plan revised December 30, 2024, revealed the resident required assistance for transferring from one position to another related to difficulty ambulating and unsteady gait. Review of facility documentation submitted to the State Survey Agency on May 29, 2025, revealed on May 28, 205, Resident R174 had a fall on the facility van while out on an appointment escorted by facility van driver, Employee E6. Review of facility documentation revealed a statement was obtained by van driver, Employee E6. Review of the statement by van driver, Employee E6, dated May 2025, revealed Resident R174 was lifted onto the ramp [in his wheelchair] to the bus and as van driver, Employee E6, walked around to the passenger door Resident R174 pulled the wheelchair breaks and he/she fell backward, hitting his/her head on the side of the bus. Continued review of facility documentation/investigation revealed no documented evidence that a statement was obtained by Resident R174 regarding details of the incident and subsequent fall. 28 Pa Code 201.14 (a) Responsibility of licensee.

Plan of Correction - To be completed: 12/09/2025

Resident R174 no longer resides at the facility.
NHA/designee to conduct an initial audit X past 14 days on current/open investigations related to a fall to ensure statement from resident involved has been obtained with a thorough investigation completed.
NPE/designee will re-educate NHA/DON on Abuse/Neglect Policy and Procedure with emphasis on obtaining resident involved statement, with a thorough investigation.
NHA/designee will audit fall investigations weekly x 4, then monthly x 2 to ensure a statement obtained from resident with a complete and thorough investigation.
Results of audits will be reviewed with the QAPI committee monthly X 3.

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

§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 clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in the language and manner they understand for two residents reviewed for hospitalizations (Resident R171 and R3). Findings include: Review of Resident R171's medical records revealed that on July 21, 2025, the resident was admitted to the hospital for tachycardia (irregular heartbeat). Continued review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. Interview with the facility administrator on September 18, 2025, at 12:35 p.m. confirmed this finding. Review of Resident R3's clinical record revealed that Resident R3 was transferred to the hospital on February 17, 2025, for influenza. Continued review revealed that the resident was transferred to the hospital on April 18, 2025, for lower extremity weakness. Further review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. Follow-up interview with the facility administrator on September 18, 2025, at 10:29 a.m. confirmed the above-mentioned findings and stated that it is not facility practice providing the residents and/or their representative with a written notice for transfers. Further interview confirmed that the ombudsman was not notified regarding Resident R3's transfers on February 17, 2025, and April 18, 2025. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 12/09/2025

Residents R171 and R3 no longer reside at the facility therefore cannot be retroactively corrected. Resident R3 transfers have been reported to the Ombudsman.

Initial audit to be completed for all discharges x past 30 days to ensure notification has been made to the Ombudsman, as well residents currently on hospital leave to ensure Bed Hold Policy has been issued.

NHA/designee will re-educate Nursing administration & Business Office staff on the Bed Hold/Notification Policy and Procedure. Social Services will be re-educated regarding notification of discharge/transfer to the Ombudsman.

NHA/designee will complete an audit weekly x 4, then monthly x 2 to ensure that all residents and/or RP's are notified in writing of transfer/discharge and Bed Hold Policy. Social Services Director/designee will complete an audit monthly X 3 to ensure notification to the Ombudsman monthly.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations: Based on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to develop comprehensive care plan for three of 33 residents reviewed (Resident R26, R102, and R61). Findings Include: Review of facility policy "Person-Centered Care Plan" revised September 15, 2025, revealed the facility will develop and implement person-centered care plan for each resident with measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs. The care plan must be customized to each individual patient's preferences and needs. Review of Resident R26's comprehensive Minimum Data Set (MDS federally mandated resident assessment and care screening) dated August 2, 2025, revealed a Brief Interview for Mental Status (BIMS - a structured interview to assess cognitive function and orientation) was not assessed because the resident is "rarely/never understood". A staff assessment of mental status was conducted which revealed Resident R26 had short and long-term memory problems. Continued Review of Resident R26's MDS dated August 2, 2025, revealed the resident had diagnoses of hemiplegia (paralysis) or hemiparesis (weakness), aphasia (loss of ability to understand or express speech, caused by brain damage), and anxiety (characterized by feelings of tension, worried thoughts, and physical changes). Per a review of the MDS Resident R26 was dependent on staff for all activities of daily living (eating, transferring, hygiene, grooming, dressing). Review of Resident R26's comprehensive care plan revised February 8, 2022, revealed the resident had impaired communication as evidenced by difficulty making self-understood. Further review of Resident R26's comprehensive care plan revised March 5, 2024, revealed the Resident R26 had impaired cognitive function or impaired thought processes. Review of Resident R102's quarterly MDS dated August 13, 2025, revealed the resident had a BIMS score of 15 (intact cognitive response) and diagnoses of depression (persistent feeling of sadness and loss of interest) and bipolar disorder (extreme mood swings). Review of Resident R102's comprehensive care plan revised February 27, 2025, revealed the resident was able to safely transfer in and out of bed without assistance. Continued review of Resident R102's comprehensive care plan revised November 1, 2021, revealed the resident had the tendency to exhibit sexually inappropriate behavior with other residents. Observations on September 15, 2025, at 1:25 p.m. revealed Resident R26 and R102 were sitting close together in front of the nurses' station holding hands. Interview with Resident R26 revealed the two have been in a "relationship" for "three years". Interview on September 15, 2025, at 1:40 p.m. with Registered Nurse, Employee E7, confirmed Resident R26 and R102 enjoy sitting together and holding hands. Registered Nurse, Employee E7, indicated that Resident R26 and R102 do not spend unsupervised time alone in either room. Resident R26 and R102 reportedly sit where staff can see them and the two only just hold hands. Review of Resident R26's clinical record revealed a care plan meeting note dated August 14, 2024, that indicated a discussion was had with Resident R26's guardian regarding friendship with Resident R102 and that the guardian was informed of the resident's holding hands. The guardian agreed with the friendship and appreciated education. Review of Resident R26 and R102's comprehensive care plans revealed no documented evidence that a person-centered care plan was developed for either resident regarding the consent/boundaries of the friendship. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Plan of Correction - To be completed: 12/09/2025

Residents R26 & R102 care plans have been updated to reflect the consent/boundaries of their friendship.

Social Services Director/designee to conduct an initial audit of other residents having a similar friendship/companionship with care plans updated as appropriate.

NPE/designee will re-educate Social Services and licensed nursing staff on Person-Centered Care Plan Policy & Procedure.

Nursing will review 5 resident Care Plans weekly who have a friendship/companionship with another resident to ensure they have a care plan in place that reflects consent/boundaries of their friendship.

Results of audits will be reviewed with the QAPI committee monthly X 3.

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

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations: Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders to place hearing aids in the residents ears each morning and remove them at bedtime for one of one resident reviewed for vision and hearing (Resident R7). Findings include: Review of physician orders dated September 7, 2025, revealed staff must "place hearing aids in bilateral ears in the morning and remove at bedtime." Observations conducted on September 15, 2025, at 12:30 p.m., during screening, Resident R7 could not hear the surveyor and was observed without hearing aids. Observations on September 16, 2025, at 9:44 a.m. and 1:00 p.m., revealed resident R7 did not have the hearing aids in place. Observations on September 17, 2025, at 9:30 a.m. revealed the resident hearing aids on. Follow-up observations on September 17, 2025, at 2:20 p.m. again revealed the resident without hearing aids. Interview and observations conducted on September 17, 2025, at 2:30 p.m. with Nurse Manager, Employee E10, confirmed that Resident R7 did not have hearing aids in place. Review of medication cart did not reveal the hearing aids. Continued interview revealed that the hearing aids had been misplaced and not offered to Resident R7. The hearing aids were later located in the narcotic box. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services

Plan of Correction - To be completed: 12/09/2025

Resident R7 consistently refuses to wear his hearing aids, staff will continue to offer daily with care plan reflected of refusals.

DON/designee to conduct an Initial audit of other residents with orders for hearing aides to ensure compliance with orders and hearing aides in place.

NPE/designee will re-educate licensed nursing staff to follow physician orders as it pertains to application of hearing aids.

DON/designee will audit all residents with orders for hearing aids to ensure compliance with physician orders weekly x 4, then monthly x 2.
Results of audits will be reviewed with the QAPI committee monthly X 3.

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.

Plan of Correction - To be completed: 12/09/2025

The resident R174 was immediately assessed by nursing staff upon arrival at the facility.

The van driver E6 has been educated on resident safety procedures during transport on facility van.

NHA/designee has educated the driver/ maintenance staff on the facility's "Vehicle Safety Competency" policy, emphasizing the requirement to remain with residents at all times while on the lift and to ensure wheelchairs are secured.

The Maintenance Director/designee will conduct 2 random weekly audits x 4 weeks then monthly x 2 months for transport observation to ensure compliance with safe transfer procedures.

Results of audits will be reviewed with the QAPI committee monthly X 3.

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

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

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

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

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

Plan of Correction - To be completed: 12/09/2025

Resident R142 was assessed, weights reviewed and interventions updated.

Registered Dietician to conduct an Initial audit X past 30 days of other residents with significant weight loss to ensure weight loss identified, assessed and appropriate interventions implemented.

DON/designee will re-educate the Registered Dietitian and licensed nursing staff to ensure weight loss identified, assessed and appropriate interventions implemented.

Registered Dietitian/designee will conduct weekly audits X 4, then monthly X 2 of residents with significant weight loss to ensure weight loss identified, assessed and appropriate interventions implemented.

Registered Dietitian will report audit results and any corrective actions during QAPI meeting x 3 months.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations: Based on observation, staff interviews, clinical record review, and review of facility policy, it was determined that the facility failed to ensure that a resident was provided with dialysis clamps for one of one resident reviewed receiving hemodialysis. (Residents 15). Findings include: Facility policy titled "Dialysis: Hemodialysis (HD) external catheter valuation and maintenance, last date revised December 16, 2024, stated under 2. "Maintain two smooth edged clamps with the patient at all times. 2.1 Smooth edged clamps must be placed at the bedside at time of admission. 2.2 Smooth edged clamps are to be attend to the patient's clothing during transport to and from dialysis facility or for any appointment(s) outside the nursing center. 2.3 If patient is mobile throughout the Center, smooth edged clamps must be attached to the patient's clothing at all times". Review of Resident R15's clinical record indicated an admission date of June 15, 2025, with diagnosis of end stage renal disease, and anima in chronic kidney disease. Review of July 2025 physician orders revealed an order dated, July 25, 2025 "monitor hemodialysis site on dialysis days, pre and post during dialysis days, Monday, Wednesday, and Friday and document. Pre and Post dialysis assessment documented. On dialysis days. Monitor hemodialysis LFA site for signs/symptoms of complications (e.g, bleeding, swelling, pain drainage, odor, hardness or redness at site), Notify the physician and dialysis center immediately with any urgent problems". On September 18, 2025, at 10:32 a.m., an interview was conducted with Licensed Nurse, Employee E4, who confirmed that Resident R15, a dialysis patient, should have clamps either at his bedside or in his wheelchair. Observations were made in Resident R15's room, and no clamps were found at the bedside. Employee E4 then stated that the clamps were located in Resident R15's wheelchair. Observations conducted at the above time with Licensed nurse, Employee E4 of Resident R15 revealed that Resident R15 was in the dining room seated in (his/her) wheelchair at an activity. Resident R15 reported that (his/her) clamps were in the wheelchair; however, upon being asked by Employee E4 to locate them, none were found. After Resident R15 stood up, Employee E4 confirmed that no dialysis clamps were present. Interview conducted on September 18, 2205 at 12:23 p.m., with the Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2. confirmed that dialysis clamps are required to remain with the resident at all times. 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Plan of Correction - To be completed: 12/09/2025

No adverse effect on resident R15, dialysis clamp was immediately replaced in the resident's room and one was attached to the resident's wheelchair.

DON/designee to conduct an initial audit on all residents with an external dialysis catheter to ensure clamps are available at bedside and present with resident at all times when not in room.

NPE/designee will re-educate licensed nursing staff on the facility's policy requiring dialysis clamps available at bedside in resident's room and present with resident at all times when not in room.

DON/designee will conduct weekly audits X 4, then monthly X 2 of all dialysis residents requiring clamps to ensure clamps are present and accessible.

DON/designee will review audit findings and any corrective actions during QAPI meetings x 3 months.

§ 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 review of nursing staff schedules, punch reports and interviews with staff, it was determined that the facility failed to maintain required staffing ratios, including one Nurse Aide per 10 residents during the Day shift, one Nurse Aide per 11 residents during the Evening shift, and one Nurse Aide per 15 residents during the Night shift for 18 of 21 days reviewed. (January 1, 2025 through September 16, 2025

Review of facility census data revealed that on January 1, 2025; January 3, 2025; January 4, 2025; January 5, 2025; January 6, 2025; and January 7, 2025, the facility did not provide One Nurse Aide per 10 Residents during the Day Shift.
Review of facility census data revealed that on January 1, 2025; and January2, 2025; the facility did not provide One Nurse Aide per 11 Residents during the Evening shift.
Review of facility census data revealed that on August 3, 2025; August 4, 2025; and August 7, 2025, the facility did not provide One Nurse Aide per 10 Residents during the Day shift.
Review of facility census data revealed that on August 3, 2025; the facility did not provide One Nurse Aide per 11 Residents during the Evening shift.
Review of facility census data revealed that on August 3, 2025; August 4, 2025; August 5, 2025; August 6, 2025; August 7, 2025; August 8, 2025; and August 9, 2025, thefacility did not provide One Nurse aide per 15 Residents during the Night shift.
Review of facility census data revealed that on September 11, 2025; September 12, 2025; September 13, 2025; September 14, 2025; September 15, 2025; and September 16, 2025, the facility did not provide One Nurse Aide per 15 Residents during the Night shift.
Review of the nursing time schedules, and punch reports confirmed the findings. No additional excess higher-level staff were available to compensate for this deficiency.
Staffing calculations, nursing staff schedules and staff punch reports were reviewed with the Nursing Home Administrator on September 17, 2025, at 12:33 p.m. The Nursing Home Administrator confirmed that the required staffing ratios for Nurse Aides was not met on the above dates.

Plan of Correction - To be completed: 12/09/2025

There were no adverse effects to the residents in the center as a result of the CNA ratio staffing during the months of January, August or September 2025.

Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings will be held daily Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels.

The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining 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.

NHA/designee will conduct random weekly audits to ensure compliance for Nursing Aide ratios for all shifts x 6 weeks. Findings will be reviewed at the QAPI Committee x3 months.

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

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

Observations:

Based on review of nurse staffing data, it was determined that the facility failed to provide a minimum of 1 LPN per 25 residents during the day shift and 1 LPN per 40 residents on the night shift for three of three weeks reviewed (01/01/2025 through 01/07/2025, 08/03/2025 through 08/09/2025, and 09/11/2025 through 09/17/2025).

Findings Include:

A review of facility census data, nursing schedules, and staff punch reports over a period of three weeks revealed the facility failed to provide 1 LPN per 25 residents during the day shift on the following dates:
- July 1, 2025, July 2, 2025, July 6, 2025, July 7, 2025
- August 4, 2025, August 8, 2025

Continued review of facility document6ation revealed that the facility failed to provide a minimum of one LPN per 30 residents during evening shift on the following dates:
- January 7, 2025
- August 4, 2025, August 8, 2025

Further review of facility documentation revealed the facility failed to provide 1 LPN per 40 residents during the night shift on the following dates:
- January 2, 2025, January 3, 2025, January 6, 2025
- August 3, 2025, August 4, 2025, August 5, 2025, August 6, 2025, August 7, 2025, August 8, 2025, August 9, 2025
- September 11, 2025, September 12, 2025, September 13, 2025, September 14, 2025, September 15, 2025, September 16, 2025

Plan of Correction - To be completed: 12/09/2025

There were no adverse effects to the residents in the center as a result of the Licensed Practical Nurse ratio staffing during the months of January, August or September 2025.

Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings will be held daily Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels.

The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a licensed nurse ratio of 1 Licensed Practical Nurse per 25 residents during the day, 1 Licensed Practical Nurse per 30 residents on evening shift, and 1 Licensed Practical Nurse per 40 residents on night shift.

NHA/designee will conduct random weekly audits to ensure compliance for Licensed Practical Nurse ratios for all shifts x 6 weeks. Findings will be reviewed in QAPI x3 months

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

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

Observations:

Based on review of nurse staffing data, it was determined that the facility failed to provide a minimum of 3.20 hours of direct nursing care per resident on three of three weeks reviewed (01/01/2025 through 01/07/2025, 08/03/2025 through 08/09/2025, and 09/11/2025 through 09/17/2025).
Findings Include:

A review of facility census data, nursing schedules, and staff punch reports over a period of three weeks revealed the facility failed to provide a minimum of 3.20 hours of direct nursing care per resident (PPD) on the following dates:
- 01/01/2025 through 01/07/2025
- 08/03/2025 through 08/09/2025
- 09/11/2025 through 09/17/2025

Plan of Correction - To be completed: 12/09/2025

There were no adverse effects to the residents in the center as a result of less than 3.2 direct care for each resident were provided during the months of January, August, and September 2025.

Chapel Manor will continue to use recruiters, our website, recruitment websites and social media to advertise our current open positions and interview immediately. Staffing meetings will be held daily Monday-Friday to review staffing ratios from the previous day, the current day, and the upcoming week to ensure appropriate staffing levels.

The Scheduling Coordinator, Nursing Supervisors and Director of Nursing were re-educated on maintaining a minimum of 3.2 direct resident care for each resident.

NHA/designee to complete random audits weekly x 6 weeks to ensure 3.2 PPD is maintained, Findings will be reviewed in QAPI x3 months

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