Pennsylvania Department of Health
 BEDFORD POST ACUTE
Patient Care Inspection Results

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BEDFORD POST ACUTE
Inspection Results For:

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BEDFORD POST ACUTE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on June 17, 2026, it was determined that Bedford Post Acute 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:


483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) REQUIREMENT Discharge Process:This is a less serious (but not lowest level) deficiency and 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.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

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

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

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

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

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

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

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

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

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

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


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the ombudsman (an independent, impartial official appointed to investigate and help resolve complaints) of a transfer to the hospital for five of 35 residents reviewed (Residents 1, 6, 9, 65 and 75).

Findings include:

A facility policy regarding transfer or discharge notices, dated January 7, 2026, indicated that residents (or resident representatives) are notified of an impending transfer or discharge and the reason for the move in writing and in a language and manner they understand. A copy of the notice is sent to the office of the State Long-Term Care Ombudsman. When a resident is sent emergently to an acute care setting, this is considered a transfer, not discharge, because the resident's return is generally expected. Notice of transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements).

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 1, dated May 19, 2026, revealed that the resident was cognitively intact, required assistance from staff for some daily care needs, and had diagnoses that included heart failure (the heart can't pump blood well enough to meet the body's needs), pneumonia and respiratory failure (blood does not have enough oxygen and causes difficulty breathing).

A nursing note for Resident 1, dated May 6, 2026, at 11:22 p.m., revealed that the resident had increased shortness of breath and the resident's pulse oximetry (measures blood oxygen levels) was 84 percent on oxygen at a rate of 3 liters per minute (LPM). His oxygen was increased to 5 LPM and his oxygen level increased to 89 percent. The physician was notified and the resident was sent to the hospital.

There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 1's hospital discharge.

A quarterly MDS assessment for Resident 6, dated May 12, 2026, revealed that the resident was cognitively impaired, was dependent on staff for all daily care needs, and had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth).

A nursing note for Resident 6, dated April 24, 2026, at 3:11 p.m. revealed that the resident's feeding tube had come out and she was sent to the hospital.

There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 6's hospital discharge.

A quarterly MDS assessment for Resident 9 dated April 17, 2026, revealed that the resident was cognitively impairment, required assistance from staff for daily care needs, and had diagnoses that included cerebrovascular disease (conditions that affect blood flow and the blood vessels in the brain) and diabetes.

A nursing note for Resident 9, dated April 3, 2026, at 11:04 a.m. revealed that the resident complained of numbness to her left hand that spread upwards to the shoulder during a doctor appointment and she was sent to the hospital.

A nursing not for Resident 9, dated May 30, 2026, at 5:52 p.m. revealed that the resident had an episode of low blood sugar, was unresponsive, and had labored breathing and was sent to the hospital.

There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 9's hospital discharges.

An annual MDS assessment for Resident 65, dated April 15, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had recent falls, and had diagnoses that included dementia.
A nursing note, dated March 29, 2026, at 6:50 p.m. revealed Resident 65 was witnessed sliding out of her chair onto the floor and had a skin tear to her right hand with bruising. At 10:45 p.m. the resident's wound was noted to have bled through the dressing. The physician was notified the excessive bleeding, and orders were received to send the resident to the hospital evaluation.
There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 65's hospital transfer.

A quarterly MDS assessment for Resident 75, dated June 13, 2026, revealed that the resident was cognitively intact. A nurse's note, dated June 2, 2026, revealed that the resident was sent to the hospital for difficulty in breathing and that she was admitted to the hospital.

There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 75's hospital transfer.

Interview with the Director of Nursing on June 15, 2026, at 9:33 a.m. confirmed that there was no documented evidence that the ombudsman was notified of the hospital transfers for Residents 1, 6. 9, 65 and 75. She indicated that as of June 15, 2026, they had not been notifying the ombudsman of resident hospital transfers.

28 Pa. Code 201.29(j) Resident Rights.





 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
The facility sent notice to the Long-Term Care Ombudsman on 7/8/2026 of resident 1 transfer to hospital on 5/6/2026, resident 6 transfer to hospital on 4/24/2026, resident 9 transfer to hospital on 4/3/2026 and 5/30/2026, resident 65 transfer to hospital on 3/29/2026, and resident 75 transfer to hospital on 6/2/2026.

Identification of Others:
Nursing Home Administrator reviewed resident transfers to the hospital for April, May and June 2026 and sent notification to the Long-Term Care Ombudsman by 7/8/2026.

Systemic Changes:
Nursing Home Administrator will assign an Interdisciplinary Team manager to be responsible for Ombudsman notification of transfers to hospital.
Nursing Home Administrator or designee will provide education to Interdisciplinary Team the Facility Transfer or Discharge Notice Policy and the requirement to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Education will be completed by 7/29/2026. Those not educated before 7/29/2026 will be educated prior to working their next shift.

Monitoring:
Nursing Home Administrator or designee will monitor resident transfers to hospital to ensure notification to the Long-Term Ombudsman was completed at least monthly. Monitoring will be completed monthly x 4 months. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.
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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure the environment remained as free of accident hazards as possible for two of 35 residents reviewed (Residents 2, 37) and failed to ensure that each resident received assistance devices to prevent accidents for two of 35 residents reviewed (Residents 15, 53).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 2, 2026, indicated that the resident was mildly cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia and epilepsy (brain condition that causes repeated seizures).

Observation of Resident 2 on June 17, 2026, at 9:44 a.m. revealed that the resident was sitting in her recliner watching television.

Interview with Director of Rehabilitation on June 17, 2026, at 9:50 a.m. stated that they have never done a recliner safety assessment on their residents.

Interview with Nursing Home Administrator on June 16, 2026, at 2:42 p.m. confirmed that no recliner safety assessment was performed.

The facility's air mattress policy, dated January 7, 2026, indicated that appropriate pressure redistribution support surfaces would be based on current recommended practices for device selection, as well as the resident's risk factors, clinical and functional needs, and preferences.

A quarterly MDS assessment for Resident 37, dated February 26, 2026, revealed that the resident was cognitively intact, required assistance for staff with daily care needs, and had a pressure ulcer. Physician's orders, dated February 13, 2026, included an order for the resident to use an air mattress.

A nursing note, dated February 20, 2026, at 7:12 p.m. revealed that Resident 37 was assessed by staff following a fall from her bed. She received skin tears to the left arm, right elbow and left knee. There was no documented evidence that the resident's air mattress was re-assessed for safety following the fall.

Observations of Resident 37 on June 16, 2026, at 9:51 a.m. revealed that she was in bed with an air mattress in place.

Interview with the Nursing Home Administrator on June 17, 2026, at 2:00 p.m. confirmed that there was no evidence that Resident 37's air mattress was re-assessed for safety following the fall on February 20, 2026.

A comprehensive MDS assessment for Resident 15, dated May 8, 2026, revealed that the resident was cognitively impaired, used a wheelchair for transport, and had diagnoses that included dementia.

Observations of Resident 15 on June 14, 2026, at 11:15 a.m. revealed that Nurse Aide 3 was pushing the resident in her wheelchair through the hall to the dining room with no leg rests on the wheelchair and staff telling her to keep her legs up while being pushed.

Interview with Nurse Aide 3 on June 14, 2026, at 11:25 a.m. confirmed that Resident 15's leg rests were not on the wheelchair and should have been applied before transporting.

A comprehensive MDS assessment for Resident 53, dated June 10, 2026, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs including transfers and locomotion, and had diagnoses that included muscle weakness and gait abnormality.

Observations of Resident 53 on June 14, 2026 at 11:24 a.m. revealed that she was being pushed in her wheelchair by Nurse Aide 4with her feet hanging down able to touch the floor. Nurse Aide 4was telling the resident to keep her feet up in the air as they went through the hall. There were no footrests on her wheelchair to prevent her feet from dragging during the transport. An interview with Nurse Aide 4 at that time confirmed that the resident should have had leg rests on her wheelchair to prevent injury during the transport.

Interview with the Director of Nursing on June 14, 2026, at 3:02 p.m. confirmed that residents should have leg rests on their wheelchairs while being pushed by staff.

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

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

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






 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
Resident 2 was assessed for safety with use of an electric recliner on 7/9/2026.
Resident 37 was assessed for safety with use of an air mattress on 7/9/2026.
Resident 15 was assessed for safety with use of footrests on 7/9/2026.
Resident 53 was assessed for safety with use of footrests on 7/9/2026.

Identification of Others:
Residents who use a wheelchair, electric recliner or air mattress have the potential to be affected by accident hazards with use of electric recliners, air mattresses and wheelchair footrests.
Residents who use an electric recliner chair and/or air mattresses will have a safety assessment completed by 7/29/2026.
Residents who use a wheelchair will have a safety assessment for use of footrests on wheelchairs completed by 7/29/2026.

Systemic Changes:
The facility created a safety assessment to be used for electric recliners and wheelchair footrests.
Director of Nursing amended the facility internal Incident Investigation Form to include completing a safety assessment following an incident that was related to a recliner, air mattress, or wheelchair footrests.
The facility adopted a new Wheelchair Footrest Use Policy. Policy was approved by facility Quality Assurance Performance Improvement committee.
Facility will purchase wheelchair bags to hold footrests for residents who require them for safety with staff assistance during locomotion and residents who need footrests removed for independence will have bags on their wheelchair by 7/29/2026.
Nurse educator will provide education to licensed nurses on the completion of safety assessment for electric recliners prior to resident use. Education to licensed nurses on completing a safety assessment for new admissions and incidents related to a recliner or wheelchair footrests. Education to licensed nurses on the air mattress assessment to include completion of assessment following a safety incident and upon applying an air mattress. Education to licensed nurses on the amended Incident Investigation Form.
Nurse educator will provide nursing staff education on the Wheelchair Footrest Use Policy that includes utilizing the wheelchair footrest bags. Education will include ensuring resident's environment remain free of accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. Education will be completed by 7/29/2026. Those not educated before 7/29/2026 will be educated prior to working their next shift.

Monitoring:
Director of Nursing or designee will monitor weekly x 4 weeks and monthly x 2 months of resident incidents involving a recliner, air mattress or wheelchair footrests and residents with a new electric recliner or air mattress to ensure a safety or mattress assessment is completed prior to use or after an incident to ensure residents environments remain free of accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for two of 35 residents reviewed (Residents 51 and 59).

Findings include:

A facility policy related to psychoactive/psychotropic medication use, dated January 7, 2025, indicated that the resident or resident representative has the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the Alternative or option he or she prefers. Prior to administration of a psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or, as appropriate, the resident representative) for use of a psychotropic medication and document the consent in the medical record. The facility must record the signed written consent in the resident's medical record. A new informed consent must be obtained for dosage increases of psychotropic medication.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 51, dated June 1, 2026, indicated that the resident was cognitively impaired, was dependent of staff for daily care needs, received psychotropic medications including antianxiety and antidepressant medications, and had diagnoses that included dementia, anxiety, and depression.

Physician's orders for Resident 51, dated October 15, 2025, included orders for the resident to receive 10 milligrams (mg) of Paxil (an antidepressant) daily for depression.

Physician's orders for Resident 51, dated January 8, 2026, included orders for the resident to receive 20 mg of Paxil daily for depression.

Physician's orders for Resident 51, dated January 16, 2026, included orders for the resident to receive 5 mg of Valium (a psychotropic medication used to treat anxiety) every eight hours for worsening behaviors related to anxiety disorder.

There was no documented evidence in Resident 51's clinical record to indicate that the resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dosages of Paxil and Valium.

Interview with the Nursing Home Administrator on June 16, 2026, at 11:46 a.m. confirmed that there was no documented evidence in Resident 51's clinical record to indicate that the resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dosages of Paxil and Valium.

A quarterly MDS assessment for Resident 59, dated April 20, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, received psychotropic medications including antidepressant and antipsychotic (used to treat mental health disorders) medications, and had diagnoses that included dementia, anxiety, and depression.

A nursing note for Resident 59, dated November 14, 2025, at 2:42 p.m. revealed that the physician gave a new order to increase the resident's Seroquel (an antipsychotic medication) to 50 mg daily at bedtime.

Physician's orders for Resident 59, dated November 14, 2025, included orders for the resident to receive 50 mg of Seroquel daily at bedtime for Behavioral and Psychological Symptoms of Dementia (BPSD).

There was no documented evidence in Resident 59's clinical record to indicate that the resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dosage of Seroquel.

Interview with the Nursing Home Administrator on June 17, 2026, at 1:11 p.m. confirmed that there was no documented evidence in Resident 59's clinical record to indicate that the resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dosage of Seroquel.

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

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

28 Pa. Code 201.29(a): Resident rights.






 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
Resident 51's representative gave verbal consent on was given informed consent on 7/9/2026 for current psychotropic medications, including Paxil and Valium. Resident 59's representative gave verbal consent on 7/9/2026 for current psychotropic medications including Seroquel.

Identification of Others:
Residents receiving psychotropic medications are at risk of being affected. The Director of Nursing or designee performed an audit on June 19, 2026, of residents receiving psychotropic medications to verify they have informed consent in place for current doses. Corrective action taken immediately upon discovery of any missing informed consents.

Systemic Changes:
Nurse educator will educate Licensed Nurses on Psychoactive/Psychotropic Medication Use Policy for obtaining informed consent prior to the administration of any new psychotropic medications or dosage increases in current psychotropic medication orders. Education includes ensuring the resident or representative is informed, in advance, of the risks and benefits of psychotropic medications and the treatment alternatives prior to initiating the administration of and increasing the dose of the medication. Education will be completed by 7/29/2026. Those not educated before 7/29/2026 will be educated prior to working their next shift.

Monitoring:
The Director of Nursing or designee will monitor new psychotropic medication orders or dosage changes to ensure informed consent was obtained. Monitoring will be done weekly x 4 weeks, then monthly x 2 months. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.
483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.
Observations:


Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 35 residents reviewed (Residents 42 and 65).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section N0415F1 Antibiotic Medications was to be coded if an antibiotic medication was taken by the resident at any time during the seven-day look-back period.

Physician's orders for Resident 42, dated February 24, 2026, included an order for staff to apply 2% lidocaine/Nystatin/Silvadene /20% zinc topical cream (pain reliever/antifungal/ antibiotic/protective barrier) to the resident's sacrum (area located at the lower part of the spine) every day and evening shift for wound care.

Review of the Medication Administration Record (MAR) for Resident 42, dated May 2026, revealed that staff had administered the 2% lidocaine/Nystatin/Silvadene /20% zinc cream to the resident's sacrum on May 1 through May 14, 2026.

A quarterly MDS for Resident 42, dated May 14, 2026, revealed that section N0415F1 was not coded, indicating that the resident did not receive an antibiotic medication during the seven-day look-back assessment period.

Physician's orders for Resident 65, dated April 3, 2026, included an order for the resident to receive 500-125 milligrams (mg) of Augmentin (an antibiotic) every twelve hours for seven days for cellulitis (bacterial skin infection).

Review of the MAR for Resident 65, dated April 2026, revealed that staff had administered the Augmentin to the resident on April 3 through April 10, 2026.

An annual MDS for Resident 65, dated April 15, 2026, revealed that section N0415F1 was not coded, indicating that the resident did not receive an antibiotic medication during the seven-day look-back assessment period.

Interview with the Nursing Home Administrator on June 17, 2026, at 1:44 p.m. confirmed that the MDS was coded incorrectly for Residents 42 and 65.

28 Pa. Code 211.5(f) Medical records






 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
The MDS completed on Resident 42 in May 2026 was updated to reflect the administration of antibiotics on 7/8/2026. The MDS completed on resident 65 in April 2026 was updated to reflect the administration of antibiotics on 7/8/2026.

Identification of Others:
Registered Nurse Assessment Coordinator reviewed current residents who were administered antibiotics and had an MDS in May and June 2026 to ensure the MDS reflected the antibiotic administration if given in the seven -day look back and it was coded in section N0415F1. Any discrepancies identified had the MDS updated to reflect the administration of antibiotics by 7/29/2026.

Systemic Changes:
Nursing Home Administrator or designee will provide education to the Registered Nurse Assessment Coordinator on the requirement for the accuracy of resident assessments that include section N0415F1, Antibiotic medications are to be coded if the resident receives an antibiotic any day during the seven-day lookback. Education will be completed by 7/29/2026. Those not educated before 7/29/2026 will be educated prior to working their next shift.

Monitoring:
Nursing Home Administrator or designee will monitor residents receiving antibiotics to ensure if the resident was in the seven-day lookback for an MSD that the antibiotics were reflected in section N0415F1, weekly x 4 weeks and monthly x 2 months. Results of audits will be reported monthly to the Quality Assurance Performance Improvement changes in frequency until resolved.

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


Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of 35 residents reviewed (Resident 10), and failed to follow consultant recommendations to send a representative/staff member to an appointment for a resident unable to communicate causing the appointment to be canceled and a delay in treatment for one of 35 residents reviewed (Resident 68).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 10, dated March 16, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had skin tears, received application of nonsurgical dressings (with or without topical medications) other than to feet, and had a diagnosis of Coronary Artery Disease (CAD-a disease that limits blood flow to the heart caused by plaque buildup in the arteries). A care plan for the resident, dated December 9, 2023, included an intervention to apply tubi-grips (compression bandage designed to provide support and even pressure to an injured or swollen limb) to the bilateral lower extremities for edema.

A wound consultant note for Resident 10, dated May 18, 2026, indicated that the resident had wounds and edema to the bilateral lower extremities and included recommendations to apply tubi-grips to the bilateral lower extremities daily on in the a.m. and off in the p.m. for edema.

A physician's order for Resident 10, dated May 19, 2026, included an order to apply tubi-grips to bilateral lower extremities for edema and to remove tubi-grips to bilateral lower extremities every evening shift.

Observations of Resident 10 on June 14, 2026, at 11:40 a.m. revealed that the resident was sitting in her wheelchair with visible bandages on her bilateral lower legs and no tubi-grips applied.

Observations of Resident 10 on June 17, 2026, at 10:28 a.m. revealed that the resident was sitting in her wheelchair with visible bandages on her bilateral lower legs and no tubi-grips applied. The tubi-grips were observed sitting on her overbed table and the resident stated that "they don't put them on".

Interview with Licensed Practical Nurse 1on June 17, 2026, at 12:39 p.m. confirmed that Resident 10's tubi-grips were not applied and they should have been.

Interview with the Director of Nursing on June 17, 2026, at 2:30 p.m. confirmed that Resident 10's tubi-grips should have been applied and they were not.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated May 13, 2026, revealed that the resident was severely cognitively impaired, was non-verbal, and had diagnoses that included aphasia (a disorder that affects how you communicate).

Physician's orders for Resident 68, dated March 9, 2026, included an order for the resident to have a caregiver attend her next appointment with her due to her inability to communicate with others. Review of Resident 68's consultation record from her neurology (specialist) appointment dated June 14, 2026, revealed that the resident did not have a caregiver present for the appointment as ordered on March 9, 2026 and therefore the physician could not assess the resident.

Interview with the Director of Nursing on June 15, 2026, at 2:12 p.m. confirmed that Resident 68 was unable to communicate and that an attendant should have attended her physician's appointments, but did not.

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

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





 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
The facility cannot make corrections for resident 68 and 10.

Identification of Others:
Residents with physician orders have the potential to be affected. The Director of Nursing/designee performed an audit of new physician orders /consultant recommendations written on June 22, 2026, to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Systemic Changes:
The Interdisciplinary Team will review upcoming appointments Monday-Friday to identify the need for a resident requiring a caregiver to accompany the resident to an appointment. Nursing Management will review new orders Monday-Friday to ensure physician and consultant orders are followed as ordered.
Director of Nursing or designee will educate licensed nurses on professional standards of care to include following physician's orders and to follow consultant recommendations to prevent delay in treatment and ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Education will be completed by 7/29/2026. Those not educated before 7/29/2026 will be educated prior to working their next shift.

Monitoring:
Director of nursing/designee will audit 5 random newly written physician orders/consultant recommendations weekly x 4 weeks then monthly x 2 months to ensure physician orders/ pharmacy recommendations are followed. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(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 policies, manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for two of 35 residents reviewed (Residents 42, 63) and failed to label one multi-dose vial of Tubersol solution with the date it was opened in one of two medications rooms reviewed.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated May 14, 2026, revealed that the resident was moderately cognitively impaired, had pain frequently, received routine and as needed pain medications, and received an opioid (narcotic pain reliever).

Physician's orders for Resident 42 dated May 20, 2026, included an order for the resident to receive 5 milligrams (mg) of Oxycodone twice a day for pain and 5 mg of Oxycodone every six hours as needed for moderate/severe pain.

A review of the controlled drug count record (tracks each dose of a controlled medication) for Resident 42, revealed that the routine dose of Oxycodone was signed out of the as needed Oxycodone medication card on June 3 through 8, 2026.

Interview with the Director of Nursing on June 16, 2026, at 1:02 p.m. revealed that the pharmacy only sends one card of Oxycodone and the routine and as needed doses are signed out of the card despite the label instructions.

The facility's policy regarding Medication Administration, dated January 7, 2026, revealed that medication labels should be checked three times for the right dose, right time, and right method of administration prior to administering.

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated May 25, 2026, revealed that the resident was cognitively impaired and had diagnoses that included disorientation and depression.

Physician's orders for Resident 63 dated March 26, 2026, included an order for the resident to receive 0.5 milligrams (mg) of Lorazepam (anti-anxiety medication) daily for depression (mood disorder). Observations on June 16, 2026, at 1:56 p.m. revealed that the label on the card of Lorazepam did not match the current physician's order. The label reads Lorazepam 0.5 mg give one table by mouth every eight hours as needed for agitation.

Interview with the Director of Nursing on June 16, 2026, at 2:23 p.m. revealed that the label on Resident 63's Lorazepam should match the current physician's order for the medication and it did not.

The facility's policy regarding medication labeling, dated January 7, 2026, revealed that multi-dose vials were to be labeled when opened.

Manufacturer's instructions for Tubersol, undated, revealed that the vial of Tubersol is good for 30 days once opened.

Observations in the TCU med room on June 15, 2026, at 12:38 p.m. revealed that there was an opened and undated vial of Tubersol solution in the fridge.

Interview with Registered Nurse 2on June 15, 2026, at 12:39 p.m. revealed that the Tubersol vial should have been labeled with the date when it was opened.

28 Pa. Code 2119(a)(1) Pharmacy Services







 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
Resident's 42 expired, no corrective action is taken. Resident 63 narcotic medication has changed and an updated card with correct label was delivered. The open multi-dose vial of tuberculin solution was disposed of immediately upon discovery during the survey.

Identification of Others:
Residents who have narcotic medications have the potential to be affected. The Director of Nursing/designee performed an audit on 6/18/2026, of residents receiving narcotic medications to ensure that both the Medication Administration Record and the label on the medication cards match. Corrective action was taken immediately upon discovery of any discrepancies. The vaccine refrigerator was audited on 6/18/2026 to ensure any open muti-dose vials of tuberculin solution were marked with the date opened.

Systemic Changes:
Director of Nursing has ordered stickers per the pharmacist recommendation that will indicate directions have changed and will be used with narcotic cards that have had a change in directions.
Nurse educator will educate licensed nurses on the process of administering narcotic medication as well as medication storage and include ensuring medications are properly labeled according to the physician orders and multi-dose vials are labeled with the open date. Education will be completed by 7/29/2026. Those not educated before 7/29/2026 will be educated prior to working their next shift.

Monitoring:
The Director of Nursing/designee will monitor residents receiving narcotic medications to ensure the label on the medication card matches the physician's order and will monitor multi dose vials to ensure they are properly labeled. Monitoring will be completed weekly x 4 weeks, then monthly x 2 months. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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.
§483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:

Based on review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat as ordered by the physician for one of 35 residents reviewed (Resident 37).

Findings include:

The facility policy for assistive devices, dated January 7, 2026, indicated that certain devices and equipment that assist with mobility, safety, and independence were provided for residents. They may include specialized eating utensils and equipment, safety devices for the bathroom, and mobility devices.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated March 31, 2026, indicated that the resident was moderately cognitively impaired and required supervision from staff with eating. A care plan, dated May 22, 2026, revealed the resident was at risk for altered nutrition and was to have all foods in separate bowls for each meal.

Observations of Resident 37 during the lunch meal on June 17, 2026, at 12:01 p.m. revealed that the resident was in bed eating lunch and she had a regular plate with her food items on it, she did not have a separate bowl for each food item. The resident's meal ticket for the noon meal indicated that she was to have all food items in separate bowls.

Interview with Licensed Practical Nurse 1 on June 17, 2026, at 12:11 p.m. confirmed that Resident 37 did not have her food items in separate bowls and should have, according to the resident's meal ticket.

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







 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
Resident 37's food items were corrected upon discovery during survey and food was provided to resident 37 in separate bowls.

Identification of Others:
Residents requiring special eating equipment and utensils have the potential to be affected. Director of Nursing conducted an audit on 6/18/2026 to ensure that residents ordered to have adaptive equipment with meals had equipment in place during meals with corrective action taken immediately upon discovery.

Systemic Changes:
Nurse educator or designee will educate nursing staff on the Assistive Devices Policy related to special eating equipment and utensils. Dietary Manger or designee will educate dietary staff on the Assistive Devices Policy related to special eating equipment and utensils. Education will be completed by 7/29/2026. Those not educated before 7/29/2026 will be educated prior to working their next shift.

Monitoring:
Director of Nursing/designee will conduct audits weekly of residents who require special eating equipment and utensils weekly x 4 weeks, then monthly x 2 months to ensure residents are provided with special eating equipment and utensils as ordered. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

483.75(c)(1)-(4)d)(1)(2)(e)(1)-(3)(g)(2)(ii)(iii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§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:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending July 2, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending June 17, 2026, identified repeated deficiencies related to failure to correct deficient practices related to quality care, safe environment free from accident hazards, and storage and labeling of medications.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending July 2, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care.

The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending July 2, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards.

The facility's plans of correction for deficiencies regarding storage and labeling of medications, cited during the survey ending July 2, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storage and labeling of medications.

Refer to F684, F689, F761

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

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






 Plan of Correction - To be completed: 07/29/2026

No corrective action could be taken to ensure the facility had maintained compliance with cited nursing home regulations from the prior survey related to repeated deficiencies related to quality care, safe environment free from accident hazards, and storage and labeling of medications.

Identification of Others:
Residents residing in the facility are at risk related to the facility having repeated deficiencies.

Systemic Changes:
The Nursing Home Administrator will add current survey results for the Quality Assurance Performance Improvement committee to review at least quarterly to ensure the corrective actions are still effective, and to prevent repeated deficiencies. Nursing Home Administrator will provide education to the Quality Assurance Performance Improvement committee on 7/22/2026 of the requirements of Quality Assurance Performance Improvement including the facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and maintained beyond the identified monitoring times provided in the plan of corrections. Education will be completed by 7/29/2026. Those not educated before 7/29/2026 will be educated prior to working their next shift.

Monitoring:
Nursing Home Administrator or designee will complete monitoring of the Quality Assurance Performance Improvement program quarterly for one year to ensure the facility maintains compliance of the cited regulations and the corrective actions and systemic changes are realized and maintained. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand-washing techniques were used during medication administration for one of 35 residents observed (Residents 7).

Findings include:

The facility's policies regarding Medication Administration, dated January 7, 2026, indicated that staff should follow infection control procedures, including hand sanitization for administration of medications.

Observations during medication administration on June 15, 2026, at 8:50 a.m. revealed that Licensed Practical Nurse 5 was preparing Resident 7's medications. Using her bare hands, Licensed Practical Nurse 5 took a pill out of the cup and broke it in half. She then administered the medication to Resident 7.

Interview with Licensed Practical Nurse 5 on June 15, 2026, at 8:55 a.m. confirmed that she should not have touched the pill with her bare hands.

Interview with the Director of Nursing on June 15, 2026, at 2:12 p.m. confirmed that Licensed Practical Nurse 5 should not have touched the pill with her bare hands and administer the medication to Resident 7.

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







 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
No corrective action could be taken regarding the licensed nurse using bare hands to touch a medication.

Identification of Others:
Residents who receive medications have the potential to be affected. The Director of Nursing performed an audit of two medication passes on June 22, 2026, to ensure proper hand hygiene was performed during medication passes with no infection control concerns identified.

Systemic Changes:
Nurse educator will educate Licensed Nurses on the Medication Administration Policy to include proper hand hygiene and touching pills without gloves, during medication administration. Education will be completed by 7/29/2026. Those not educated before 7/29/2026 will be educated prior to working their next shift.

Monitoring:
Director of Nursing or designee will monitor medication administrations weekly x 4 weeks, then monthly x 2 months to ensure proper hand hygiene and glove use when touching pills is performed during medication administration. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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.
§483.80(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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the influenza and/or the pneumococcal immunizations for four of 35 residents reviewed (Residents 3, 13, 37, 42).

Findings include:

The facility's influenza and pneumonia vaccination policies, dated January 7, 2026 revealed that all residents would be offered the influenza and pneumonia vaccines.

A quarterly Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated April 30, 2026, revealed that the resident was admitted to the facility on December 16, 2025. Section O0250 A (Influenza Vaccination) revealed that the resident did not receive the influenza vaccine in the facility for the year's influenza vaccination season, due to not being offered the vaccine.

There was no documented evidence that the facility offered or administered the influenza vaccine to Resident 3.

A quarterly MDS assessment for Resident 13, dated May 29, 2026 revealed that the resident was cognitively impaired, was admitted to the facility on January 6, 2026, and that she was not offered the influenza or pneumonia vaccine.

There was no documented evidence that Resident 13 was offered the influenza or pneumonia vaccine.

A quarterly MDS assessment for Resident 37, dated March 31, 2026, revealed that the resident was admitted to the facility on October 9, 2025. Section O0300A (Pneumococcal Vaccination) revealed that the resident's pneumococcal vaccine was not up to date and that the resident was not offered the pneumococcal vaccine.

A quarterly MDS assessment for Resident 42, dated May 14, 2026, revealed that the resident was admitted to the facility on February 23, 2026. Section O0250A (Influenza Vaccination) revealed that the resident did not receive the influenza vaccine in the facility for the year's influenza vaccination season, due to not being offered the vaccine.

Interview with the Nursing Home Administrator on June 16, 2026 at 1:16 p.m. revealed that Residents 3, 13, 37, and 42 were not offered the influenza vaccine or the pneumonia vaccine and they should have been.

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

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

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






 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
The facility cannot offer the flu vaccine to resident 3, 13, 37, and 42 because it is not currently flu season. The Pneumonia vaccines were offered to residents 13 and 37.

Identification of Others:
Residents staying in the facility during flu season have the potential to be affected. Residents who have not received a pneumonia vaccine have the potential to be affected. A whole house audit was performed by the Infection Preventionist to check the status of resident pneumonia vaccines. Residents that were not up to date with the pneumonia vaccine will be offered to receive the vaccine by 7/29/2026.

Systemic Changes:
The Infection Preventionist will report to the Quality Assurance Performance Improvement committee on the flu and pneumonia vaccines to ensure residents are offered, have received or declined the pneumonia vaccines upon admission and residents are offered the flu vaccine upon admission during flu season and annually during flu season.
Nursing Home Administrator/designee will educate the Infection Prevention nurse on regulations regarding offering and administration of influenza and pneumonia vaccines. Education will be completed by 7/29/2026.

Monitoring:
Nursing Home Administrator or designee will monitor new admissions weekly x 4 weeks and monthly x 2 months to ensure new admissions are offered the pneumonia vaccine and offered the flu vaccine during flu season. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization: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.
§483.80 Infection control
§483.80(d)(3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses.
(v) The resident or resident representative, has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision; and
(vi) The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident, or
(C) If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.
(vii) The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Observations: Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for one of 35 residents reviewed (Resident 13). Findings include: A quarterly MDS assessment for Resident 13, dated May 29, 2026, revealed that the resident was cognitively impaired, was admitted to the facility on January 6, 2026, and that she was not offered the influenza or pneumonia vaccine. Review of Resident 13's clinical record revealed no immunization or declination information documented related to the COVID-19 vaccine. Interview with the Nursing Home Administrator on June 16, 2026, revealed that Resident 13 was not offered the covid vaccination and should have been. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.
 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
The facility cannot offer the covid vaccine to resident 13 because it is not currently in season.

Identification of Others:
Residents residing in the facility during covid season have the potential to be affected. Residents residing in the facility will be offered the covid vaccine during the next season when the vaccine is available.

Systemic Changes:
The Infection Preventionist will report to Quality Assurance Performance Improvement committee on the covid vaccine to ensure residents are offered, have received or declined the covid vaccines upon admission and annually during covid season.
Nursing Home Administrator or designee will educate the Infection Prevention nurse on regulations regarding offering and administration of the Covid vaccine. Education will be completed by 7/29/2026.

Monitoring:
Nursing Home Administrator or designee will monitor covid vaccines during Quality Assurance Performance Improvement from October to February to ensure new admissions and current residents are offered the covid vaccine when in season. Results of audits will be reported monthly to the Quality Assurance Performance for changes in frequency until resolved.

483.95(d) REQUIREMENT QAPI Training: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.
§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.
Observations: Based on review of the Nursing Assistant job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to five of five nurse aides reviewed (Nurse Aides 6, 7, 8, 9, and 10). Findings include: Review of the facility nursing assistant job description indicated that nurse aides were to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. Review of Nurse Aide 6'spersonnel file revealed that she was hired on February 19, 2019. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 7's personnel file revealed that she was hired on August 21, 2017. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 8's personnel file revealed that she was hired on November 23, 2012. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 9's personnel file revealed that she was hired on June 24, 2021. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 10'spersonnel file revealed that she was hired on November 7, 1995. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Interview with the Nursing Home Administrator on June 16, 2026, at 2:27 p.m. confirmed that Nurse Aides 6, 7, 8, 9, and 10failed to complete the necessary education regarding Quality Assurance and Performance Improvement (QAPI) training. 28 Pa. Code: 201.14(a) Responsibility of Licensee 28 Pa. Code: 201.20(a) Staff Development
 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
No corrective action could be for Nurse Aides 6, 7, 8, 9, and 10 not completing the Quality Assurance Performance Improvement Training.

Identification of Others:
The Quality Assurance Performance Improvement training was assigned to staff on the facility education program. Staff will complete the Quality Assurance Performance Improvement training by 7/29/2026 or prior to their next shift worked.

Systemic Changes:
The Nurse Educator was provided education by the Nursing Home Administrator on the requirements of Quality Assurance Performance Improvement training for staff, the facility education program and how to assign the Quality Assurance Performance Improvement training to new hired staff and annually for staff and the requirements that staff must complete the Quality Assurance Performance Improvement training annually during their hire month or within the prior 12 months. Education includes that staff who do not complete their training within the prior 12 months will not be eligible to work until it is completed. Education will be completed by 7/29/2026.

Monitoring:
Nursing Home Administrator or designee will monitor monthly x 3 months of new hired staff to ensure they have completed their required education, and to ensure staff have completed annual education within the prior 12 months.
 Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

§ 201.14(c) LICENSURE Responsibility of licensee.:State only Deficiency.
(c) The licensee through the administrator shall report as soon as possible, or, at the latest, within 24 hours to the appropriate Division of Nursing Care Facilities field office serious incidents involving residents as set forth in § 51.3 (relating to notification). For purposes of this subpart, references to patients in § 51.3 include references to residents.

Observations:


Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the Department of Health of a resident incident involving a skin tear injury requiring a transfer to the hospital and sutures for one of 35 residents reviewed (Resident 10).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 10, dated March 16, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs and had skin tears.

A nursing note for Resident 10, dated April 15, 2026, at 10:13 p.m. revealed that the resident obtained a very deep skin tear that occurred while being transferred to her bed. The physician was notified and the resident was sent to the hospital.

An incident report for Resident 10, dated April 15, 2026, revealed that the resident obtained a skin tear that occurred during a transfer, and the resident thought that her leg hit or got stuck on the wheelchair.

A nursing note for Resident 10, dated April 16, 2026, at 3:35 a.m. indicated that an update from the hospitalrevealed that the resident required internal stitching of the right lower leg and steri-strips (thin, sterile, reinforced adhesive strips used to close shallow cuts, secure surgical incisions, or support wounds after stitches are removed) were used to put the skin back in place due to skin being too fragile to be stitched.

There was no documented evidence to indicate that this skin tear incident that required a transfer to the hospital and sutures was reported to the Department of Health.

Interview with the Nursing Home Administrator on June 17, 2026, at 12:12 p.m. confirmed that the Department of Health was not notified of Resident 10's skin tear incident that required a transfer to the hospital and sutures.






 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
Resident 10's incident was reported to the Department of Health on 06/30/2026.

Identification of Others:
Residents who are transferred to the hospital due to a serious incident are at risk. The Nursing Home Administrator reviewed residents who have transferred to the hospital in the last 3 months due to a serious incident and ensured the incident was reported to the Dept of Health.

Systemic Changes:
Nursing Home Administrator or designee will provide education to Director of Nursing on the requirements to report as soon as possible, or, at the latest, within 24 hours, to the Dept of Health, of serious incidents involving residents transferred to the Hospital/Emergency Room. Education will be completed by 7/29/2026.

Monitoring:
Nursing Home Administrator will monitor resident transfers to the hospital to ensure any transfer related to a serious incident is reported to the Dept of Health. weekly x 4 weeks, then monthly x 2 months. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 schedules, staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to provide one nurse aide (NA) per 10 residents on the day shift for 10 of 21 days, failed to provide one NA per 11 residents on the evening shift for five of 21 days, and failed to provide one NA per 15 residents on the night shift for 12 of 21 days reviewed for May 27 through June 2, 2026; June 3 through June 9, 2026; and June 10 through June 16, 2026.

Findings include:

Review of facility census data revealed:

On May 28, 2026, the facility census was 64, during the day shift, which required 6.40 NA's during the day shift. Review of the nursing time schedules revealed 5.00 NA's provided care on the day shift.

On May 29, 2026, the facility census was 66, during the day shift, which required 6.60 NA's during the day shift. Review of the nursing time schedules revealed 6.00 NA's provided care on the day shift.

On May 30, 2026, the facility census was 67, during the day shift, which required 6.70 NA's during the day shift. Review of the nursing time schedules revealed 5.80 NA's provided care on the day shift.

On May 31, 2026, the facility census was 67, during the day shift, which required 6.70 NA's during the day shift. Review of the nursing time schedules revealed 5.80 NA's provided care on the day shift.

On June 1, 2026, the facility census was 67, during the day shift, which required 6.70 NA's during the day shift. Review of the nursing time schedules revealed 6.00 NA's provided care on the day shift.

On June 2, 2026, the facility census was 69, during the day shift, which required 6.90 NA's during the day shift. Review of the nursing time schedules revealed 6.00 NA's provided care on the day shift.

On June 3, 2026, the facility census was 69, during the day shift, which required 6.90 NA's during the day shift. Review of the nursing time schedules revealed 6.00 NA's provided care on the day shift.

On June 10, 2026, the facility census was 67, during the day shift, which required 6.70 NA's during the day shift. Review of the nursing time schedules revealed 6.34 NA's provided care on the day shift.

On June 12, 2026, the facility census was 68, during the day shift, which required 6.80 NA's during the day shift. Review of the nursing time schedules revealed 6.00 NA's provided care on the day shift.

On June 14, 2026, the facility census was 69, during the day shift, which required 6.90 NA's during the day shift. Review of the nursing time schedules revealed 5.07 NA's provided care on the day shift.

On May 28, 2026, the facility census was 65, during the evening shift, which required 5.91 NA's during the evening shift. Review of the nursing time schedules revealed 5.00 NA's provided care on the evening shift.

On May 29, 2026, the facility census was 66, during the evening shift, which required 6.00 NA's during the evening shift. Review of the nursing time schedules revealed 5.53 NA's provided care on the evening shift.

On June 6, 2026, the facility census was 69, during the evening shift, which required 6.27 NA's during the evening shift. Review of the nursing time schedules revealed 5.20 NA's provided care on the evening shift.

On June 7, 2026, the facility census was 68, during the evening shift, which required 6.18 NA's during the evening shift. Review of the nursing time schedules revealed 5.67 NA's provided care on the evening shift.

On June 12, 2026, the facility census was 69, during the evening shift, which required 6.27 NA's during the evening shift. Review of the nursing time schedules revealed 6.13 NA's provided care on the evening shift.

On May 29, 2026, the facility census was 66, during the night shift, which required 4.40 NA's during the night shift. Review of the nursing time schedules revealed 3.40 NA's provided care on the night shift.

On May 30, 2026, the facility census was 67, during the night shift, which required 4.47 NA's during the night shift. Review of the nursing time schedules revealed 3.87 NA's provided care on the night shift.

On May 31, 2026, the facility census was 67, during the night shift, which required 4.47 NA's during the night shift. Review of the nursing time schedules revealed 3.53 NA's provided care on the night shift.

On June 2, 2026, the facility census was 69, during the night shift, which required 4.60 NA's during the night shift. Review of the nursing time schedules revealed 4.00 NA's provided care on the night shift.

On June 3, 2026, the facility census was 70, during the night shift, which required 4.67 NA's during the night shift. Review of the nursing time schedules revealed 4.00 NA's provided care on the night shift.

On June 4, 2026, the facility census was 69, during the night shift, which required 4.60 NA's during the night shift. Review of the nursing time schedules revealed 4.07 NA's provided care on the night shift.

On June 5, 2026, the facility census was 71, during the night shift, which required 4.73 NA's during the night shift. Review of the nursing time schedules revealed 4.07 NA's provided care on the night shift.

On June 6, 2026, the facility census was 69, during the night shift, which required 4.60 NA's during the night shift. Review of the nursing time schedules revealed 4.07 NA's provided care on the night shift.

On June 7, 2026, the facility census was 68, during the night shift, which required 4.53 NA's during the night shift. Review of the nursing time schedules revealed 3.93 NA's provided care on the night shift.

On June 8, 2026, the facility census was 66, during the night shift, which required 4.40 NA's during the night shift. Review of the nursing time schedules revealed 4.07 NA's provided care on the night shift.

On June 9, 2026, the facility census was 67, during the night shift, which required 4.47 NA's during the night shift. Review of the nursing time schedules revealed 4.00 NA's provided care on the night shift.

On June 12, 2026, the facility census was 69, during the night shift, which required 4.60 NA's during the night shift. Review of the nursing time schedules revealed 4.13 NA's provided care on the night shift.

However, there were no additional excess higher-level staff available to compensate for these deficiencies.

Interview with the Director of Nursing on June 17, 2026, at 3:01 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.






 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
The facility is unable to retroactively correct the identified days the facility did not meet the nurse aide staffing requirement. There is no known negative outcome identified for residents during the days of concern.

Identification of Others:
Residents who receive care from nurse aides have the potential to be affected by the facility not meeting the nurse aide staffing requirement.
The Staffing Coordinator, Director of Nursing and Human Resources reviewed current schedule and have reached out to staff and agency staff to fill the nurse aide positions for shifts that fall short of the requirements. Nursing Home Administrator is actively working with facility recruiters to fill open positions and explore staffing options that will attract new staff.

Systemic Changes:
Scheduling Coordinator and Nurse management will review daily and weekly schedules. Quality Assurance Performance Improvement was updated to include review of nurse aide staffing. The facility is working on actively recruiting nurse aides and utilizing bonuses for emergent situations to fill shifts. The facility will review census and staffing at morning meetings to ensure sufficient staffing is assigned to meet the care needs of the facility. SC and Nurse Management will exhaust every effort to fill shifts that do not meet the requirements that may include, assigning nurse aide licensed admin staff, nursing management or nurses to fill nurse aid positions. The facility will continue to offer competitive wages, benefits, and recognition to hire and retain nurse aides. The facility has signed up to attend a job fair on 9/16/2026. Staff call-offs are tracked by nursing management and will follow the attendance policy to ensure the care needs of the residents are provided.

Monitoring:
Director of Nursing or designee will monitor nurse aide staffing to ensure the facility is staffed as is possible to meet the 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. Monitoring to be done weekly x 4 weeks, monthly x 2 months.
 Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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 nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 30 residents on the evening shift for one of 21 days for May 27 through June 2, 2026; June 3 through June 9, 2026; and June 10 through June 16, 2026.

Findings include:

Review of facility census data revealed:

On June 7, 2026, the facility's census was 68 during the evening shift, which required 2.27 LPN's on the evening shift. Review of the nursing time schedules revealed that 2.06 LPN's provided care during the evening shift.

However, there were no additional excess higher-level staff available to compensate for these deficiencies.

Interview with the Director of Nursing on June 17, 2026, at 3:01 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.






 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
The facility is unable to retroactively correct the identified days the facility did not meet the Licensed Practical Nurse staffing requirement. There is no known negative outcome identified for residents during the days of concern.

Identification of Others:
Residents who require nurse services have the potential to be affected by the facility not meeting the Licensed Practical Nurse staffing requirement.
The Staffing Coordinator, Director of Nursing and Human Resources reviewed current schedule and have reached out to staff and agency staff to fill the open Licensed Practical Nurse positions for shifts that fall short of the requirements. Nursing Home Administrator is actively working with facility recruiters to fill open positions and explore staffing options that will attract new staff.

Systemic Changes:
Staffing Coordinator and Nurse management will review daily and weekly schedules. Quality Assurance Performance Improvement was updated to include review of Licensed Practical Nurse staffing. The facility is working on actively recruiting Licensed Practical Nurse and utilizing bonuses for emergent situations to fill shifts. The facility will review census and staffing at morning meetings to ensure sufficient staffing is assigned to meet the care needs of the facility. Scheduling Coordinator and Nurse Management will exhaust every effort to fill shifts that do not meet the requirements that may include assigning licensed nursing management or Registered Nurses to fill Licensed Practical Nurse positions. The facility will continue to offer competitive wages, benefits, and recognition to hire and retain Licensed Nurses The facility has signed up to attend a job fair on 9/16/2026. Staff call-offs are tracked by nursing management and will follow the attendance policy to ensure the care needs of the residents are provided.

Monitoring:
Director of Nursing or designee will monitor Licensed Practical Nurse staffing to ensure the facility is staffed as is possible to meet the minimum of 1 Licensed Practical Nurse per 25 residents during the day, 1 Licensed Practical Nurse per 30 residents during the evening, and 1 Licensed Practical Nurse per 40 residents overnight. Monitoring to be done weekly x 4 weeks, monthly x 2 months. Results of audits will be reported monthly to the Quality Assurance Performance Improvement for changes in frequency until resolved.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(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 nursing schedules and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for 14 of 21 days (24-hour periods) reviewed for May 27 through June 2, 2026; June 3 through June 9, 2026; and June 10 through June 16, 2026.

Findings include:

Review of the nursing time schedules provided by the facility revealed that the facility provided 3.16 hours of direct care for each resident on May 27; 3.03 hours of direct care for each resident on May 28; 2.97 hours of direct care for each resident on May 29; 3.01 hours of direct care for each resident on May 30; 3.03 hours of direct care for each resident on May 31; 3.08 hours of direct care for each resident on June 1; 3.01 hours of direct care for each resident on June 2; 3.06 hours of direct care for each resident on June 3; 3.16 hours of direct care for each resident on June 4; 3.15 hours of direct care for each resident on June 5; 2.96 hours of direct care for each resident on June 6; 2.97 hours of direct care for each resident on June 7; 3.04 hours of direct care for each resident on June 12; and 3.04 hours of direct care for each resident on June 14.

Interview with the Director of Nursing on June 17, 2026, at 3:01 p.m. confirmed that the facility did not meet the required daily hours of direct resident care for each resident on the days listed above.






 Plan of Correction - To be completed: 07/29/2026

Corrective Action:
The facility is unable to retroactively correct the identified days the facility did not meet a minimum 3.2 hours of direct care for each resident. There is no known negative outcome identified for residents during the days of concern.

Identification of Others:
Residents who receive nursing services have the potential to be affected by the facility not meeting direct care hours requirement.
The Staffing Coordinator, Director of Nursing and Human Resources reviewed current schedule and have reached out to staff and agency staff to fill open positions for shifts that fall short of the requirements. Nursing Home Administrator is actively working with facility recruiters to fill open positions and explore staffing options that will attract new staff.

Systemic Changes:
Staffing Coordinator and Nurse management will review daily and weekly schedules. Quality Assurance Performance Improvement was updated to include review of direct care hours per resident. The facility is working on actively recruiting staff and utilizing bonuses for emergent situations to fill shifts. The facility will review census and staffing at morning meetings to ensure sufficient staffing is assigned to meet the care needs of the facility. Staffing Coordinator and Nurse Management will exhaust every effort to fill shifts that do not meet the requirements that may include assigning licensed admin and management staff to fill open nursing shifts. The facility will continue to offer competitive wages, benefits, and recognition to hire and retain staff. The facility has signed up to attend a job fair on 9/16/2026. Staff call-offs are tracked by nursing management and will follow the attendance policy to ensure the care needs of the residents are provided.
Monitoring:
Director of Nursing or designee will monitor direct care per resident hours to ensure the facility is staffed as is possible to meet the minimum of 3.2 hours per resident of direct resident care. Monitoring to be done weekly x 4 weeks, monthly x 2 months. Results of audits will be reported monthly to the Quality Assurance Performance Improvement changes in frequency until resolved.


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