Pennsylvania Department of Health
QUALITY LIFE SERVICES - CHICORA
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

QUALITY LIFE SERVICES - CHICORA
Inspection Results For:

There are 128 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.


QUALITY LIFE SERVICES - CHICORA - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance survey completed on December 5, 2025, it was determined that Quality Life Services-Chicora was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the walk-in cooler which created the potential for cross contamination in the designated main kitchen.

Findings include:

During an observation of the main designated kitchen on 12/1/25, at 10:30 a.m. the following was observed:

-(2) fans in walk-in cooler- brown debris
-ceiling in walk-in cooler-brown debris

During an interview on 12/1/25 at 1:30 p.m. Dietary Director Employee E11 confirmed the brown debris in the walk-in cooler.

During an interview on 12/2/25 at 10:00 a.m., Dietary Manager Employee E11 confirmed that the facility failed to maintain sanitary conditions which created the potential for cross contamination.

28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.6(c) Dietary services.
28 Pa. Code: 201.14(a) Responsibility of licensee.

Plan of Correction - To be completed: 01/13/2026

Fans and walk in cooler were cleaned of the brown debris at the time it was brought to the dietary managers attention.
A sanitation audit will be completed by the NHA to determine other areas that may need cleaned
Education to be completed to the CDM by the NHA on the importance of proper identification and cleaning of the dietary department
A weekly audit will be completed times 30 days to ensure cleanliness of the dietary department.
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

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

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

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

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

Observations:

Based on review of facility policy, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) for one of three residents (Resident R94) and failed to provide adequate supervision to ensure a safe environment resulting in a burn for one of three resident's (Resident R35).

Review of the facility policy "Accidents and Incidents" dated 10/13/25, indicated a safe environment will be promoted for all residents.

Review of Resident R35's admission record indicated she was admitted to the facility on 1/11/21.

Review of Resident R35's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 10/21/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depressive disorder and hypertension.

Review of Resident R35's physician's orders dated 11/3/25, indicated restorative dining.

Review of a progress note dated 11/7/25, at 1:02 p.m. indicated "Nurse was informed by CNA that resident was in the dining area for activities and had coffee spilled in her lap and it was red and blistered. Resident assessed and RN supervisor notified. Daughter was notified of incident. "

Review of facility provided documents indicated Coffee was provided by the Activities department and not dietary. The temperature of the coffee was not taken prior to serving the resident's.

During an interview on 12/3/25, at 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision for one of three residents, which resulted in a burn.

Review of the facility policy "Elopement Prevention" dated 10/13/25, indicated the facility properly assesses residents and plans their care to prevent accidents related to wandering behavior or elopement. The admitting nurse will perform an initial assessment. A care plan will be developed that reflects the potential for elopement and preventative measures.

Review of the Admission Record indicated Resident R94 was admitted to the facility on 10/3/25, with the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain).

Review of the Nursing Review V-12 form dated 10/3/25, at 1:46 p.m. indicated family brought resident to the facility due to living alone and having severe dementia. Resident is walking independently. Resident is alert to person only and sometimes understands others. Resident has a known history of wandering. Does not understand surroundings. Resident photo will be added to those at risk.

Review of Resident R94's baseline care plan on 12/1/25, failed to include interventions for supervision and resident centered interventions to prevent elopement.

Review of Resident R94's progress notes indicated the following:
-10/4/25, at 9:42 a.m. indicated Resident R94 was asking "Where is the door so I can leave?". Wander guard placed on resident's right wrist. Resident refused to have it placed on the ankle.
-10/4/25, at 5:42 p.m. indicated staff took resident dinner tray to the room, on the tray table was the wander guard that was placed that morning on the wrist. Resident removed the wander guard. Staff immediately began searching for the resident. Personal care staff notified the skilled nursing side that resident was in the personal care unit. Resident stated they were looking for their sister.
-10/4/25, at 9:50 p.m. indicated safety checks began every 15 minutes.
-10/5/25, at 4:42 p.m. indicated Resident was sitting in the lounge, got up quickly and stated "I am getting out of here. My sister's blue Subaru just pulled up to pick me up". Writer attempted to show resident that no cars had pulled up outside, when resident pushed past writer stating, "She is out there." continues to pace in front of the window looking for the blue Subaru.
-10/5/25, at 5:19 p.m. indicated Resident was pacing back and forth in front of the window watching for the sister's car. Writer walked around the corner to the printer and heard the wander guard alarm. Writer immediately returned to where resident was last seen, and they were no longer there. Writer ran to the front door and resident was standing outside the front doors with another resident's family standing with resident and asking resident where they were going. Resident indicated "I'm looking for my sister's blue Subaru; there is a Subaru right there (pointing at cars in the parking lot).

Review of Personal Care Employee E10's undated witness statement indicated on 10/4/25, while working on the personal care unit, they heard the door alarm sound. Staff went to the door to see who it was, and an elderly man was through the door. Staff asked resident if they needed something as they kept walking down the hall. Resident said that they were looking for their sister. When staff reached the personal care unit's lobby, they had the resident sit down to take a break on the couch. Staff then called over to the skilled nursing side and told them Resident R94 was on the personal care unit.

Interview on 12/3/25, at 11:15 a.m. the Director of Nursing confirmed the facility failed to ensure proper supervision and failed to implement patient centered interventions for a resident identified as an elopement risk, which resulted in an elopement to personal care on 10/4/25, and elopement out the front doors of the facility on 10/5/25.

28 Pa. Code 201.14 Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 201.29 Responsibility of Licensee.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
28 Pa. Code 211.10(d) Resident care policies.

Plan of Correction - To be completed: 01/13/2026

R 35's burn is healing. R 94's care plan has reviewed and resident centered interventions has been added for risk of elopement
A new policy has been devised for the serving of hot beverages during activities
Education will be provided to the Activity department on the new policy by the DON/designee. Education will also be provided to nursing staff on the importance of a resident centered intervention to be implemented when a resident shows a behavior of exit seeking.
An audit of all resident's care plan who are identified as at risk of elopement will be completed by the DOH/designee weekly times 30 days to ensure better supervision is added by way of resident centered interventions
Weekly audits will be completed by the DON/NHA times 30 days during activities when hot beverages are being served to ensure new hot beverage policy is being followed.
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

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

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

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

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

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

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

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

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

Plan of Correction - To be completed: 01/13/2026

The facility is unable to correct the deficient practice

A dressing competency/education will be completed with licensed nursing staff by the director of nursing/designee for proper technique and infection control technique

Current infections will be reviewed by the director of nursing/designee to ensure contact isolation is ordered and in place for any resident requiring contact isolation.

Education to be provided to the Infection preventionist and licensed nursing staff on the requirement/need for contact isolation in regards to physician orders and care planning

A weekly audit will be completed by the DON/designee on at least 2 dressing changes for 30 days to ensure proper technique is being used

A weekly audit of infections will be completed by the DON/designee times 30 days to ensure contact isolation is ordered when necessary and care planned when ordered

Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of the Quality Assurance attendance records and staff interview it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required members for three of three quarters (Quarter one, two, three of 2025).

Findings:

Review of Quality Assessment and Assurance minutes sign in sheets and attendance records for Quarter One, Two and Three of 2025, failed to reveal the Infection Preventionist was in attendance.

During an interview 12/4/25, at 1:30 p.m. Clinical Services Specialist Employee E5 confirmed that the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all the required committee members for three of three quarterly meetings (Quarter one, two, three of 2025), as required.

28 Pa. Code 201.18 (e)(1)(2)(3)(4) Management.

Plan of Correction - To be completed: 01/13/2026

Unable to correct the deficient practice
Education to be provided to the NHA and QAPI team members on the federal regulation that QAPI is to be completed at least quarterly as well as requirements for attendance.
The Chief Nursing Officer will complete an audit for the next 6 months to ensure QAPI is being conducted at least quarterly
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

483.35(e)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

§483.35(e)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Plan of Correction - To be completed: 01/13/2026

E 12, E 13, E 14 and E 15 will have their annual performance evaluation completed
An in-house audit will be completed by the DON/designee of all nursing assistants to determine if their annual performance evaluation was completed or not
Education to be completed to the DON/designee by the NHA on the expectation that each nursing assistant have an annual performance evaluation.
A weekly audit will be completed by the NHA/designee time 30 days to ensure performance evaluations are being completed on time
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

483.25(n)(1)-(4) REQUIREMENT Bedrails:

§483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

§483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

§483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.

Plan of Correction - To be completed: 01/13/2026

R 1, R 63 and R 92 will be assessed for use of siderails and determine the appropriate use of each. Each of these resident's care plan will reflect any changes made to the siderail use
An in-house audit will be completed for any resident using siderails to determine if appropriate assessment was completed as well as correct care planning
Education to be completed by the DON/designee on the appropriate assessment and care planning associated with siderail use.
A weekly audit will be completed by the DON/designee times 30 days to ensure any siderail in use is appropriately assessed and care planned.
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

483.25(m) REQUIREMENT Trauma Informed Care:

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

Observations:

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for three of three residents (Residents R24, R41, and R81).

Findings include:

Review of facility job description "Social Worker", indicated that the Social Worker will carry out social evaluations and plan interventions based on evaluation findings, and counsel residents/family/caregivers as needed in relationship to stress and other identified coping difficulties. Ensure compliance with all Federal, State, and local regulations.

Review of the admission record indicated Resident R24 admitted to the facility on 4/4/25.

Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/28/25, indicated the diagnoses of post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in persons that have witnessed a traumatic event causing intense, disturbing thoughts and feelings related to the experience), anemia (the blood doesn't have enough healthy red blood cells), and paranoid schizophrenia (delusions and hallucinations that blur the line between what is real and what isn't).

Review of Resident R24's current care plan indicated the resident has delirium (a sudden severe state of confusion and altered awareness, not a disease but symptom of an underlying medical problem). Resident will be free of the signs and symptoms of delirium such as the following: exhibiting a change in behavior, mood, cognitive function, communication, level of consciousness, or restlessness through the next review date.

During an interview on 12/4/25, at 11:34 a.m. Social Worker Employee E4 confirmed that Resident R24 did not have a traumatic informed care plan addressing the PTSD or identifying potential triggers and prevention for re-traumatization.

Review of the clinical record revealed Resident R41 was admitted to the facility on 2/10/25 with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), PTSD, and muscle weakness.

Review of the resident's Social Services assessment dated 2/17/25, revealed the facility documented the resident does not have a history of trauma/Post-Traumatic Stress Disorder.

Review of the resident's Social Services assessment dated 3/7/25, revealed the facility documented the resident does not have a history of trauma/Post-Traumatic Stress Disorder.

Review of the resident's Social Services assessment dated 6/5/25, revealed the facility documented the resident does not have a history of trauma/Post-Traumatic Stress Disorder.

Review of the resident's Social Services assessment dated 9/5/25/25, revealed the facility documented the resident does not have a history of trauma/Post-Traumatic Stress Disorder.

Review of Resident R41's care plan on 12/1/25, failed to address PTSD by identifying any triggers or how to avoid them.

During an interview on 12/4/24, at 11:34 a.m. Social Worker Employee E4 stated Resident R41's Social Service assessments should be documented to reflect the resident does have a history of trauma/Post-Traumatic Stress Disorder and confirmed Resident R41's care plan failed to address PTSD by identifying any triggers or how to avoid them.

Review of the admission record indicated Resident R81 admitted to the facility on 11/8/22.

Review of Resident R81's MDS dated 10/9/25, indicated the diagnoses of anemia, PTSD, and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids).

Review of Resident R81's current care plan indicated trauma informed care: resident has a history of actual trauma : PTSD related to Vietnam War. Resident will feel safe and comfortable in the home environment and will express any concerns or fears to the staff.

During an interview on 12/4/25, at 11:34 a.m. Social Worker Employee E4 confirmed that Resident R81 did not have a traumatic informed care plan addressing the PTSD in identifying potential triggers and prevention for re-traumatization.

Interview on 12/5/25, at 12:30 p.m. the Director of Nursing confirmed the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for three of three residents (Resident R24, R41, and R81).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.

Plan of Correction - To be completed: 01/13/2026

R 24, R 41 and R 81's care plan will be updated to reflect potential triggers that may cause re-traumatization related to a PTSD diagnosis
An inhouse audit will be completed by the Social Worker/ designee of all residents with a diagnosis of PTSD to ensure potential triggers are listed on the care plan.
Education to be provided to the Social Worker by the Chief Nursing Officer on the importance of each resident identified with a diagnosis of PTSD that their care plan will include potential triggers
A weekly audit will be completed by the DON/designee on to ensure any resident identified with a diagnosis of PTSD that their care plan includes potential triggers
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

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

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

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

Observations:

Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R25).

Findings include:

Review of the facility policy "Self-Administration of Medications" dated 10/13/25, indicated in order to maintain the residents' high level of independence, resident's who desire to self-administer medications are permitted to do so if the facility 's interdisciplinary team has determined the practice would be safe for the resident and other resident's of the facility and there is a prescriber's order to self-administer.

Review of the admission record indicated Resident R25 was admitted to the facility on 11/15/21.

Review of Resident R25's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/17/25, indicated the diagnoses of malignant neoplasm of upper lobe, right bronchus or lung, respiratory failure and chronic kidney disease.

Observation on 12/1/25, at 10:30 a.m. of Resident R25's room indicated a two medicine cup's at the bedside table, one with liquid and the other with three pills.

Interview with Registered Nurse (RN) Employee E9 confirmed the cup with three pills were fish oil, zoloft and movantik and the liquid was MiraLax and confirmed she left the pills and liquid at the bedside unattended.

Review of Resident R25's clinical record failed to have a physician order, assessment, or plan of care addressing self-administration of medications.

Interview on 12/1/25, at 10:45 a.m. RN Employee E9 confirmed the medications were stored in the resident room inappropriately and that Resident R25 failed to have an assessment, physician order, or plan of care for self-administration of medications.

28 Pa code: 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 01/13/2026

Medications were removed from bedside when brought to the nurse's attention
An in-house audit will be completed by the DON/designee to ensure no other medications are being left at bedside.
Education to be provided to licensed staff by the DON/designee on the importance of not leaving medications at bedside.
A weekly audit will be completed by the DON/designee of no less than 15 residents to ensure medications are not left at bedside.
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

483.95(a) REQUIREMENT Communication Training:

§483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff.

Observations:

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five staff members (Nurse Aide (NA) Employee E15).

Findings include:

Review of NA Employee E15's personnel record indicated a hire date of 1/6/23.
Review of NA Employee E15's education documents on 12/3/25, at 12:00 p.m. failed to include evidence of required communication training.

Interview on 12/3/25, at 2:30 p.m. the Clinical Services Specialist Employee E5 confirmed that the facility failed to provide training on effective communication for one of five staff members (NA Employee E15).

28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
28 Pa Code: 201.20 (a)(6)(d) Staff development.

Plan of Correction - To be completed: 01/13/2026

Employee E 15 has been educated on the required communication training.
The Director of Nursing will be educated by the Clinical Services Specialist/designee on the requirement for each nursing assistant to receive education on communication.
Director of Nursing/designee will complete an audit was completed on all employees to ensure that all employees have had the required communication training scheduled
Director of Nursing/Designee will complete an audit monthly times two to ensure that new hires have been scheduled for communication training.
Results of the audits will be reviewed at the monthly Quality Assurance meeting.

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

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

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

Observations:

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to follow resident consent for pneumococcal vaccination and failed to administer the vaccination in a timely manner for one of five residents (Resident R65).

Findings include:

Review of facility policy "Standing Orders for Administering Pneumococcal Vaccine to Adults" dated 10/13/25, indicated staff will identify adults in need of vaccination with pneumococcal polysaccharide vaccine (PPSV - a vaccine that protects against 23 types of streptococcus pneumoniae bacteria). Record the date the vaccine was administered, the manufacturer and lot number, the vaccine site and route, and the name and title of the person administering the vaccine. If the vaccine was not given, record the reason for non-receipt of the vaccine.

Review of the admission record indicated that Resident R65 was admitted to the facility on 8/30/23.

Review of R65's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/6/25, included diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life).

Review of Resident R65's immunization record failed to include evidence the resident was offered and received the pneumococcal vaccination.

Further review of Resident R65's clinical record indicated a "Resident Pneumococcal Vaccine Consent/Declination Form" dated 8/30/23, that documented consent to the administration of the pneumococcal vaccine.

Interview on 12/4/25, at 11:00 a.m. the Director of Nursing confirmed the consent was obtained; however, the vaccination was never administered to Resident R65 as requested and consented to and that the facility failed to follow resident consent for pneumococcal vaccination and failed to administer the vaccination in a timely manner for one of five residents (Resident R65).

28 Pa. Code 211.5(f) Clinical records

Plan of Correction - To be completed: 01/13/2026

Resident records will be reviewed for consent documentation for pneumococcal vaccinations and administration will be completed for Resident R65.
Education will be provided by the DON/designee to the licensed staff for follow through with administration once consent is obtained.
New admission chart audits for the last 20 admissions will be conducted ensure completion of consent forms and administration of pneumococcal is given timely when wanted. New admission charts will be audited for one month to ensure compliance for consents and administration.
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role:

§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.

Observations:

Based on a review of facility provided documents and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections during the periods of 10/4/25, through 10/13/25, and 11/16/25, to present.

Findings included:

During an interview on 12/5/25, at 1:25 p.m. the Director of Nursing (DON) stated, "I was the Infection Preventionist and Assistant Director of Nursing for the period of 10/13/25, - 11/16/25, when I became the Interim DON. Prior to my tenure IP Employee E16's last day of work was on 10/4/25.

During an interview on 12/5/25, at 12:30 p.m. the DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections during the periods of 10/4/25, through 10/13/25, and 11/16/25, to present.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 201.19(3) Personnel records.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 01/13/2026

Unable to correct the deficient practice
A new Infection control preventionist has been identified and certification on file.
Education will be provided to the DON by the Chief Nursing on the education requirements for the infection preventionist and audit completed that certification is on file.
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of three medication rooms (Memory Lane Medication Room).

Findings include:

Review of facility policy "Storage of Medications" dated 10/13/25, indicated certain medications such as multiple dose injectable vials require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency.

During an observation on 12/4/25, at 9:14 a.m. of the Memory Lane Medication Room Refrigerator revealed two tuberculin multiple dose vial (a substance used in the tuberculin skin test (TST) to diagnose tuberculosis infection) that was opened and not labeled with the date opened as required.

During an interview on 12/4/25, at 9:14 a.m. Licensed Practical Nurse (LPN) Employee E16 confirmed the above observation and that the facility failed to properly store medication in one of three medication rooms (Memory Lane Medication Room).

28 Pa. Code: 201(a) Responsibility of licensee.
28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 01/13/2026

Both vials of TB solution were discarded at the time it was brought to nursing's attention
An in-house audit will be completed of all medication rooms by the DON/designee to determine medications are properly stored with appropriate open dates
Education to be completed by the DON/designee to the licensed nursing staff on proper medication storage and labelling of opened medications.
A weekly audit of each medication room will be completed by the DON/designee for 30 days to ensure proper storage of medications and labelling of opened medications
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

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 review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of two residents (Residents R13 and R92).

Findings include:

Review of the clinical record indicated Resident R92 was admitted to the facility on 11/1/24.

Review of Resident R92's MDS dated 10/23/25, indicated diagnoses of high blood pressure, diabetes mellitus (DM, a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood).

Review of a physician order dated 11/5/25, indicated Resident R92 receives dialysis treatment at an outside facility every Monday, Wednesday, and Friday.

Review of Resident R92s clinical record did not include complete communication forms for four days during the period of 11/1/25, through 11/30/25. The incomplete forms were on the following dates: 11/19/25, 11/21/25, and 11/25/25. No communication form was located for 11/5/25.

During an interview on 12/3/25, at 2:20 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above dates did not include complete dialysis communication forms and that the facility failed to provide consistent and complete communication with the dialysis center for Resident R92.

Review of the clinical record indicated that Resident R13 was admitted to the facility on 11/2/24.

Review of Resident R13's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/11/25, indicated with the diagnoses of end stage kidney disease (a condition where the kidney reaches advanced state of loss of function), dependance on renal dialysis and anxiety disorder.

Review of R13's physician order dated 11/19/25, indicated the resident has dialysis one time a day every Tuesday, Thursday and Saturday.

Review of Resident R13's "Dialysis Communication Records" indicated no completed communication records.

Interview on 12/3/25 at 11:15 a.m. the Director of Nursing confirmed the facility failed to provide consistent and complete communication with the dialysis center for two of two residents reviewed (Residents R92, R13).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 01/13/2026

The facility is unable to correct the deficient practice for R13 and R 92
In-house audit will be completed for all dialysis residents by the DON/designee to determine if communication forms have been sent to dialysis with residents
Education will be provided to the nursing staff by the DON/designee on the importance of sending the communication record with each resident when leaving for dialysis.
A weekly audit of all dialysis resident will be completed by the DON/designee times 30 days to ensure communication record is sent to dialysis with resident
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

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 policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of five residents (Resident R92).

Findings include:

Review of facility policy "Care Plan and Interdisciplinary Care Conferences" dated 10/13/25, indicated the care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals.

Review of the clinical record indicated Resident R92 was admitted to the facility on 11/1/24.

Review of Resident R92's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/23/25, indicated diagnoses of high blood pressure, diabetes mellitus (DM, a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood).

Review of a physician order dated 5/6/25, indicated to apply Dexcom G7 Sensor (a wearable continuous blood glucose monitor) transdermally (to the skin) every evening shift every 10 days for DM.

Review of Resident R92's current care plan failed to include the development of goals and interventions related to the resident's wearable continuous blood glucose sensor.

During an interview on 12/3/25, at 1:11 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to develop a comprehensive care plan to meet resident care needs for Resident R92.

28 Pa Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 01/13/2026

R 92's care plan was corrected to reflect the use of the Dexcom G7 Sensor
An in-house audit will be completed by the DON/designee to identify any other resident who is using the Dexcom G 7 Sensor
Education will be provided to the licensed nursing staff and RNAC on appropriate care planning for a resident who is using a Dexcom G 7 Sensor
A weekly audit will be completed by the DON/designee for 30 days to identify any other resident using the Dexcom G7 Sensor and that it is care planned appropriately.
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints:

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical . . . restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free from physical . . . restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Observations:

Based on review of facility policies, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a scoop mattress (a specialty medical mattress with soft raised foam edges) as a possible restraint, and failed to assess the functional status of the individual resident to determine if the use of a scoop mattress is a restraint for one of three residents (Resident R63).

Findings include:

Review of facility policy "Physical Restraint Policy and Procedure" dated 10/13/25, indicated physical restraints are defined as any manual method of physical or mechanical device, material or equipment attached or adjacent to the elder's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body.

Review of the clinical record indicated Resident R63 was admitted to the facility on 9/17/15.

Review of Resident R63's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/12/25, indicated diagnoses of anemia (too little iron in the blood), Parkinson's Disease (neuromuscular disorder causing tremors and difficulty walking), and depression. Section GG - Functional Abilities, Question GG0170A: Roll left and right, indicated the resident was coded "1" dependent, helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.

Review of a physician order dated 10/21/24, indicated resident provided a scoop mattress for positioning/comfort and safety while in bed.

During an observation on 12/1/25, at 10:05 a.m. Resident R63's mattress was observed with bilateral (both sides) raised edges on the top and bottom portions.

Review of Resident R63's clinical record failed to identify any assessments or ongoing evaluations for the usage of the scoop mattress.

During an interview on 12/3/25, at 1:08 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to identify a scoop mattress as a possible restraint and failed to assess the functional status of the individual to determine if the use of a scoop mattress is a restraint for Resident R63.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.8(e) Use of restraints.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 01/13/2026

R 63 will be evaluated for the use of a scoop mattress
An in-house audit will be completed by the DON/designee of any resident using siderails or a scoop mattress to ensure a restraint evaluation was completed prior to the use of the device
Education will be provided to the licensed nursing staff by the DON/designee on the need for a restraint assessment to be completed prior to the use of a scoop mattress or siderails.
A weekly audit will be completed by the DON/designee for 30 days to ensure any use of a siderail or scoop mattress that a restraint assessment is completed prior to the use
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.

Observations:

Based on observations and staff interview, it was determined that the facility failed to post complete contact information for State Long-Term Care Ombudsman program and complete contact information for State Survey Agency at the facility as required.

Findings include:

During observations completed on 12/4/25, State Long-Term Care Ombudsman information posted in the front hallway did not include the Ombudsman's email as required.

This observation also revealed that the State Survey Agency (SSA) information posted in the front hallway did not include the SSA's address and email as required.

During an interview on 12/4/25, at 11:40 a.m. the Clinical Service Specialist Employee E5 confirmed that the facility failed to post complete contact information for State Long-Term Care Ombudsman program and completed contact information for State Survey Agency as required.

28 Pa. Code: 201.14(a)Responsibility of licensee.
28 Pa. Code: 201.18(e) Management.

Plan of Correction - To be completed: 01/13/2026

The postings were corrected to include the Ombudsman's email address and the State Survey Agency address and email address.
The NHA will conduct a facility wide audit to ensure that alike posting will have the required information.
Education will be provided to the NHA by the Chief Nursing Officer on address and email address being present on the postings.
Weekly audit will be completed for one month by the NHA to ensure email and address is present on the posting.
Results of the audit will be reviewed at the monthly QAPI meeting for tracking and trending purposes.

51.3 (k) LICENSURE NOTIFICATION:

51.3 Notification

(k) The notification requirements
of this section do not require a
facility, in providing a notification
under subsection (e) or (f), to
include information which is deemed
confidential and not reportable to the
Department under other provisions of
federal or State law or regulations.

Observations:

Based on review of the facility's Covid-19 Documentation, it was determined that the facility failed to notify the State Agency (SA) in writing of positive COVID-19 staff and resident cases that could affect resident health and safety.

Findings include:

Review of the facility's line listing for Covid-19 outbreaks and reports submitted to the local State field office from 9/10/25, to 9/11/25, failed to include a report for 45 of 48 total cases between residents and staff.

During an interview on 12/4/25, at 11:30 a.m. the Clinical Services Specialist Employee E5 stated, "We weren't having them report every resident and staff and thought it was just required for a new outbreak".

During an interview on 12/4/25, at 2:35 p.m. the Director of Nursing confirmed that the facility failed to notify the State Agency in writing of positive COVID-19 staff and resident cases that could affect resident health and safety.

Plan of Correction - To be completed: 01/13/2026

The facility has submitted the covid outbreak from 9-10-25 through 9-11-25 via the electronic reporting system on 12-10-25.
The facility will ensure, moving forward, that each Covid positive resident is reported via the electronic reporting system.
Clinical Services Specialist/designee will educate the Director of Nursing and the infection control nurse of the need to ensure they are reporting each individual positive covid.
Audits will be completed for the next three covid outbreaks to ensure the appropriate reporting is being completed.
Results of the audits will be reviewed at the monthly Quality Assurance meeting.

§ 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 Committee attendance records, the facility failed to ensure that the nine required multidisciplinary members were present at the Infection Control meetings for three of four quarters (Quarter 1, Quarter 2, and Quarter 3).

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 at infection control meetings includes medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member, and a member of the infection control team.

Review of the facility's Infection Control Committee Attendance Log for the last four Quarters revealed the following absent multidisciplinary members:

Quarter 1: (1/21/25, - 3/18/25) - interdisciplinary members that were not in attendance as required were the Medical Director, a laboratory representative, infection preventionist, and a community member.

Quarter 2: (4/15/25, - 6/17/25) - interdisciplinary members that were not in attendance as required were the Safety Officer, infection preventionist, and a community member.

Quarter 3: (7/22/25, - 9/16/25) - interdisciplinary members that were not in attendance as required were the Nursing Home Administrator, a laboratory representative, a Physical Plant representative, and the Safety Officer.

During an interview on 12/4/25, at 1:00 p.m., the Director of Nursing confirmed that the facility failed to ensure that the nine required multidisciplinary members were present at the Infection Control meetings for three of four quarters (Quarter 1, Quarter 2, and Quarter 3).

Plan of Correction - To be completed: 01/13/2026

The facility is unable to correct the deficiency for the previous quarters.
Beginning with quarter 1 of 2026 the facility will ensure that the required multidisciplinary staff members are present for the infection control meeting.
Clinical Services Specialist/designee will educate the Director of Nursing, Nursing Home Administrator, infection control nurse and all team members on the attendance requirements for the Infection Control Committee meeting.
Audits will be completed for two quarters by the Nursing Home Administrator/designee to ensure the appropriate multidisciplinary staff members are present.
Results of the audits will be reviewed at the monthly Quality Assurance meeting.

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