Pennsylvania Department of Health
ROSE CITY NURSING AND REHAB AT LANCASTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ROSE CITY NURSING AND REHAB AT LANCASTER
Inspection Results For:

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ROSE CITY NURSING AND REHAB AT LANCASTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State licensure,Rights Compliance Survey and an abbreviated survey for three complaints completed on May 20, 2026, it was determined that Rose City Nursing and Rehab at Lancasternot in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.

Plan of Correction:

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

This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. 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 observations, facility record review, as well as resident and staff interviews, it was determined the facility failed to ensure resident smoking materials were stored securely and monitored for four residents (Residents 18, 74, 92, 93) on two units, posing a risk for fire, resulting in immediate jeopardy to the residents (first and third floor units).

Findings include:

Interview with the Nursing Home Administrator (NHA) during the entrance conference on May 17, 2026, at approximately 10:30 a.m., revealed the facility is a non-smoking facility and have no smoking policy.

Further interview with the NHA revealed there were four residents in the building who were permitted to smoke if they had a physician's order allowing them to leave the facility unaccompanied. Continued interview with Nursing Home Administrator revealed, the four residents were assessed for smoking which demonstrated each could independently use smoking materials safely, and they signed a smoking agreement that stipulated the resident agreed to keep smoking materials in a locked box provided by the facility. The resident was allowed to keep the key, and a nursing supervisor would have a copy of the key.

Observation of Resident 4 on May 18, 2026, at approximately 1:00 p.m. revealed Resident 4 ambulating on the first-floor unit, although Resident 4 resides on the second-floor unit.

Review of Resident 4's May 2026 quarterly Minimum Data Set (mandatory assessment of resident needs and condition) revealed resident is cognitively impaired and ambulates independently throughout the nursing units.

Interview and observation with Resident 18 on May 19. 2026 at approximately 10:45 a.m. revealed the resident resides on the fourth floor and keeps smoking materials in a compartment on her walker.

Observation conducted of Resident 18 revealed the walker's compartment does not have a locking mechanism and smoking paraphernalia which includes cigarettes and lighter could easily be accessed.

Interview and observation of Resident 74 on May 19. 2026 at approximately 10:50 a.m. revealed the resident resides on the fourth floor and the smoking materials were stored in an unlocked drawer at the resident's bedside.

Observation of Resident 92 on May 19, 2026, at approximately 10:50 a.m. revealed that the resident resides on the fourth floor and the smoking materials were kept on top of his dresser. Smoking material would be in plain view of anyone walking by the resident's room.

Interview and observation of Resident 93 on May 19. 2026 at approximately 10:50 revealed the resident resides on the first floor and the resident has a lock box for storing her smoking materials but stated "I don't use it. I know I should." Resident 93 opened her hand to reveal one cigarette and lighter.

Review of Resident 18's clinical record revealed resident had a smoking assessment completed on May 12, 2026, to verify the resident was safe to smoke. Review of Resident 18's care plan revealed that resident was care planned to be allowed to smoke. Review of Resident 18, clinical record revealed that Resident 18 had a physician's order dated November 12, 2025, allowing the resident to leave the facility by herself.

Review of clinical record for Resident 74 revealed that Resident 74 had a smoking assessment completed on May 12, 2026, to verify that the resident was safe to smoke. Review of Resident 74's care plan revealed that resident was care planned to be allowed to smoke. Review of Resident 74, clinical record revealed that Resident 74 had a physician's order dated October 31, 2025, allowing the resident to leave the facility by himself.

Review of clinical record for Resident 92 revealed that Resident 92 had a smoking assessment completed on May 12, 2026, to verify that the resident was safe to smoke. Review of Resident 92's care plan revealed that resident was care planned to be allowed to smoke. Review of Resident 92' clinical record revealed that Resident 92 had a physician's order dated January 23, 2026, allowing the resident to leave the facility by himself.

Review of clinical record for Resident 93 revealed that Resident 93 had a smoking assessment completed on May 12, 2026, to verify that the resident was safe to smoke. Review of Resident 93's care plan revealed that resident was care planned to be allowed to smoke. Review of Resident 93's clinical record revealed that Resident 93 had a physician's order dated April 12, 2026, allowing the resident to leave the facility by herself.

Review of Resident 104's care plan revealed that Resident 104 had a history of problematic behaviors "characterized by wandering...[and] trespassing into other resident's rooms." Resident 104 resides on the first floor, but free to ambulate around facility.

Interview with Nursing Home Administrator on May 19, 2026, at approximately 11:00 a.m. revealed facility staff are not responsible for monitoring or ensuring the residents' smoking materials are secured to prevent cognitively impaired or mentally ill residents access to flammable items.

Based on the above findings an immediate jeopardy situation was identified to the NHA on May 19, 2026, at 2:35 p.m. The Facility failed to ensure that residents who smoked adhered to the facility policy of locking smoking materials away when not in use. Staff were not monitoring location of the smoking materials causing a situation where a cognitively impaired or mentally ill resident could obtain flammable smoking materials. An immediate action plan was requested.

On May 19, 2026, at 5:29 p.m., an acceptable action plan was approved, which included the following interventions: Facility staff conducted a facility wide audit to ensure no other residents possessed smoking materials. No smoking materials were found. All facility staff and Residents 18, 74, 92, and 83 were educated and informed that smoking materials would be secured near the front door in a lock box. An RN supervisor and receptionist will have the key to the lock box. The residents must sign out each time they take smoking materials from the lock box and sign the materials back in when they return to the facility. Smoking materials cannot be taken into the resident care areas. The residents must leave the property to smoke, following leave of absence procedures. The residents must never smoke on the property nor inside the building. The resident will never share nor give nor hand out any smoking materials to any other residents. The residents will not ask others for any smoking materials from other residents. The procedure of smoking agreement was signed by each resident identified as a smoking resident (Residents 18, 74, 92, 93) on May 19. 2026.

Observations conducted on May 20, 2026, of the smoking material sign out procedure, as well as review of facility staff education documentation and interviews conducted with 14 nursing and ancillary staff confirmed the facility's action plan was implemented and immediate jeopardy was lifted on May 20, 2026, at 11:48 a.m.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

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

1. Residents 18, 74, 92, and 93 have all been educated and informed that smoking paraphernalia will be secured near the front door in a lock box. All have signed the revised smoking agreement and are aware
2. Facility performed an in house audit to ensure there is no other smoking paraphernalia unsecured. No more paraphernalia has been found.
New admits will be informed that Rose City is a non-smoking facility and will not be permitted to smoke, even with LOA.
3. NHA revised smoking agreement of current residents 18, 74, 92, and 93. NHA educated department managers on revised agreement of residents 18, 74, 92, and 93, being grandfathered. NHA educated department managers that new admissions will not be permitted to smoke, even with LOA. Department managers have educated respective department staff regarding revised smoking agreement for residents 18, 74, 92, and 93 and they have signed. Department managers have called and spoken to employees that are not in facility and have been educated on revised smoking agreement. Overall education has been 95%
4. NHA, or designee, will audit residents 18, 74, 92 and 93 to ensure they do not have any smoking paraphernalia with them daily for one week, then 3 times a week for one week, then weekly for one week. Results of audits will be submitted to monthly QAPI for review and recommendations.

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

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.

�483.80 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 upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for 2 of 22 (Resident 13 and Resident 14) residents reviewed and failed to practice infection control prevention and mangement during tracheostomy (A surgical procedure that creates an opening through the neck directly into the windpipe) care and Gastrostomy tube (GT- A medical device inserted directly through the abdomen into stomach) care. For one of 22 residents reviewed (Resident 5).

Findings:

A review of the facility policy "Tracheostomy Care", undated revealed the following: Aseptic technique (A collection of medical practices and procedures that helps protect patients from dangerous germs) must be used: during cleaning and sterilization of reusable tracheostomy tubes; during all dressing changes until tracheostomy wound healed; and during tracheostomy tube changes, either reusable or disposable. Sterile gloves must be used during aseptic procedures. The same policy revealed "perform hand hygiene" before the procedure, after removing old dressing, after removing the old cannula, after placing a new cannula, after cleaning the stoma and surrounding site.

Review of facility policy, "Enhanced Barrier Precautions", reviewed December 2024, indicated that "enhanced barrier precautions (EBP) apply when a resident is infected or colonized CDC- targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained... Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. Personal protective equipment and alcohol-based hand rub are readily accessible to staff."

A review of Resident 5's physician order revealed the following: Tracheostomy care every shift for infection prevention and Cleanse GT with normal saline solution, apply Zinc Oxide (barrier cream), apply Calcium Alginate (Are absorbent, non-adhesive dressings made from seaweed fibers used to mane moderately to heavy exuding wounds), cover with split gauze two times a day.

A tracheostomy and GT care observation for Resident 5 was conducted on May 19, 2026, at 2:15 p.m., with licensed nurse Employee E7, the following were observed: Employee E7 put on mask, gown, and gloves (clean) then proceeded to the resident's bedside where tracheostomy and GT care supplies were already prepared. Employee E7 took a white towel from the cabinet and went to the bathroom to wet it. Upon returning, Employee E7 removed the resident's old necktie and old dressing then cleansed the back of the neck with the wet towel. Employee E7 took off their used gloves and put on a new clean glove without performing hand hygiene. Employee E7 removed the old cannula, discarded it and without changing their gloves proceeded in opening the sterile package of cannula then placed it to the resident's tracheostomy. Employee E7 took off their glove, applied a new clean glove then suctioned the resident. Employee E7 took off their glove, applied a new clean glove then applied a sterile slit gauze below tracheostomy, placed the tracheostomy collar back then discarded all used tracheostomy supplies. Employee E7 removed used gloves, without performing hand hygiene applied a new clean glove then proceeded into cleaning the resident's GT with normal saline with gauze, placed the ointment on their gloved fingertip then applied it into the GT's surrounding area, then applied the calcium alginate then covered with gauze. Employee E7 completed both tracheostomy and GT care without performing hand hygiene before starting the procedure and in between procedures.

An interview was conducted with Employee E7 on May 17, 2026, at 2:30 p.m. Employee E7 acknowledged that hand hygiene was not performed during the tracheostomy and GT care.

The above was conveyed with the Director of Nursing on May 20, 2026, at 10:00 a.m.
The facility failed to ensure infection control prevention and management were implemented during tracheostomy and GT care procedures.

Review of Resident 14 quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated March 10, 2026, revealed under section M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage, that the resident was marked as having two stage 3 pressure ulcers.

Observation of Resident 14's room on May 17, 2026, at 9:50am; May 18, 2026, at 12:10 pm and May 19, 2026, 9:51 am revealed no signage indicating EBP was in place and no personal protective equipment available in or outside Resident 14's room.

Interview with licensed staff Employee E10 on May 19, 2026, at 9:47 a.m. confirmed that Resident 14 should have EBP signage outside of room.

28 Pa. Code 211.10(d) Resident care policies

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

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

1. Resident 13 and resident 14 enhanced barrier precautions were placed; facility cannot retroactively correct the trach and GT care that was performed for resident 5.
2. ADON performed an audit to ensure that residents with enhanced barrier precautions have proper notifications present. No other issues noted.
3. ADON, or designee, will educate/re-educate staff on proper enhanced barrier precaution notifications; ADON, or designee, will educate/re-educate licensed staff on proper procedures for trach care and GT care procedures.
4. ADON, or designee, will perform weekly audits to ensure that proper notification is present for those residents requiring enhanced barrier precautions. ADON, or designee, will perform weekly audits to ensure that proper procedures are used during trach care and GT care. Results of audits will be submitted to monthly QAPI for review and recommendation.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

�483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure staff were provided with a safe, functional, sanitary, and comfortable environment for three of the three medication rooms observed (Second, Third, and Fourth Medication Rooms).

Findings:

An observation of the Second-Floor medication room was conducted on May 18, 2026, at 9:20 a.m., in the presence of licensed nurse Employee E9. The observation revealed the following:The medication refrigerator's bottom shelves were covered with a dry brown substance. Further observation revealed a black substance on the edges of the washing sink. Employee E9 acknowledged that the medication refrigerator and washing sink were dirty and required cleaning.

An observation of the Third-Floor medication room was conducted on May 18, 2026, at 9:51 a.m., in the presence of licensed nurse Employee E10. The observation revealed empty medication refrigerator had multiple dry, dark brown substances on the top and bottom shelves. Further observation revealed a dark brown substance on the edges of the washing sink. In addition, the cabinet below the sink does not close, exposing the bottom of the sink that has used/dirty winter gloves, empty plastic bottles, and black substances on the floor.

An interview with Employee E10, conducted at 9:55 a.m., revealed that they are agency staff. Employee E10 does not know what the dark brown substances on the sink were, but acknowledged that the room needs to be cleaned.

An observation of the Fourth-Floor medication room was conducted on May 18, 2026, at 10:00 a.m. and revealed multiple white and orange dry substances in the washing sink. Further observations revealed broken cabinets.

The above was conveyed to the Nursing Home Administrator on May 19, 2026, at 2:00 p.m.

The facility failed to ensurestaff were provided with a safe, functional, sanitary, and comfortable environment in the Second, Third, and Fourth Floor medication rooms.

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

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

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

1. The second floor medication room sink and medication refrigerator were cleaned and sanitized; the third floor medication room sink and medication refrigerator was cleaned and sanitized; also on the third floor medication room the cabinet under the sink was cleaned and sanitized; the fourth floor medication room was cleaned and sanitized and the broken cabinets were repaired.
2. DON performed an audit of the remaining medication room and medication refrigerator and no issue was noted.
3. DON, or designee, will educate/re-educate licensed staff to report any broken or damaged cabinets into facility TELS system and to clean medication refrigerators as needed.
4. DON, or designee, will perform weekly audits to ensure that the medication rooms and medication refrigerators are clean and sanitized. Results of audits will be submitted to monthly QAPI for review and recommendation.

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

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

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

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

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

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

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

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

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

Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure safe, clean and homelike environment was provided for one of four units observed (Second Floor Unit).

Findings:

An observation conducted in Resident 5's bathroom on May 20, 2026, at 9:36 a.m., in the presence of licensed nurse Employee E7 revealed two broken tiles behind the toilet bowl exposing an approximate one foot by half foot hole on the wall.

Interview with Employee E7 on May 20, 2026, at 9:40 a.m., revealed that they were not aware of the hole on the wall until shown by surveyor.

The above was conveyed with the Nursing Home Administrator on May 20, 2026, at 3:00 p.m.

The facility failed to ensure safe, clean and home-like environment was provided to the residents on the Second Floor Unit.

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

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

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

1. Resident 5's bathroom had the tiles replaced behind the toilet.
2. Maintenance Director and assistant audited all resident bathrooms to ensure there were no more broken tiles. No other issues were found.
3. NHA, or designee, will educate facility staff to ensure that if they see an area that needs maintenance attention, to report it to their supervisor, and /or enter it into our TELS system.
4. NHA, or designee, will perform weekly audits of random resident bathrooms to ensure that there are no maintenance issues that need addressed. Results of audits will be submitted to monthly QAPI for review and recommendations.

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

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

Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to create a comprehensive care plan with interventions for one of 22 residents reviewed (Resident 1).

Findings include:

Review of Resident 1's face sheet revealed medical diagnoses that included dementia (general loss of cognitive abilities, including memory).

Review of the Resident 1's progress note of 3/20/2026 atv19:36 nursing note stated "Resident exit seeking and getting angry at staff. Redirection and 1:1 effective."

Review of Resident 1's clinical records revealed physician orders dated March 25, 2026, for Wanderguard (wearable bracelets and door sensors to track at-risk individuals, prevent them from leaving secure areas, and instantly alert caregivers if a boundary is breached) to Left Wrist A-1425-3796 every nightshift check for proper function AND every shift check for proper placement.

Review of Resident 1's clinical records failed to reveal a care plan for wander guard and elopement.

Interview with Director of Nursing on May 20, 2026, at 10:35 a.m. confirmed the above findings.

28 Pa. Code 211.5(f) Clinical records

28 Pa Code 211.11(d) Resident care plan

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

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

1. Resident 1's care plan was updated to reflect 1's care plan is updated to reflect the wanderguard and elopement.
2. DON, or designee, completed an audit of those residents at risk for elopement and/or wearing a wanderguard to ensure their care plans reflected both. No other issues were discovered.
3. DON, or designee, will educate/re-educate licensed staff and on the policy of wanderguards and elopement to ensure that licensed staff are adding appropriate care plans.
4. DON, or designee, will perform weekly audits of those residents wearing a wanderguard or are an elopement risk to ensure that all care plans reflect the appropriate plan of care. Results of audits will be submitted to monthly QAPI for review and recommendations.

483.25 REQUIREMENT Quality of Care:

� 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 clinical records review and staff interview, it was determined that the facility failed to ensure that the ordered medication to promote comfort was administered to a resident with a terminal diagnosis for one of eight residents reviewed (Resident 71).

Findings:

A review of Resident 71's admission progress notes dated April 3, 2026, at 4:30 p.m., revealed the resident was admitted to the facility with a recent left parietal intraparenchymal hemorrhage to CAA (Cerebral Amyloid Angiopathy- A spontaneous bleed in the outer brain tissue). The resident also had a diagnosis of cognitive impairment and seizure disorder (A chronic neurological condition characterized by recurrent seizures caused by abnormal electrical activity in the brain). The same note revealed "Patient was admitted to TNU (Transitional Neurology Unit) with TACS (Trauma and Acute Care Surgery) consult for critical management. During this 12-day hospitalization, the family decided, after physician recommendation, to place [them]on end-of-life/hospice care". The same note revealed that hospice was aware, waiting for insurance information/authorization. Admission assessment revealed the following: Unable to move right upper and lower extremity; Resident is awake and alert, mumbles in Spanish but was aphasic (A neurological language disorder that impairs the ability to speak, write, and understand both spoken and written language); with foley catheter (A thin, flexible tube inserted into the bladder through the urethra to collect and drain urine); and a wound to the right buttock and left hip.

A review of Resident 71's physicians order dated April 3, 2026, revealed the following orders: Lorazepam (anti-anxiety medication) give 1 mg by mouth two times a day for restlessness / agitation for 10 days terminal condition: and Morphine Sulfate (An opioid medication used for the management of severe pain) oral solution give 10mg/ml give 2.5 ml by mouth every six hours as needed for pain, discomfort, restlessness, SOB (shortness of breath), hospice/end of life.

A review of the nursing progress notes dated April 3, 2026, at 5:13 p.m., revealed "Writer calling the pharmacy right after faxing, re (regarding) controlled medication order (prior to 1700). [Name] at the pharmacy says they pulled them in the queue, so we can request a script from Cubex (automated medication storage).

A review of the facility's emergency medication list, "Inventory on Hand," revealed that both Morphine and Lorazepam were available in the facility.

A review of the nursing progress notes dated April 3, 2026, at 9:50 p.m., revealed: "Resident is noted to be anxious and keeps on touching the foley catheter. Due meds (medications) are given, though some are still pending for delivery. Called pharmacy to speed up the delivery".

A review of Resident 71, April 2026, MAR (Medication Administration Record) revealed that residents were not administered with as-needed Lorazepam and Morphine ordered for discomfort and restlessness on the evening of April 3, 2026.

A review of Resident 71's nursing progress notes dated April 4, 2026, at 7:22 p.m., revealed: "Resident is noted to be anxious and keeps touching the foley catheter. Needs anticipated and due nursing care given. Monitoring continues".

A review of the nursing progress notes dated April 4, 2026, at 9:09 p.m., revealed "Family contacted this writer, concerned about pt (patient) pain medications. PT was provided PRN (as needed) Tylenol for pain from the nurse present and PRN for anxiety. This writer contacted the on-call pharmacist". The same notes revealed family reports they had contacted hospice, but pt is not admitted yet (to hospice).

A review of the nursing progress notes dated April 4, 2026, at 22:16 p.m., revealed: "Family resident requested pain medication because they think the [resident] is in pain".

A review of Resident 71's MAR revealed the resident was not administered the ordered Lorazepam until the morning of April 4, 2026. MAR revealed ordered Morphine as needed for discomfort and restlessness was not administered until April 4, 2026, at 10:16 p.m., with a PAINAD (A tool used to assess pain for cognitively impaired person) pain level of "6" (moderate pain).

The above was conveyed to the Director of Nursing on May 20, 2026, at 11:00 a.m.

The facility failed to ensure that Resident 71's ordered medication to promote comfort for a terminal condition was followed.

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

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

1. Facility cannot retroactively administer the ordered medication to resident 71.
2. DON, or designee, completed an audit of residents to ensure that PRN medications are given as ordered, if indicated by residents PAINAID scale. No other issues were discovered.
3. DON, or Designee, will educate/re-educate licensed nursing staff on following physician orders for PRN medication administration as indicated on PAINAID scale
4. DON, or designee, will perform weekly audits to ensure that the PAINAID scale is being utilized and medications are being administered appropriately. Results of audits will be submitted to monthly QAPI for review and recommendations

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

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

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

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

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

Observations:

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of three residents reviewed for nutrition (Resident 10 and Resident 106).

Findings include:

Review of facility policy, "Weight Assessment and Intervention", revised March 2019, revealed that "Any weight gain or loss of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician or Dietician. The Dietician and/or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate."

Review of Resident 10's clinical record revealed recorded weights of 243.5 pounds on March 1, 2026; 234.4 pounds on April 3, 2026; (loss of 9.1pounds in one month). There was no re-weigh conducted to address the weight loss.

Further review of Resident 10's clinical record failed to reveal recommendations to address the weight loss.

Interview with Employee E4 on May 20, 2026, at 9:20 a.m. confirmed that further dietary interventions should have been implemented to address Resident 10's weight loss.

Review of Resident 106's weights showed documented weights of 170.6 pounds on March 06,2026, and 161.5 pounds on April 09, 2026, reflecting a loss of 9.1 pounds in one month and three days. The clinical record did not contain evidence that staff re-weighed Resident 106 to confirm the weight loss as required by facility policy.

Further review of Resident 106's clinical record showed no documented recommendations or interventions to address the weight loss.

An interview with the Nursing Home Administrator (NHA) conducted on May 20, 2026, at 12:36 p.m., confirmed that Resident 106 was not re-weighed after the documented loss and no additional dietary interventions were implemented to address Resident 106's weight loss.

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.10(c) Resident Care Policies

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

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

1. Residents 10 and 106 weights were obtained.
2. DON and ADON performed an audit to ensure there were no other residents that triggered for monthly weight loss. No other issues were found
3. DON, or designee, will educate/re-educate nursing staff on weight policy regarding weight change more than 5 pounds to notify supervisor.
4. DON, or designee, will perform weekly audits to ensure that any resident with a 5 pound weight change, will be addressed by dietician. Results of audits will be submitted to monthly QAPI review and recommendation.

483.25(l) REQUIREMENT Dialysis:

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

Observations:

Based on a clinical records review and interview with residents and staff, it was determined that the facility failed to ensure medication orders for dialysis residents were followed for one of two residents reviewed (Residents 11).

Findings:

A review of Resident 11's diagnosis list includes End Stage Renal Failure (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own), and dependence on Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally).

A review of Resident 11's physician's order revealed: Dialysis every Tuesday, Thursday, Saturday (11:15am pick-up for 12pm arrival).

A review of Resident 11's physician's order dated December 11, 2025, revealed an order for Calcium Acetate (A phosphate binder medication used to treat excess phosphate in the blood) 667, give two tablets three times a day. The medication was scheduled at 8:00 a.m., 12:00 noon, and 4:00 p.m.

A review of Resident 11's April and May 2026, Medication Administration Record (MAR) revealed that Calcium Acetate was not administered at 12:00 noon on the following dates April 2, 4, 7, 9, 11, 14, 16, 18, 21, 23, 25, 28, 30, 2026, and May 5, 7, 9, 12, 16, and 19 2026. MAR review revealed medication was not administered due to the residents being on "Leave of Absence".

There was no documentation indicating that the physician was notified of missed Calcium Acetate due to the resident being out for Dialysis.

The above was conveyed to the Director of Nursing (DON) on May 20, 2026, at 11:00 a.m.

The facility failed to ensure Resident 11's medication order was followed.

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

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

1. Facility cannot retroactively follow resident 11 medication orders for dialysis days. DON spoke with medical director and new orders obtained for Calcium Acetate to be given twice a day, at 8am and 4pm (around dialysis).
2. DON performed an audit of other dialysis residents to ensure that medication orders were being followed. No other issues noted.
3. DON, or designee, will educate/re-educate licensed staff on following physician orders and notifying physician, if medication is not administered as ordered.
4. DON, or designee, will perform weekly audits to ensure that residents going to dialysis are receiving medications as ordered. Results of audits will be submitted to monthly QAPI for review and recommendations.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

�483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in �483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

�483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

�483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

�483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

�483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

�483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of the facility's policy, observations, and staff interviews, it was determined that the facility failed to properly stored medications in one of three medication rooms observed (Second Floor Medication Room).

Findings:

A review of the facility's policy titled "Medication Labeling and Storage", undated, revealed "If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The same policy revealed "The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

An observation of the Second-Floor medication room was conducted on May 18, 2026, at 9:20 a.m., in the presence of licensed nurse Employee E9. The observation revealed the following: The medication refrigerator's bottom shelves were covered with a dry brown substance. Further observation revealed five Insulin Glargine pens with an expiration date of February 25, 2026.

An interview with Employee E9 conducted on May 18, 2026, at 9:22 a.m., revealed that 11-7 shift staff are responsible for cleaning and checking the medication refrigerator. Employee E9 was unable to provide an explanation for why outdated medications were still stored in the medication refrigerator. Employee E9 confirmed that the refrigerator was dirty and required cleaning.

The above was conveyed with the Nursing Home Administrator on May 19, 2026, at 2:00 p.m.

The facility failed to ensure medications were properly stored on the Second-Floor medication room storage.

28 Pa. Code 211.10(c) Resident Care Policies

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

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

1. The expired medications in the second floor medication room were disposed of at time of observation.
2. DON performed an audit of medication rooms for expired medications and no other issues for discovered.
3. DON, or designee, will educate/re-educate licensed staff on ensuring that expired medications are disposed of timely and properly and notify pharmacy of need for replacement medication that was disposed of.
4. DON, or designee, will perform weekly audits to ensure that medications are current and not expired. Results of audits will be submitted to monthly QAPI for review and recommendations.

483.50(a)(1)(i) REQUIREMENT Laboratory Services:

�483.50(a) Laboratory Services.
�483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Observations:

Based on clinical records review and staff interview, it was determined that the facility failed to follow laboratory orders for two of 22 residents reviewed (Resident 3 and 109).

Findings include:

Review of Resident 3's quarterly minimum data set (MDS - a mandatory assessment of a resident's physical condition and care needs) dated February 26, 2026 revealed that Resident 3 was cognitively intact and had the diagnoses anxiety disorder (a group of serious mental health conditions characterized by persistent, excessive fear or worry that is out of proportion to the actual situation) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).

Review of Resident 3's medication administration record revealed physician order for Depakote (an anti-seizure medication often used to manage mood disorders) 125 MG (milligrams) twice a day for depression.

A psychiatric progress note dated January 12, 2026 at 5:52 p.m. revealed: "Recommend valproic acid serum level (a blood test ordered for patients taking Depakote to determine if the substance valproic acid is at optimal levels) be drawn this week and every 6 months, for monitoring related to Depakote pharmacotherapy (treatment that uses pharmaceutical drugs to address a health condition)."

Review of physician orders dated January 16, 2026 revealed an order for bloodwork that included "Valproic acid serum level q3 (every 3) months."

Review of laboratory records revealed no evidence that Valproic acid levels were obtained.
Review of psychiatric progress note dated February 23, 2026 at 4:29 p.m. revealed: "recommend valproic acid serum level be drawn this week and every 6 months for monitoring related to Depakote pharmacotherapy."

Review of nursing progress notes dated February 24, 2026 at 4:01 p.m. revealed "Psych (psychiatric provider) in for resident visit and review , with n.n.o. (no new orders) for med changes. Psych suggesting to check valproic acid level with next labs and labs q 6 months, however, request these labs routine q 3 months. Notification to be sent to psych regarding labs."

Review of laboratory records revealed no evidence that Valproic acid levels were obtained.
Interview with the DON and NHA on May 20, 2026 at approximately 12:30 p.m. revealed that there were no results because the bloodwork had not been obtained.

A review of Resident 109's physician's order dated December 25, 2025, revealed and order for CBC (complete blood count), CMP (complete metabolic count), Vitamin b12, Vitamin D, Ferritin level every night shift every three month (s) starting on the 1st related to Myotonic Muscular Dystrophy (A genetic disorder that causes progressive muscle weakness, wasting, and inability to relax muscle). The laboratory order was scheduled for January 1, 2026, and April 1, 2026.

A review of the laboratory result page revealed that there was no blood work done for April 1, 2026.

A review of Resident 109's physician order dated April 14, 2026, revealed an order for CBC with differentials and CMP today.

A review of the laboratory result page revealed that there was no blood work done for April 14, 2026.

There was no documentation indicating that physicians were notified of the missed laboratory orders.

An interview with the Director of Nursing was conducted on May 21, 2026, at 10:00 a.m. The DON confirmed that there was no blood work done on April 1 and 14, 2026. The DON could not provide a reason why the ordered blood work was not done. The DON confirmed that the physicians were not notified of the missed laboratory orders.

The facility failed to ensure that Resident 109's blood work for April 1, 2026, and April 14, 2026, was followed.

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

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

1. Resident 3 labs were obtained as ordered; resident 109 has been discharged
2. DON performed an audit to ensure other residents did not have any missing labs that were ordered. No other issues noted.
3. DON, or designee, will educate/re-educate licensed staff on obtaining labs as ordered from physician. If labs were not obtained, then documentation as to why not obtained and documenting notification of physician that labs were not obtained, why physician response to notification.
4. DON, or designee, will perform weekly audits to ensure that labws are obtained as ordered. Results of audits will be submitted to monthly QAPI for review and recommendation.

483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs:

�483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

�483.55(a) Skilled Nursing Facilities
A facility-

�483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with �483.70(f) of this part, routine and emergency dental services to meet the needs of each resident;

�483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

�483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

�483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

�483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.

Observations:

Based on observations, interview, and review of facility documentation, the facility failed to provide dentures to one out of seven residents reviewed (Resident 2).

Findings include:

Review of facility policy titled, Dental Services, revised in December 2026, revealed "Routine and emergency detail services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care."

Interview with Resident 2 on May 18, 2026 at approximately 2:05 p.m., revealed that he had been fitted for dentures in "last year". Further, he revealed that he had yet to receive any dentures and no facility staff had followed up with him about the dentures. Further interview revealed that Resident 2 felt that without any teeth he "talked funny" and it was difficult to eat some foods.

Review of Resident 2's care plan revealed Resident 2 was care planned for "oral/dental health problems r/t (related to) possible broken/carious teeth."

Review of Resident 2's physician orders reveal a therapeutic (prescribed for a particular health condition), regular texture diet with thin liquids.

Review of Resident 2's weight chart revealed that Resident 2 weighed 192.3 pounds in December 2025, 196.4 pounds in January 2026, 199.2 pounds in February1 2026, 197.2 pounds in March 2026, 195.8 pounds in April 2026, and 193 pounds in May 2026, reflecting no significant weight loss.

Review of Resident2's dental consult sheet dated November 17, 2025 revealed a dental a note that stated: "Pt (patient) wants FU/FL (full upper and full lower dentures). Has had FMX (full mouth x-rays) done and lower impressions done."

Review of Resident 2's clinical chart failed to reveal any documentation of the request for dentures or the dental services provided on November 17, 2025 in the progress notes.

Review of Resident 2's dental consult sheet dated December 31, 2026 revealed a form with recommendations for full upper and full lower dentures circled and that a full mouth x-ray series was performed.

A review of nursing progress notes dated December 31, 2026 at 8:43 a.m. revealed: "Seen by Dental Services on 12/30/25. No new orders. Recommended for full upper and lower dentures."

Interview with the Nursing Home Administrator (NHA) on May 20, 2026 at approximately 11:00 a.m. confirmed that Resident 2 was fitted for dentures and the dentures were made, but the company that made the dentures claimed there was a balance due and would not release the dentures to the resident. Subsequently the dentures were not delivered to Resident 2 because of the dispute that remains ongoing.

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

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

1. Dental company notified of need for resident 2 dentures to be provided to facility.
2. DON performed an audit to determine if there are any other residents not having dental services timely. No other issues noted.
3. DON, or designee, will educate/re-educate licensed nursing staff on following recommendations from dental services.
4. DON, or designee, will perform weekly audits to ensure that recommendations from dental services is being followed through�dental service come to facility once a month. Results of audits will be submitted to monthly QAPI for review and recommendations.

483.70 REQUIREMENT Administration:

�483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Observations:

Based on the review of job descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of residents when residents who smoke were permitted to keep smoking materials unsecured in their rooms and on their person. This failure resulted in an Immediate Jeopardy situation.

Findings Include:

Review of the job description for the Nursing Home Administrator (NHA) states position purpose is to manage the Facility in accordance with current applicable federal, state, and local guidelines, and regulations that govern long term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.

Review of the job description for the Director of Nursing (DON) states that the position is to: Plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that cover the facility and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times.

The findings in this report identified the facility failed to maintain the safety of the residents from risk of fire by ensuring that there was a system in place to monitor and account for smoking materials for the residents who were assessed to be allowed to smoke during their leaves of absence.

Refer to F689 28

Pa Code 201.14(a) Responsibility of licensee

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

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

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

1. Facility cannot retroactively correct that NHA and DON did not maintain the safety of the residents from risk of fire by ensuring that the system in place was being monitored and accounted for smoking materials for the residents who were assessed to be allowed to
2. Facility has changed practices for those residents that sign LOA and go outside, off property to smoke.
3. RDO will educate NHA and DON on ensuring the safety of residents from risk of fire ensuring that the system is monitored and accounted for smoking materials for the residents who were assessed to be allowed to smoke during their LOA.
4. RDO, or designee, will perform weekly audits to ensure that the NHA and DON are ensuring that the system of monitoring smoking paraphernalia is followed. Results of audits will be submitted to monthly QAP for review and recommendation.

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

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

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

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

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

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

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

Observations:

Based on staff interview, observation, and clinical record review, it was determined that the facility failed to ensure an accurate clinical medical record for 1 of 1 resident reviewed (Resident 106).

Findings include:

A review of the facility policy titled "Charting and Documentation", last revised July 2017, revealed the policy states, "Documentation in the medical records will be objective, complete, and accurate."

A review of Resident 106's diagnoses included Muscle Weakness (generalized weakness meaning overall reduced strength throughout the body).

A review of Resident 106's physician order dated February 16, 2026, at 3:00 p.m., revealed an order for "Weekly Skin Review on Mondays 3-11 shift. Complete Weekly Skin Review on the Tab FORMS. Document refusal every evening shift every Mon." and another physician order dated April 8, 2026, at 3:00 p.m., for "Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to left buttocks topically every day and evening shift for Wound care."

A review of Resident 106's April 2026 and May 2026 electronic Medication Administration Record (eMAR) revealed the Triad treatment was not administered on the following dates and shifts:

April 12, 2026, day shift.April 14, 2026, evening shift.May 5, 2026, day shift.May 13, 2026, evening shift.

A review of Resident 106's nursing progress notes failed to reveal any documentation explaining why the Triad was not administered on the dates listed above.

A review of Resident 106's skin assessment dated April 7, 2026, revealed no new areas of concern.

A review of Resident 106's skin assessment dated April 8, 2026, revealed, "Resident seen by wound care nurse yesterday 4/07/2026, new orders for wound to left buttocks, cleanse wound with Normal saline apply Triad Hydrophilic Wound Dress External Paste to wound BID."

A review of Resident 106's skin assessment dated April 13, 2026, revealed no new areas of concern.

A review of Resident 106's skin assessment dated April 27, 2026, revealed no new areas of concern.

A review of Resident 106's skin assessment dated May 4, 2026, revealed "Left buttock wound continues with treatment in place."

A review of Resident 106's skin assessment dated May 13, 2026, revealed no new areas of concern.

An interview with the Nursing Home Administrator (NHA) conducted on May 20, 2026, at 12:36 p.m., confirmed the Triad treatment was incorrectly entered in Resident 106's clinical record, the skin assessment documentation present in Resident 106's clinical record belonged to a different resident, and Resident 106 does not currently have a wound.

The facility failed to ensure that Resident 106's clinical medical records were complete and accurate.

28 Pa. Code 211.5(f)(h) Clinical records.

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

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

1. Resident 106 clinical record was corrected to reflect accurate information at time of observation.
2. DON performed an audit to ensure that information is resident charts was accurate and correct. No other issues noted.
3. DON, or designee, will educate/re-educate licensed staff on proper documentation to include correct resident, correct medical record, and accurate notes.
4. DON, or designee, will perform weekly audits to ensure proper documentation on proper medical records. Results of audits will be submitted to monthly QAPI for review and recommendation.

� 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of staffing documentation, it was determined the facility failed to ensure that adequate nurse aide ratios were maintained according to State regulations for three of three weeks reviewed. (April19, 2026-April 25,2026; April 26, 2026- May 2, 2026, and May 13, 2026- May 19, 2026).

Findings include:

Review of staffing documentation revealed the facility failed to meet the nurse aide ratio on the following dates and shifts:

April 24, 2026, day shift
April 25, 2026, evening shift
May 14, 2026, day shift
May 15, 2026, evening shift
May 17, 2026, day shift
May 17, 2026, evening shift
May 18, 2026, evening shift

The above findings were confirmed by the Nursing Home Administrator on May 21, 2026 at 4:16pm.

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

1. Facility cannot retroactively correct the staffing schedule to meet the required CNA ratios for dayshift on 04/24, 05/14, and 05/17; for evening shift on 04/25, 05/15,05/17, and 05/18
2. NHA, DON and staffing scheduler have weekday meetings to ensure CNA staffing ratios are above minimum requirements of 1CNA per 10 residents on dayshift, 1 CNA per 11 residents on evening shift, and 1 CNA per 15 residents on night shift
3. NHA, or designee, will educate Director of Nursing and nursing scheduler on CNA staff ratio requirements
4. NHA, or designee, will perform audits of CNA ratios for all three shifts 5 days a week. Results will be submitted to monthly QAPI meetings for review and recommendations.

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

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

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

1. Facility cannot retroactively correct the staffing schedule to meet the required LPN ratios for dayshift on 04/19, 04/20, 04/21, 04/22, 04/23, 04/24, 04/25, 04/26, 04/27, 04/28, 04/29, 04/30, 05/01, 05/02, 05/13, 05/14, 05/15, 05/17, 05/18, and05/19
2. NHA, DON and staffing scheduler have weekday meetings to ensure LPN staffing ratios are above the minimum requirements of 1 LPN per 25 residents on dayshift, 1 LPN per 30 residents on evening shift, and 1 LPN per 40 residents on nights shift
3. NHA, or designee, will educate the Director of Nursing and nursing scheduler on LPN staff ratio requirements
4. NHA, or designee, will perform audits of LPN ratios for all three shifts 5 days a week. Results of audits will be submitted to monthly QAPI for review and recommendations

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

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

Observations:

Based on review of facility staffing records, it was determined that the facility failed to ensure the total number of general nursing care hours provided in each 24-hour period be a minimum of 3.20 hours per patient day (PPD) for the three of three weeks reviewed. (Weeks of April 19, 2026-April 25,2026; April 26, 2026- May 2, 2026, and May 13, 2026- May 19, 2026.)

Findings include:

Review of the staffing records revealed the following dates were below 3.20 hours PPD:

April 23, 2026
April 24, 2026
April 25, 2026
May 2,2026
May 14,2026
May 15,2026
May 17, 2026
May 18, 2026.

The above findings were confirmed by the Nursing Home Administrator on May 21, 2026, at 4:16pm.

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

1. Facility cannot retroactively correct the staffing schedule to meet the required minimum PPD hours of 3.2 hours of direct resident care for each resident for 04/23, 04/24, 04/25, 05/02, 05/14, 05/15, 05/17, 05/18
2. NHA, DON, and staffing scheduler have weekday meetings to ensure daily PPD hours are above minimum requirements of 3.2
3. NHA, or designee, will educate Director of Nursing and nursing scheduler on daily PPD hour requirements
4. NHA, or designee, will perform audits of PPD hours 5 days a week for one week. Results of audits will be submitted to monthly QAPI for review and recommendations.

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